#54 – Kevin Sayer, CEO of Dexcom: Continuous glucose monitors – impact of food, sleep, and stress on glucose, the unmatched power of CGM to drive behavioral change, and the exciting future of CGM

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Hey everyone. Welcome to the Peter Attia Drive. I'm your host, Peter Attia. The Drive is a result of my hunger for optimizing performance, health, longevity, critical thinking, along with a few other obsessions along the way. I've spent the last several years working with some of the most successful, top performing individuals in the world, and this podcast is my attempt to synthesize what I've learned along the way to help you live a higher quality, more fulfilling life. If you enjoy this podcast, you can find more information on today's episode and other topics@peterattiamd.com. Hey everybody. Welcome to this week's episode of the Drive. I'd like to take a couple of minutes to talk about why we don't run ads on this podcast and why instead we've chosen to rely entirely on listener support. If you're listening to this, you probably already know, but the two things I care most about professionally are how to live longer and how to live better. 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Again, the podcast will remain free to all, but my hope is that many of you will find enough value in 1 the podcast itself and 2 the additional content exclusive for members to support us at a level that makes sense for you. I want to thank you for taking a moment to listen to this. If you learn from and find value in the content I produce, please consider supporting us directly by signing up for a monthly subscription. My guest this week is Kevin Sayre. Kevin is the Executive Chairman of the Board of Directors and the President and CEO of dexcom. During his tenure with Dexcom, he's been instrumental in leading the development of new technology including the G5, the G4, and of course now the G6. If you've followed me for some time, you probably know how much I love my Dexcom glucose monitor. I consider it to be one of the two most important devices that I wear, and I wear it pretty much all the time. I would say 300 to 330 days a year. I am wearing my CGM. It's offered me great insight, not just into the obvious things like how does eating food X impact my glucose, although I still continue to learn a lot through that lens, but also the impact of exercise, sleep and stress on mitigating those things or amplifying those things. So for example, one of the things I've noticed much more recently is the role that cortisol in the evening plays on my glucose. In this interview with Kevin, we talk about a bunch of things. We talk about how we met and his path to becoming the CEO of Dexcom. We talk about how the CGM technology works and what makes the G6 what I conceive to be is the best model yet. We talk about the challenges of working in the US healthcare system after getting CGM insured. We talk about developing an even smaller, more user friendly, less costly product while maintaining performance and accuracy. And Kevin does a really good job of explaining his framework on what are the constitutive elements that would drive a CGM device. And you'll see where this performance and accuracy become important. Talk about what's the next thing on horizon for patients with type 1 diabetes? The accuracy of the G6 software improvements for people with type 2 diabetes and the remarkable benefits of real time feedback that drive behavioral change for anybody using this. Talk a little bit about Dexcom versus the competitors. There's basically three large companies that do this, Dexcom being one of Abbott being the other through the acquisition of Libre and Medtronic. And we talk about less invasive options that people have asked about a lot. Talk about the cost, why you need a prescription when there might be an OTC that's over the counter option. We talk about smartwatch integration, Bluetooth, exciting collaborations and partnerships and future places for CGM such as in the hospital. We talk about lessons learned through failures and successes. Before we get to this, I want to read a disclaimer that Kevin's team has asked me to read. And that's of course because he's the CEO of a publicly traded company. This presentation includes forward looking statements. All forward looking statements included in this presentation are made as of September 21, 2018. That was the date of the interview. Based on information currently available to Dexcom and are subject to various risks and uncertainties and the actual results could differ. Dexcom undertakes no obligation to update such statements. With that said, and without further delay, please enjoy my conversation with Kevin Sayre. Kevin, how are you?

I'm great.

Thanks so much for making time. I don't often come into somebody's office, take them away from their work and ask them to sit down and talk.

You know, our discussions have been so interesting over time. I was thrilled when you asked me to do this. I can't imagine what journey will go on as we talk for the next while, but I'm really looking forward to it.

So, speaking of which, I think I've told the story a couple of times to some friends, how we met. But it's sort of funny to me because anyone who knows me knows when I'm on an airplane, I'm there to mostly just work, and I don't really talk to people. Occasionally, if somebody talks to me, I'll certainly be polite, but I'm really focused. And so, of course, it was about three years ago you and I met on an airplane. The funny part to me is how it happened, which is I'm taking a little break from work to look at one of my 12 favorite watch sites. And you look over. Do you remember what you said?

I do. I took my headphones off and I said, are you sure you want one of those? And I'm the same as you, Peter. I get on a plane and my wife claims I am the most unfriendly individual in the world, because I sit down, I wait for that moment when I can open up my computer, I'm hooked to WI Fi, I start working, and I'm thrilled. Or I just take a break from life and watch something on the screen. So we hadn't said a word, and all of a sudden you open up to watches. And I go, I've got to talk with this guy. We've got to look at these things and make sure he picks the right one. It was a very fun meeting. And then neither of us worked the rest of the flight.

Yeah. But the best part is we talked about watches for an hour, and then we're about an hour outside of New York, and at some point, we literally hadn't talked about anything but watches. But I just sort of said, oh, are you heading home or heading to work? And you said, oh, you're going to work. And then it was like, what do you do? And then. This is the part I don't think I told you. I had only heard about Dexcom two months earlier from a guy named Jake Kushner. I don't know if you know Jake, but Jake is a pediatric endocrinologist. Yeah. And so I was having dinner in Houston with Jake a couple months earlier, and he was showing me his data on his kids with type 1 diabetes that are walking around with hemoglobin A1Cs of 5.6. And he's saying to me, it's a game changer. We're done with telling kids with T1D that 7.5 is normal. The new normal is 5.6. And we're having no hypo events. And he goes, but we can't do it without this thing called cgm. And I was like, tell me more. And he said, so we use this thing. I think it was the G5 that they were using at the time. And I remember sort of thinking about it and going, God, that sounds so interesting. That's on my list of things I need to learn more about. And then I ask you what you do and this is what you just. They couldn't have made it up.

No. And this is all we do here at Dexcom, and we do see remarkable results in type 1 diabetes with these kids and with everybody who uses the technology.

Well, I've been wearing one now for almost three years. I think after that flight, you said, well, you gotta come in one day and we'll shoot the breeze. And within like a week, I was wearing one and I've never stopped.

Well, and I also use you as a critique because if we give Peter technology, you're a very, very good critic and very objective, versus our diabetes patients, who, while they love the technology, it's life saving for them, for you. You kind of look at it from a different perspective. And I use observations like that all the time when I talk to engineers and as we design future products, I love different perspectives on things. And one of the things in our culture that is very unique, we are very curious as an executive team by nature. And curious is the word that I would use. We love to learn, explore. We all wear these things, we all wear the new ones. In fact, I'm supposed to get a prototype of a new one next week that's going to communicate with some other devices. It's really fun and it does allow for learning. It keeps your mind going very quickly. We put peter on our G6 technology. Right. As it was approved.

Yeah, well, actually, I mean, I was on that G5X about a year ago, which was almost a G6, minus the calibration issue.

That's right.

So now let's go back a little bit. What were you doing before Dexcom?

So if you go back in the history of my career, I started in diabetes in 1994. I met an individual named Alman, who's one of the most remarkable entrepreneurs ever. And he had designed the insulin pump that is now Medtronic Diabetes. And we had a glucose sensor there. That's where I saw the first one. And I worked in diabetes there as the finance person and very much a business person till we sold the company to Medtronic. I stayed on with Medtronic for a while and we launched the first continuous glucose monitor at Minimed and Medtronic back in those days. And then I decided I didn't love big company. So I left and I found a couple of other jobs that were interesting, but I didn't love them. And my job right before this company was culturally fascinating. It was a Singapore headquartered, Singapore public company and I was head of the US operation and the chief financial officer of the entire company. But we had operations in China, Japan and all over Europe at the same time I joined the Dexcom board. My dear friend and associate from minimed, Terry Gregg, was the CEO here. And as we wrapped our other company down, as it became obvious we weren't going to be a U.S. presence, the opportunity came to move to San Diego and go to work at Dexcom. So I went home after our board meeting in December of 2010 and told my wife, I think we're leaving our dream house here in north la. We're going to go have another adventure. And we moved down here in June of 2011 and it's been just a tremendous ride ever since.

Now, between the time you spent at Medtronic where you were a finance guy, but obviously, as the listener's going to learn soon, you have pretty good technical chops on this stuff. But you were working on CGM then and you probably just by osmosis absorbed a lot of it. But between what sounds like the mid to late 90s and then your return here via Dexcom, were you still in a CGM space?

Nope. My position right after Medtronic was with a specialty laboratory that ran esoteric lab tests and did that for a little while. And my company right before here, the Singapore based company, was a drug eluting stent business. And we had a proprietary drug formulation and a proprietary polymer that was bioabsorbable. So when the drug eluting stent was expanded into the vessel, both the drug and the polymer would absorb for better safety rates. But getting a stent approved in the United States was too big of a deal for a company as small as ours.

We didn't realize, well, especially when Abbott, Medtronic, JJ and Boston Scientific, the four of them own the entire market.

The law of four medical device companies. You see technologies, you start with a couple, they swell up to 10 or 11, and then you go back down to three or four.

So this is amazing. I didn't even know this about you. So once we're done with this podcast, when we go grab coffee, we'll talk about my previous life where I had to know everything about drug eluding stents. I spent two months interviewing 150, 50 interventional cardiologists around the country when I was at McKinsey, trying to learn everything about this for our client, which was obvious, I can't say who, but it was one of those four. And it was at the reintroduction because, remember, there was a period of time when they had to go back to bare metal.

Oh, yeah.

And then they had to reintroduce. So fascinating topic. So basically you came back to this company and what I assume you were bringing that was of most value was you understood medical devices, you understand durable medical goods, you understood the law of healthcare. It wasn't that you were the world's expert on cgm.

No, I'd been on the board and I really will never be the world's CGM technical expert. These guys here are spectacular. But what I did bring, or at least I believe is very much that curious factor I talked about and a very open and aggressive mind to grow our business. This company has gone through tremendous change. I came in for a couple reasons. A Terry is exactly 10 years older than me and I was supposed to succeed him at Medtronic. And that one didn't work out the way we wanted to. And when I joined the board, that was something we talked about early on. And I knew all these guys, I knew the technology very well, I knew how bright they were, and I just thought it would be a tremendous opportunity.

Let's take another step back just for folks to give him a basic, because there's so many questions I get asked about this. In fact, I went out to Twitter a week ago and said I was going to be sitting down with you and hey folks, if you have questions, shoot them over. And I was really amazed at how many people ask questions. And there are a lot of questions that I could answer truthfully, but there are some that I can't. So I'm going to try to assimilate the question. So I think the first question that I get asked a lot is how does this actually work? In other words, why is it that even if you don't look at cgm, if you just talk about point of care, glucose, why is it that with one prick of blood you can measure something like glucose, but you can't measure a number of other things? What is it about measuring glucose that enables that?

Well, our technology is designed to measure glucose only. And the way our sensor works is there is a small wire that's thinner, literally than a human hair, or as thin as a human hair that's inserted subcutaneously into your tissue. That wire is very special metal alloys and it's coated with a number of membranes that wire and those membranes then generate an electrochemical signal that goes up into a transmitter that sits on top of the sensor. You've worn it, you know what it looks like. And inside that transmitter is an algorithm that converts that electrochemical signal to a glucose value. So that is the only thing that we have done with this technology. There probably are other analytes we could take and develop enzymatic layers that would sense that type of chemistry. In fact, you and I have talked about some of the things that might be meaningful and useful over time, but we've grown so quickly, we just, we haven't addressed those.

But I think the key is it's an enzymatic reaction. And I think that's the point I try to make to folks, is if there's an antibody that can be linked to it, if there's an enzymatic reaction that can be done without multiple washes, that's the kind of stuff you can measure in point of care. Whereas many things that are complex, you can't, you can't measure the number of lipoproteins or something like that because that requires nmr. It's a very separate test. You can't even measure insulin. You're either going to do it through a radio immune assay or you're going to do it through multiple washes. Something called an ELISA based assay where you have to rinse and repeat and stuff like that. So out of the gate there are some things that can be measured in a drop of blood, which again is different from what you guys are doing. And glucose is one of them. Electrolytes, lactate, beta hydroxybutyrate, which you and I have talked about a lot. So I mean, I guess let's go back and so how deep is that little filament that sits inside the patient?

It goes in at an angle. Now it sits in probably a half inch under the skin. The insertion technology of the sensor, it goes in with a needle and the needle comes out. There is so many engineering hours into the insertion of that sensor. And one of the first things you Notice about the Gen 6 product, it's an automated insertion. The needle is in your skin, as the engineers tell me, less time than it takes a hummingbird to flap its wings a couple of times. So it's in and out very quickly. So a patient doesn't feel it and then the sensor rests in the subcutaneous tissue and you really don't feel that sensor at all.

I think I've commented to you probably the very first time I tried this, which was on the prototype, that with the G5, of course, you are the one as the patient who is responsible for the velocity with which that needle goes in. And if you're a human being, which we all are, I think we're just hardwired to do it a little slower than we'd like because it's a little uncomfortable. Look, it wasn't the most uncomfortable thing in the world, but if you're doing it, it's scary. Yeah, yeah.

It is not an appealing thing. You look at that our old device, which was very functional, but you look at it and it truly looks like, I don't know if I want it. And we've had patients send emails saying, I've stared at this thing for six weeks and I don't dare put it in my body. We're not having that reaction with the new one.

Yeah. And I had that reaction with a number of my patients because, as you know, a lot of the patients in my practice, though, they don't have type 1 or type 2 diabetes like me, they understand the value of even people with, quote unquote, normal glucose levels being able to track this. But occasionally folks would freak out and they'd say, we'd go through all the process of getting them a three month supply and they've already paid for it because of course their insurance isn't going to cover it. They don't have diabetes. But then that needle just sort of scares them away. Of course, the other thing that we speculate, or maybe it's not a speculation, maybe it's just a given, is the lack of trauma that's involved with the G6 insertion seems to make for a much more accurate device, which the G5 itself was remarkably accurate. But I don't know if it's anecdotal, but in my hands at least the way I track it, the G6 seems to be so accurate, it's almost hard to believe.

There's so many elements that go into the performance of a sensor. I believe the insertion process does make it more accurate. But that G6 sensor has new membrane technology versus the old one. There's also a new algorithm. In fact, one of the things that has made our company successful during this G6 project, in the middle of it, our algorithm engineers came and they said, we have a better way to do this, but it's Going to delay the project if we do it. We looked around the room and said, but if it's going to be that much better, let's delay it and put it in. And so we did and we made that decision. That algorithm has helped tremendously with the accuracy. So all those things together, the easier insertion, the new membrane technology, the new algorithm, I think even the fact that it's flatter on the body and doesn't pull as much is helpful as well.

I think on three occasions over two plus years, my kids kicked out my G5, including once on the very first day I put it in, which really bummed me out when I picked up my son and he obviously just not playing around, he horse and he kicked me and the thing came out. Whereas the G6. Yeah, it's a lower form factor and obviously this is only going to continue as the evolution of these things goes. So you talked about a couple of other things that could be measured besides glucose. Are there any that you think are commercially viable? There's lots that could be interesting, but do you think there's anything else that's commercially viable?

We don't know yet, but we have so many markets to take our technology to now that we need to capitalize on this opportunity and take care of the people that we serve and open the other markets where glucose can just be a wonderful tool that we really haven't done that much of yet.

So approximately how many patients in the United states have type 1 diabetes or what percentage of the population? How do you think about it?

About a million. And anything you read in the literature says anywhere from 1.3 to 2 million in the United States, common number is 1.5. And there are another 1.5 million people with type 2 diabetes who intensively use insulin. So they are really in need of a continuous glucose sensor to manage their health.

Now, going back to those, those folks with type 1 diabetes, what percentage of them use one of the commercially available continuous glucose monitors?

Most would estimate somewhere between 20 and 30% right now. And again, these percentages have grown rapidly over the past couple years as we've gotten better and as other products have come to the market.

So you and your competitors, and I guess your main competitor is Abbott, Abbott and Medtronic.

And Medtronic, yes.

The three of you collectively aren't even remotely close to saturating the most obvious market for this product, which is type 1 diabetes.

That's right.

Again, hard to speak speculatively about what others think, but I assume everybody's also looking at that second group you just mentioned, which is another market, which is the insulin using patients with type 2 diabetes.

Yeah. In fact, when Medicare and CMS gave us approval In January of 2017, they approved the use of CGM for intensive insulin using type 2 patients. And that was a step that we really needed. One of the barriers and it's not really a barrier, but it's very interesting as you grow a business. And one of the fascinating things about our journey here, it makes such common sense. Everybody thinks, well, everybody should just have this. And the insurance companies were very well insured and very well covered, but it's not always easy to get. I was in a state not too long ago, for example, where a patient had to document a certain number of events where their blood Sugars went below 50 before they could get a Dexcom. Even if they have type 1 diabetes.

Which is very dangerous for type 1.

Diabetic, very dangerous for anybody. And yet because of fear for spending money on devices and treatments that aren't useful, payers are hesitant sometimes not all of them. We get very, very good coverage, but it is cyclical. A payer will cover us very well for a two year period and they'll look and man, we've added so many people to this technology. What are we doing? Let's slow it down so they'll slow it down through criteria. We have a full on sales team that does nothing but call on those who reimburse for the product and we try and make it as easy as we can. There are trade offs for price and access and we try and negotiate those things on a regular basis. I believe over time at least 80% of the people with type 1, and I've said this in public forums, 80% of the type 1 intensive population should be using continuous glucose monitoring.

Has there been an economic analysis done? Ideally independently, but it might be done obviously by one of the companies or more that does the equivalent of what we would think of as an NNT for a drug trial. So for the listener, an NNT is a number needed to treat. This is an analysis that's not done economically. This is more of a life saving. So how many patients do you need to treat with a certain drug to save a life? But you can also start to do these things economically. And is there a question of how many patients need to be on a CGM or before you either save a life through a hypoglycemic event or maybe a different analysis would be the cost of the CGM versus the cost of the complications from mismanagement. So has Any of that been done?

We have done some economic models and studies in that area. What we find is the major cost that CGM prevents is exactly what you talked about. In the acute setting they prevent hospitalizations. So you end up with a specific set of patients who are are often called hypoglycemia unaware who aren't aware when their blood sugars go low. The CGM gives them alerts and alarms and our system also alerts and alarms others who give care to those patients to whereby they can be taken care of. That share feature is really one of the most remarkable things we've done here. You could be in Singapore and your wife could be here. If you had type 1 diabetes and your blood sugars went low, your wife would know and she could call the hotel and wake you up. And we hear stories like that all the time.

Does Medtronic's product or does Abbott's product do that?

I believe Medtronic's new product does. I believe they do have some sharing capabilities but I know we pioneered it, we're the ones who got it through the FDA and it took a lot of effort. So that sharing capability is really good for hypoglycemia unaware that category one hospitalization. I've seen numbers ranging from 10 to $30,000 for that one hospitalization. But not everybody's hospitalized. We certainly save on the long term complications of diabetes and that has been measured historically. And you and I have talked about this with a 1C which neither of us believe is the perfect measure. But in our studies we see at least a half a point drop over the course of a 12 month period compared to multiple finger sticks. A full point drop for the patients if you just look at them independently on continuous glucose monitoring use for a six month period that is sustained. That drop in A1C leads to reduced costs in the healthcare system. And there are very well known economic models to build that out. But here's where the rubber meets the road. A 25 year old probably isn't generating all those complications yet and a 25 year old is with an insurance plan for two years before they move to their next job and they're on another insurance plan for two years. So we have to do a better job as a company documenting these economic benefits. We run more studies to see how, you know, how much quality of lives improved. To see what we can prevent. We are currently building outcome type based models to whereby we can look, we can go into an insurance company or a payer and say look, here's what we Think we can save you if we can put everybody on cgm. But we're creating a new industry here. It's a completely new business. So every day is a challenge like that and every day there's more thoughts and more things to address along those lines. The Medicare one is the most interesting. I spoke at a conference on a January Wednesday where I told a group of our investors we would not have Medicare approval for 18 months and we got it Thursday.

That makes you look not terribly well informed.

That is correct. And. And the way it was approved, our device talks to a phone or a dedicated Dexcom receiver. The way it was approved for the Medicare patients is they couldn't use the phone app yet. Our Medicare patients are the ones most likely, other than children, to need to share the data with somebody else. It took us, I want to say, 18 months. We finally got the phone use approved for the Medicare patients. When you're creating an industry like that, there are all sorts of hurdles that you run into that you don't contemplate. You just kind of have to react.

I mean, I think that's one of the challenges that folks face in this industry in general, which is the policy piece of it is hard because you don't exactly know from a long term planning standpoint exactly what changes are going to come about. The challenge that you raised, I think is. I'm glad you brought it up because I think it's one of the most misunderstood issues in the US healthcare system. I grew up in Canada and I'm actually not incredibly that impressed with the Canadian healthcare system. I know that's going to make me a lot of enemies out there, but I don't think it's like a panacea. I don't think necessarily Canada's doing it right either. But there's one thing that I think a single payer system, at least one thing a single payer system brings over a system that we have in the United States, which is the incentive is aligned between the payer, the patient, the provider. Over a long term, it's easier to align incentives because one way or the other that payer is going to pay. It's pay now or pay later.

Yeah, that's right.

Which by the way, we were talking about children before we went on the mic and you know, you had great piece of advice which I'm going to ask of you to share with others. But my brother's advice, which is, my brother has five kids. His piece of advice is pay now or pay later.

Pay.

Pay now or pay later. You know, you can either discipline your kid when they're five or you're going to discipline them when they're older, you know, but this thing with healthcare is if you have that 25 year old and the difference between them having a hemoglobin A1C of 8% versus 6% in the next year, it's nothing, it doesn't matter. But in 20 years it matters beyond words.

That's right.

And if you as the payer are on the hook for that one way or the other, the economic model becomes so much more straightforward. Because you don't have the portability of healthcare.

That's right.

Again, I'm not close enough to this to know if a single payer system is even something that's viable in the us. It strikes me as politically very unviable. But you know, who knows? That said, it's not what you're dealing with now. So you've gotta be able. You have a harder challenge to make the case economically, I suppose.

No, we do. But again we're covered by 99, literally 99% of all reimbursement authorities. Where our coverage is a little spotty still is in the Medicaid programs. We've got several states, but it's still, there's a lot of documentation required. We're covered. Where it gets difficult is the documentation the patients have to provide or the physicians have to provide and consistency of co pays and things of that nature were also classified as durable medical equipment. So our patients have a copay and a deductible which leads to a very seasonal business for us because in the fourth quarter most of our patients are maxed out on their deductible and co pays and they want to buy everything they possibly can.

It's like Christmas.

It's like Christmas. So from October to the end of December, here it is, all hands on deck.

That's interesting. What percentage of your patients? I'm guessing it's very small. But do what me and my patients do, which is it's a cash pay business. There's no dealing with insurance. It's directly the physician writes the prescription and the patient comes straight to dexcom.

Not very many. Again, like you do. We have cash pay patients and everybody in your system uses prescription. It is important for the regulatory folks that I point that out. Not as many as we used to. We used to have a lot of Medicare patients who paid cash.

I see.

But once Medicare covered, we actually had to refuse the Medicare cash patients because if we took cash Medicare, while Medicare covered a device we were in trouble. And it took them seven or eight months to figure out how we could ship and process this new product code. So we had upset patients for, I don't know, somewhere between six and eight months before we could start serving them properly.

The people who don't live in the United States that are listening to this are scratching their heads thinking, what is going on over there? We have a really complicated healthcare system.

Yeah, we do.

But look, there are some things that I think it does well. And I think one of the things it does well is it seems to set up an economic engine that allows for an innovation that I think is hard to do outside of the United States.

Oh, I'd agree with that.

And I don't think it's a small accident that the disproportionate share of the innovations come out of the U.S. so, you know, kind of going back to some of the technical stuff, you have a partnership, you have a collaboration with Verily, we do. So tell people what is verily. How does it have. What does it have to do with Google, and how did that collaboration come about and how does it work?

Well, the way it came about was interesting. Back in 2015, there was a healthcare group within the walls of Google before Alphabet came around. And they analyzed technologies where they felt they could develop technology that would make an impact on future products. And they also analyzed disease states where they felt they could use Google's or Google Healthcare's analytic capabilities to develop better care models. Google has made a couple of attempts at healthcare, and they came down and met with us and said, look, we've looked at your product, we've looked at what you do. We have a lot of electronics expertise, we have expertise in data analytics and a bunch of other areas, areas we would like to partner with you. They also told us they were going to talk to other glucose sensor companies as well. We looked at that and said, you know what, this Google is a big company and they do a lot of things. And we looked at their concepts and their thoughts and they looked at the problems different than we do. They looked more at miniaturization and size and convenience and the things that consumers look at. Because we, as a company, again, serving our. Our population of people with type 1 diabetes, and anybody would tell you this, our core principle has been performance and accuracy. We have performance and accuracy. We always want to build the best. We were the first to be connected. But as far as really getting the thing tiny or something that somebody without diabetes could wear, that had not been a focus here. That they could wear for fitness. So when they came down and presented this to us, we decided that as an electronics and design partner that we would like to work with them. So after several months of negotiations, we. Not several months, a couple of months, we signed up a deal and we're co developing future products for Dexcom. Those products will be Dexcom sensors. Those membranes and those algorithms that we've developed to make our sensor accurate and perform very well will come from our core technology that we've always developed. The electronic side and some of the communication and the Bluetooth and those other things have been driven by the verily engineers. That's where they have great areas of expertise. The overall package and mechanical part of the system we've done together. We've talked about this, Peter. We focus on performance, patient convenience and usability. And then taking cost out of it. We kept all three of those in mind as we did that.

Yeah, it seems to me, and I like your framework. Right. So let me see if I remember what you said. It's going to be performance.

Performance first.

How accurate is this thing? End of the day, that's the single most important thing. If it doesn't perform, who cares what else it does, Right. Then the patient experience, how big is it? How easy is it to use? How often do you have to change it? Do you have to separate the sensor from the transmitter? You know, all those.

What does the software look like?

Yeah, yeah. And then cost.

And then cost.

It seems to me, having been fiddling around with this thing for a while, that the, the step between G5 and G6, you're now on the asymptotic part of the performance curve. There's not a lot of performance gain at this point, is there?

There is some performance to gain. Boy, we spend a lot of time studying this and talking about this. As far as just bringing the overall accuracy percentage down, there's not a whole lot to gain. Where there is to gain on the performance side is bringing that curve of performance. You have a bell curve of performance for every sensor pushing that bell curve in to whereby every experience is the same. Most of them are the same now and we believe it's very consistent.

But.

But that consistency and reliability enables us to do two things. Number one enables us to do very sophisticated things with people who want to control their insulin dosage with our sensor via whether through an artificial pancreas system or on their own using our data. But the other thing it enables to do, if that performs the same all the time, it will enable us to go out to broader markets because people won't question or challenge the data. They will see it and go, okay, this is right. This one works. We call it internally eliminating the outliers. And I know every company does this with what they build. So performance wise, that's where we're headed there. And those are the things that we look at in our meetings all the time.

I don't even know if I told you the story. It's kind of funny. About a year and a half ago, a mutual friend. So a friend that I introduced to you, but I won't call him out. I'll keep his identity private. He introduced me to Andy Conrad at Verily, but it was through some completely unrelated. There was a different reason for us to meet. So I'm up there and I didn't. At the time, I just. I either didn't know that you guys had worked with Verily, or I just hadn't put two and two together. So I'm sitting in his office and I see these mockups of things that look like next gen CGMs. And I said, andy, what are those? And he goes, oh, yeah, we work with this company called Dexcom. And of course, I lifted up my shirt and showed him my. It was. At the time, it was a G5. And. Oh, my God. I mean, it was. I felt like Dorothy. This was like Oz. I couldn't believe what the future could hold. So going back then, from a technical standpoint, because you alluded to what the future could hold, right now you are measuring glucose in subcutaneous fluid, correct?

Yes, that's correct.

Not in blood.

Not in blood.

People need to understand that. So even a relatively lean individual has enough subcutaneous tissue that the risk of using this thing. Is it an issue in kids? Because I've seen some really tiny little kids with type 1 diabetes.

Sometimes it is. And parents learn how to make sure they insert it and the. The needle doesn't go into the muscle tissue. There will be an occasional instance where a sensor may go too far in the tissue. And. But by and large, no, it's very successful. There's a meeting in Florida every year, a group called Children with Diabetes. And look at all the kids who wear this. It's not an issue for children. They do extremely well with it.

You know, and I think. I don't know if I'd ever told you this story, but I was at a swim meet. It was my daughter's swim meet. I had just finished my swim workout at the same pool. So I'm in my Bathing suit. Finishing my workout as the kids are about to start the meet. And this kid comes over to me and his eyes light up like saucers because he sees that I have a sensor on and he's got a sensor on and he is tiny. He is the littlest kid I've ever seen. And he was like, do you have type 1 diabetes? And I said, no, why? And he looked. I didn't even realize what he was looking at. And he said, because you're wearing the same thing I'm wearing. And I said, oh, hey, little buddy, let me tell you, I volunteer to wear this thing. That's how cool it is to wear.

Oh, that's great.

Yeah, he loved it. He loved that there was some adult who was wearing this who didn't quote, unquote, have to wear it. But I was like, yeah, we're the coolest guys here, I assure you.

One of the most humbling things about this job is when I go out to a diabetes function and meet the children or the adult patients, whoever, who has had this device save their life or change their life the way that it has, they want their picture taken with me. I said, how about we just take care. No, we want you. Nobody needs their picture with me. No, they want to take a picture. They are so gracious, they are so. They are so indebted to our company. And it is really why we come to work every day, what keeps us going. We had my favorite meeting ever. An 11 year old young man comes in, we sit down and people come to San Diego on vacation and they come to Dexcom.

So we got Legoland, SeaWorld, Dexcom.

And parents will bring their kids in and if, whichever, the executive team is here, we'll take them on a tour of the factory and then we'll sit in the conference room with them because that is the best market research in the world to sit and talk to somebody who uses this each and every day. This 11 year old young man said, I have some questions. I said, okay.

Tougher than any analyst.

He pulls like a legal pad out of his notebook, out of his backpack and he has 40 questions. He wanted to know the chemical composition of the membrane. 11. We just looked at him and go, no, we're not going to tell you all those things. But he had thoughtfully written out all these questions and then had several suggestions for us. It's just amazing. And your story, it happens all the time.

Yeah, it's really special. And I do have a friend with type 1 diabetes and she did say something to me that I've thought a lot about since she said, peter, you have the luxury of if you don't want to wear that sensor for a couple of weeks, you don't have to wear that sensor. She goes, I don't have that luxury. Again, she wasn't saying that to be critical of how much I loved using it. She was just saying, understand that my relationship with this CGM is different from yours. This is my lifeline for you. This is just a gain in your health, but it's not necessary for you to function. And I was sort of humbled by that a little bit. And I realized, you know, I can understand why someone who's got type 1 diabetes has sort of a different relationship with this on both extremes.

On both extremes, it is love, a lot of time. It's sometimes hate.

And the hate, I think, is the I have to do this. I have to have this thing on me. I had two close friends in residency who had type 1 diabetes. And this was back in the Wild West. I mean, it was. I couldn't believe how archaic it was and how hard it was for them to manage their diabetes. Because in a surgical residency, it's very difficult to predict when you're going to eat.

Oh, yeah.

And therefore, it's very difficult to predict when you're going to use insulin and which insulin you're going to use. And I remember one of my friends who's now a cardiac surgeon in Minnesota, there would be times when he always had to have a thing of orange juice and candies and in the or next to his pager, and he would hopefully get to the point where he could say to a nurse while he's operating, hey, I need some orange juice quickly. And she would bring over the orange juice and tuck the straw behind the mask and let him sip some orange juice or stick a candy in his mouth or something like that, if he was. This was an operation that was supposed to be done in three hours, and now it's five hours. That kind of thing. We take for granted in many ways what this disease meant before banting.

Oh, I don't know how people did it. Well, they did it, they managed, and people have lived long, healthy lives. But this tool is so much better than what we had before and the things that can come in the future. We made an acquisition a couple weeks ago. The next thing on the Horizon for type 1 diabetes. Let me take a step back. Is to develop algorithms to go with the sensor. Because right now, we tell your glucose value, we tell you your trend, we tell you how fast you're going up or going down. We will give you alerts and alarms based on what's going on, but we don't tell you what to do. And algorithms have been developed for automated insulin delivery that will automatically do things for you. One product that we're partnered with is Tandem's new insulin pump. And it shuts off when your glucose goes too low and then turns back on based on insulin sensor signals. And the early read on that product from consumers has been wonderful from patients, but these algorithms are getting more and more sophisticated.

Explain for the listener where that product sits, how does it actually work?

So there's an insulin pump that is on your body. It's about the size of a good old fashioned pager that you used to carry around in your hand. And there's an insulin cartridge inside that pump contains software that regulates the delivery of insulin through that insulin cartridge to a small infusion set that is usually placed on your abdomen. A little Teflon cannula that goes under your skin, and the sensor resides another place on your body. And the sensor signal is read by that pump, which then takes all the information about insulin that it knows, how much has been delivered, your glucose value, and will determine, at least for this system, if your blood sugars go too low, it turns off insulin delivery for some period of time, then turns it back on when it sees the trend that you're coming back up. Algorithms over time will do more than that. They can regulate your insulin delivery all throughout the day, whether you're high or you're low, and detect things like meals. I mean, this is very futuristic, but there are algorithms that will detect, okay, it's very apparent that Kevin just ate. Let's put some insulin in here and see how it goes. Their algorithms, again, to take care of you more during the nighttime, because during the nighttime, while you sleep, you're not eating and you're not exercising. So there's not as many variables involved. So we acquired one of these algorithms two or three weeks ago, just because it's an asset we felt we needed to have and develop. Not everybody uses an insulin pump. Not everyone will have access to that technology. It's not inexpensive either. We think a lot of people will. But we also think we can take these algorithms and apply them to people who use multiple daily injections as well to develop decision support. You know, I always tell the engineers, I want the staples button, I want the easy button. I want to take a shot, and I want to hit something and say, how much insulin do I take? Or I want, at 10 o', clock, I want to hit a button that says I'm about to go to bed. What do you predict is going to happen? Those types of things are an engineer's dream, which is again, why it's so fun to work here. We have chemical engineers, software engineers, electrical engineers, mechanical engineers, packaging. Any engineer you could think of. Well, the algorithm guys, and along with the wonderful asset we acquired, are going to look at developing those type of decision support tools to help make this easier for patients to make good decisions. Now the question becomes, how much benefit does that add to their care? If they only go from 8A 1C to 7.8 is probably not worth it and nobody's going to pay for that. But we think we can build a very strong outcome case over time.

But even if you went from 8 to 8, but reduced bad outcomes like hypos.

Yeah. And reduced hypos. Yeah. That oftentimes happens. Your A1C may stay the same, but your time hypoglycemic may go away.

That's the thing. I was impressed with Jake's data way back, even before you and I met, which was they dropped hemoglobin A1C. I want to say like 2% on average. But they reduced the hypos too.

Oh, yeah.

And that's the part that, like I remember in medical school, the standard teaching was, you don't care about the hypers are fine, yes, you can go to hyper, but the thing that you have to ward against is the hypo, and you'll accept a higher A1C to do it. And I think the tide is changing. I think people are understanding that because of how long a person is going to live with type 1 diabetes, the microvascular complications are real. And as you probably know, there are data that actually suggest, I saw this through Jake's work, that better glycemic control in kids when they're young. These are not randomized, so there's an obvious confounder here, but it can predict better intellectual performance in school and stuff like that. Now, again, the obvious confounder there is maybe the kids that have better glycemic control have better glycemic control because of some other variable that's impacting their performance later on socioeconomic status or the education of parents or the attention of parents. So there's lots of other things there. I don't follow this literature closely, so it's possible that there's actually been a randomization that would allow for determining that. But the other thing we talk a lot about average blood glucose and instantaneous blood glucose. But another variable that I find very informative is the standard deviation. So every day I look at my report, I always do the seven day report. I want to see a seven day report every day. And that's showing me my average blood glucose for the last seven days and my standard deviation. And then every month or so I want to see my 90 day trailing report. And you brought up hemoglobin A1C earlier. I'm one of those people for whom hemoglobin A1C is categorically useless because I have beta thalassemia minor. So my red blood cells are very small. They stick around for very long periods of time. My hemoglobin A1C on a blood test generally varies between 5.6 and 6.0. Basically, I'm pre diabetic on a. Yeah, on that test. On that test. But using CGM for the last few years and calibrating it, because even the G6, I still calibrate every day just to.

We left that option in, by the.

Way, that is a very elegant option. That's basically when I took my Libre and threw it out the door because I used to use the two in parallel. And I just gave up on the Libre because you couldn't force the calibration and it was so inaccurate and you couldn't get real time. I mean, there was just too many problems with it to even discuss here. But using these forced calibrations, I realized this thing's plus or minus 3% day in. And there are many days, Kevin, when it is the exact same number. And I think to myself, this can't be happening. The meter says I'm 88. And I poke my finger and it says I'm 88.

And I'm like, how we call that the Unicorn.

But I get a lot of Unicorns. Today before I came here, I did a calibration and I don't know, the device said 89 and I was 88 or something. I mean, it was staggering.

It's an interesting dynamic because you are very focused on accuracy. I would say the biggest benefit of G6 to our users has been the accuracy without the calibrations. We had somebody in yesterday who's been on our product for a very long time, one of our Dexcom warriors. And I asked him how was it going? And he held his hands out to me and he goes, my fingers have not felt like this, this for 15 years. And that's how long I've had diabetes.

Well, That's. That's another interesting point you bring up, which is when I do my fasts, I'm calibrating twice a day. I'm checking ketones two or three times a day. Just 14 days of that kind of checking. My fingers are all blue.

Oh, yeah.

And they hurt like crazy. And that's another realization for me, which is, think of all those kids that. That is their life.

That's right.

It sounds like how big a deal is that? It's really painful. In fact, you start to lose sensation.

One day, I was upset about some clinical results I saw because we were calibrating the sensor with a meter, and it became apparent that the meter was off. So I got in my car, I drove to the drugstore, I bought three meters, and I stuck my finger 60 times in a day, 20 times with each of the three meters. And I made my own little spreadsheet, recorded all the meters, recorded the CGM reading to see what had happened. Because in the old days, when you had to calibrate this device twice a day, a bad finger stick would set it off for a while. Now, we have since revised the algorithm to identify a finger stick that we just think is inaccurate, and we'll wait a while and ask for another one if somebody enters them. But it was very discouraging because we'd submitted a clinical trial to the FDA based on a meter from a large company that we were told was fabulous. And it turned out to be high all the time. And that drives our accuracy level off.

Do you have a point of view about which of the commercially available drugstore meters do you find the most accurate?

I wouldn't offer that. I have idea. I think most of them are okay. I would tell you my experience, the meters is also about the consistency. So oftentimes when I'm wearing our sensor and go to check the accuracy, now, I don't enter the calibrations like you. I like to see what the patient is experiencing. But I'll stick my finger twice in a row and get like, some meters I'll get a big difference. Others, I don't get very much.

And do you do two sticks or same blood?

I vary it.

Okay. So here's a little tip that I've learned. And maybe you've already heard this from patients, but by washing your hands before you do it, then using the alcohol, you can get some false elevations if you have any food on your hands. So if you have just a little, you know, again, like a crumb on your hand can actually raise the glucose. So And I remember my friend in residency again, I'm glad I'm not identifying as. I don't call him out. I mean he wouldn't even wash his hands before he'd be poking his finger because he was just like, you know.

On the go all the time.

Yeah, on the go. It's like I don't have alcohol pads. I'm just going to poke my finger and you know. But you know, those little things do I think add up to a little bit of benefit. For what it's worth, I guess I can say what I like the most. For glucose. I like the One Touch Ultra. Okay, I've switched to that. I used to use an Abbott meter or a different meter by, I think it was by Abbott. And I don't know, I found the One Touch Ultra to be pretty darn good. And I've done the same sort of experience, the thing you've done where I've gone, multiple sticks, multiple fingers, blah blah, blah, blah, blah. Going back to finish the A1C thing, my 90 day trailing average glucose under these very tight conditions shows an imputed A1C of 4.5 to 5.1 depending on how tight my nutrition is. So in other words, my hemoglobin A1C is a full percent higher.

Oh yeah.

And that's actually posed real difficulties for me when applying for life insurance because they say you're a pre diabetic and I say I'm not a pre diabetic. No. And they say, yeah, but your hemoglobin A1C is, you know, 5.8 or whatever it is. And I've had many interesting discussions with the actuaries as I explain the limitations of hemoglobin A1C. But if I could be health czar for a day and wave a magic wand, I would love to have something that meets all of your criteria. So it does the performance, it's got the patient, it costs very little. But I really think that if everybody had a CGM on every minute of every day in some completely fantasy based way where it doesn't hurt, it doesn't cost anything, but they had that data, it just drives such a behavioral change. And I think that that's why the use of cgm, even without a deliberate intervention, superimposed, improves outcomes because it is really hard to not pay attention to how activities in your life, mostly food, but not just food stress. It's amazing what stress can do to your glucose level. I think one of the first insights I remember coming and talking to your team about a couple of years ago was how high nighttime cortisol levels were raising my glucose levels at night. You know, I'd go to bed with a glucose of 93 hours after eating dinner, and I'd wake up with a glucose of 105. And, you know, once I started measuring nighttime cortisol levels by collecting urine overnight, I could sort of correlate this amount of cortisol produced at night to how much that glucose level would rise in the morning. And today, I'll tell patients that, you know, fasting glucose is not nearly as helpful as people think it is inside of a reasonably physiologic range. So someone who has a fasting glucose of 130, that's a different situation. There's something going on there. But I have patients that get very upset if their fasting glucose is 100 instead of being 90. And I say, you know, it's very difficult to understand what's going on there. That can very easily be explained by cortisol or hepatic glucose output for some other reason. That's not a function of insulin resistance. So that's why I just think that these tools are so valuable. And, like, even yesterday, I was on a late flight coming back from. I was in Chicago, and I just hadn't eaten much, and my flight was delayed. That's the other thing. So I went into, like, the little store near the gate, and they don't sell anything but crap.

Absolutely.

Yeah. Yeah. And I've already, like, there are certain snacks that I love, and they're kind of my comfort food when my flights are delayed. Like, I feel like I deserve a treat because I'm stuck in the airport, and I bought one. I bought my treat. My treat is trail mix. I love trail mix.

Trail mix will spike you as fast as anything you can eat.

Yep. So I get on the plane and I buy the big trail mix because I don't do anything in moderation. So it's got, you know, it's full of M&M's and raisins and peanuts and little whatever. And I get on the plane, and I'm looking at the bag, and I'm looking at my glucose, and my glucose level's great. And I just decide I'm not eating it. So I didn't eat it.

Oh, my goodness.

I promise you, if I didn't have that cgm, I would have eaten it. But I just didn't feel like looking at that glucose because I know I've done it in the past. I eat that whole bag of trail mix. My Blood glucose will be 130 easily.

Oh, then that shows what good shape you're in because that'll get me up to 150 or 160. It'll get me higher. The worst glucose experience I've ever had was in an airport and I had been with investors all day long and I had not. My glucose hadn't spiked at all because when I sit in those meetings all day, I don't eat very much. And I'm in the airport and I'm in Boston. I say, you know what? I'm going to try something here. The yogurt covered raisins in the little thing where you turn the wheel like the bubble gum machine. Got myself a cup of yogurt covered raisins. I think there's some chocolate raisins in it too. And ate the whole little cup of them. And I'm telling you, that was my only ever above 200 glucose spike in my life. And it only took 30 minutes. It just right up as fast as possible and it came down very quickly as well.

Yeah, and then it overshoots. It probably came down to 60 and.

Then it overshot and I was, yeah, overshot down in the low 70s because I put so much glucose into my body. That's how my pancreas reacted to. But all of our bodies behave differently. We've talked a lot about type 1 diabetes today, and one of our visions going forward is to get into other conditions. And you're certainly a pioneer in this. And really one of our first. We started doing work in type 2 diabetes. So again, let's paint a picture. We've talked about kids with type 1, adults with type 1 who have to deal with insulin their entire lives or they die. And the device is a love hate relationship because it always reminds them. Now let's look at somebody with type 2 diabetes, they're my age, 60 years old, may have had type 2 diabetes for five years. All they do is they go to the doctor, they get some pills, they get a meter, they go home and nobody tells them what's going on. And they say you need to eat less and exercise more and take your pills. And after 5, 10 years of this, all of a sudden your A1C is at 11 and what do you. So we start adding more drugs and you can turn on the television anytime you want to. And you can See more Type 2 diabetes drug advertisements probably than any other pharmaceutical product because these drugs are expensive and there is a big population here to be addressed. So we start prescribing other compounds, hoping the A1C will come down. And it might come down a little bit, it might not. And if it doesn't come down enough, we prescribe another compound and another compound and another compound. At some point in time, that patient gets the dreaded information they've got to go on insulin. But type 2 diabetes, I'm not as near as scientific as you, but it's almost not diabetes. It's almost a completely different disorder with all the insulin resistance and all the other things that go on in your body.

Yeah, the biggest disservice that I think has been done to this field, this is hyperbolic. I mean, there have been many disservices, but it's the fact that we refer to them both as diabetes. Now, I understand why historically that's the case, but you're absolutely right. Type 1 diabetes and Type 2 diabetes are so different. And I try to be disciplined about always referring to them that way and not just saying diabetes, because it really does a disservice to them. What you point out is very important, Kevin, which is that the real problem in type 2 diabetes is that we have fixated so much on just the glucose and not worrying about how we get there. So when you use a class of drugs that increases endogenous insulin production and. Or when you use more insulin, what you reduce is the glucose, and what you reduce are the microvascular complications. You do not save lives. They're still getting cancer, they're still getting heart disease, they're still getting Alzheimer's disease at a much higher rate. The challenge in type 2 diabetes is the combination of the hyperglycemia with the hyperinsulinemia. So the therapies that save lives in type 2 diabetes would be things like metformin, where you're actually fixing the glucose side of the equation and not just adding more insulin to the system. The SGLT2 inhibitors, these are the things that are getting the glucose out of the system. Which actually brings me to a question, based on something you said earlier. Is there any way it is algorithmically possible to estimate, say, the average insulin that a non diabetic would make over the course of the day based on glucose? If you had some data points. So if I came to you, Kevin, and said, look, let me go and get under test conditions, certain levels of glucose and insulin that are associated, we develop a kinetics model for it, and then by tracking my continuous glucose data over time, could we ever try to estimate what my insulin levels are in between?

We have some studies that are very preliminary, and I really can't talk too much about it, but we do believe that it's possible to measure how quickly insulin reacts and how much by the slope of the glucose curves, but not at our five minute measurement intervals. So we're looking at other ways to record data to develop algorithms to do that. But it's very preliminary right now, I think over time. And this gets back into another thing that dexcom will do over time. We have an open architecture platform as well, so we've developed APIs to whereby we will provide data to other software platforms if they can analyze glucose values better than we can. One drop. There are a number of them. They haven't produced a lot for us commercially, but we've made the decision that this is the type of company we want to be because we just can't do everything. I think over time that might be something that we'll look at, but it also might be something somebody might be able to look at better than us.

Your raisins one, by the way, is so funny because I've had a number of those experiences similar to that one. Where I was shocked was grapes.

Oh, grapes are awful for glucose value.

Yeah, I had not eaten anything in about 18 hours and you had grapes.

But the glucose sensor on.

And I was so pissed off. I was like, I thought the thing was broken. I was like ready to rip it off my body. I was like, there is no way my glucose is this high after. I haven't had a grape since. That was about six months ago. And I was on an airplane about a month ago and they had like a snack tray and it was like some cheese, you know, a strawberry and some grapes. And it had like five grapes. And I was actually really hungry. I ate everything, but I didn't eat the five grapes. Now, I'm sure the five grapes wouldn't have done anything, but I'm boycotting grapes. I am done with that, what I call quasi fruit.

Well, I have not eaten many yogurt covered raisins since that episode in Boston either. So there you go.

But see, that's my point, right? I think CGM has the potential to change the way people eat more than any other technology I have ever laid eyes on. I'm heavily biased. I mean, I've stated my bias many times. I'm a very big proponent of cgm, but I also believe in real time feedback. I think it's very difficult to curb a person's behavior when the feedback loop is so long. And the weight on the scale. The blood test that you get at Your doctor every six months. Those things are valuable, they help. But Nothing trumps the 30 minutes after I eat the chocolate covered raisins A I see what it looks like. And now I can correlate that feeling of I feel like crap an hour later because my glucose has gone from 200 to 60. That's a crappy feeling. That's not physiologically reasonable. And now people see why.

So over time, where this gets very interesting is that core technology platform I talked about where we make products perform well that patients will use and that cost less. Never goes away. But there's a software element to what we do that we can change dramatically given the experience we want a patient to have or that a patient needs. And again, I'll give you the perfect example. Our type 1 patients, the alerts and the alarms at nighttime while they sleep are absolutely critical. But somebody with type 2 diabetes who's taking these compounds, that may not be as critical for them. But what would be critical is an analysis at the end of the day where we compliment somebody on, gee, you kept your glucose within range extremely well. Or insights as we look back. What did you eat for dinner today? Or integrating the CGM data into a food database to whereby you take pictures of what you eat over time. And when you go back, you look at that food and say, wow, I ate those scrambled eggs this morning and my glucose values didn't go up. Maybe scrambled eggs for breakfast is a good thing for me. And then you take a picture of pancakes and the next time you sit down to eat, if you take a picture of those pancakes, you get reminded, you know, you had pancakes a month ago and that may not have been the outcome that you're looking for.

And I think this is the kind of stuff Neutrino is working on. And I agree with you. That stuff is so powerful. I feel like people assume I know a lot about food because of sort of the work I've done and the things I've talked about and written about. But the reality of it is I'm still humbled by how much I don't know. Because it's not just what you eat, but it's the physiologic state you are in when you eat it. It's very different. What happens if you eat a bowl of pasta after you've exercised 30 minutes after a hard workout versus eating it after having not exercised? A very different glycemic response, stress. We've talked about this and it can't be understated how much higher my glucose levels are when my sleep is crappy.

Oh. Or the correlation between high glucose levels and crappy sleep. Because if you go to bed with very high glucose levels after eating a very high carb dinner, I've seen a direct correlation between my sleep and my glucose values. Personally.

Anyway, I can't make this case enough. Now, we talked about. There are a couple other companies out there that are doing this. Is there any publicly available information that compares the performance and fidelity of the Abbott product or the Medtronic product to your current product?

We all have accuracy tables in our user guides, but they're biased towards the way the companies want to project themselves. We have studies that we've published comparing ours to the other products. We maintain our performance all the time.

Yeah, it's not subtle in my hands. I mean I've been pretty vocal about it. It's not a subtle difference and it isn't.

We perform extremely well across all the range of glucose in the low and in the high range. I won't speak as much to the other guys. Our patients know. Our patients know what a Dexcom is versus the others and we can live with that one.

Do you think that you will be able to maintain performance as the sensor gets smaller and smaller? So in other words, is there a day when there's going to be a 1 millimeter sensor so something that really doesn't even get into the interstitium but is still sort of in the dermis itself that can perform this well, or is there just a technical limit to being able to do this without accessing interstitial fluid?

For us today we've only gone down to the interstitial fluid. We have looked at technologies that would go down more shallow. We have within our R and D group an advanced technology group who looks at nothing but things like that. Our second verily product, one of our goals is to have a shorter sensor and to make it smaller, but there are complications of a shorter sensor. What do the membrane layers look like so you can get an extended wear on a 14 day sensor? How's the electrochemical reaction on a 14, you know, on a longer life sensor, if it's shorter versus the one that we have now? So we go through a lot of trial and error as we look at these things to determine what is the best combination of all of these features. I think we'll have a shorter one. Right now we're very comfortable with the.

Interstitial fluid if the pain of insertion is effectively eliminated, which it is once it's in there. You don't. I don't actually know the difference between it being in me versus on the. Yeah, on the skin. And I've played with other sensors out there that there are some that are, you know, as short as 400 microns.

There's some very short ones. And we evaluate those technologies, we look at them. One of the beautiful things of being a public company, having resources, if we saw one that we thought was remarkable, we'd talk to them and see if there's something we can do to further it along. But right now we're comfortable with what we're doing and what we have.

Now. Another question I get asked a lot is why can't this be done optically? Why can't this be done the way a pulse oximeter, where you put it on your finger? So for someone listening to this, who doesn't know what that is, but if you've ever had surgery or anything like that, when you're under anesthesia, there's a little device they usually put on your finger or on your earlobe and using light, it's actually measuring or estimating the saturation of oxygen. And can't we just do that to measure glucose? Are there limitations to this that are just too great?

It has been tried on numerous occasions to do that. Several technologies have tried non invasive sensors. In fact, the first glucose sensor that I saw somebody wear, other than one we developed at Mini Medtronic, was one called the glucowatch, which actually was a watch that sat on your wrist and would take fluid out of your skin through reverse ionophoresis and measure it that way.

Wow.

It would leave a red mark on your, on the outside of your arm. And it was hard. We've seen a lot of non invasive glucose sensors and people call our sensor invasive because there's a needle and a needle that goes in your body and comes out and a sensor that remains. So oftentimes people say we're going to develop something that is non invasive. If it's 2 inches by 3 inches and sits on the outside of your body and you can say, yeah, it was non invasive. Well, how do you find invasive? To me, invasive is, does it invade your lifestyle and does it produce the result that you're looking for? A lot of people have worked on that type of thing. They've worked on just measuring on the skin. There's one company that has one that measures in your tears that you put inside your eye that I've seen.

Are these accurate?

Not accurate enough. And none of them have been to market yet, but only time will tell. People will continue to look, but they're not solving the fundamental problem. I'll go back to those three things we build our product around and I'll add a fourth. If it's accurate, if you solve the accuracy problem, if you make it more convenient and solve the convenient problem, if you lower the cost. And finally, if you can produce a healthcare outcome, you have something that's meaningful. Well, not having the little wire in your skin, while one can try and paint a horse story around that, it's not really that invasive to your body. So anything that comes has to solve one of those problems better than the technologies that are on the market. And if somebody can do that with an infrared sensor, optical sensor, then we've had a wonderful technological step and we'll all figure out where we move from there. We just haven't seen anything yet that's accurate enough, performs well enough.

Yeah, I suspect it's going to depend heavily on how much this stuff matters and meaning how much accuracy matters. Obviously, for me and for my patients, that's the highest priority in what you give up right now is cost. I think of the four metrics you just identified, the place where this is by far the biggest barrier is the economic barrier.

It's the economics. I would agree.

So on that thread, anyone listening to this who says, gosh, I got to have a cgm, they have to go get a prescription from their doctor, and very likely they're going to pay out of pocket for it.

Unless they have diabetes. If they have diabetes, they.

Including type 2.

Depends. A few payers cover type 2. Not many, but a few.

Do you have the liberty of saying which payers? Do you know which payers cover type 2?

Not off the top, because it's going.

To depend by region as well.

It's very regional and most of the type 2 patients are patients who use intensive insulin, such as the cms, Medicare patients. And this gets into our payer negotiations. Sometimes we sit and we discuss. We want to make this easier for everyone to get. We want to cover type 2s, we want to cover type 1s, we want all these things. And they go back to their economic models and say, well, we can't do all those things, but we can give you this, and we can give you this for the type 1s. And it is very much a business negotiation. And then based on your insurance plan, typically our patients pay 20% of the cost. Standard CO pay for durable medical equipment and depending upon the timing of the year, if you buy it the first of the year, and their co Payments and their deductibles have not been met. It's more expensive for them.

And is the cash cost fixed across the country or is that regional?

We have cash prices here that are, that are pretty much national.

You can say what the cash is.

I don't even, I'll be honest with you, I don't even know what they are.

I should know this. My office does all the buying. The sensors come in boxes of threes, right? Three sensors and we typically buy them nine at a time. So that's about a three month supply because it's 10 days per cent. So that's 90 days. You know what I used to do the math on what are you paying per day? I'd amortize the whole thing over a per day cost. Does nine bucks a day sound about right?

That's about right. As to what somebody pays on the.

Outside, yeah, I think that's what we pay. Nine or ten bucks a day.

Between nine and eleven dollars a day. We say on our earnings calls, for example, our average price per sensor is X. We used to be only seven day sensors, so our average price is always between $70 and $75. That we have recognized in our revenue. Our 10 day sensor, we have different models. As we've gotten that reimbursed, that cost per day has to come down.

What do you think? Or have you guys done an internal analysis that says, look, at this point, this is a product where if we have 1% of the population has type 2 diabetes, you've obviously built a very successful company where your customer base is 1% of the US population or less. You've got a type 2 diabetes population that I think would benefit from this as much as the type 1 population would. Even though, as you've pointed out, eloquently different diseases basically. So that takes you to 10% of the population. Then you got the pre diabetic population, another 10. Exactly. But then you've got like sort of half the people are kind of, I hate the term wellness, but these are people that we're trying to optimize health for and they don't have a disease. But it's not just that we're trying to prevent them from getting diabetes, but we're trying to figure out if you can actually, you know, make them live longer through better glycemic control. What do you think or what's your intuition about what does that need to cost per day to make that group say, look out of pocket, I'm going to pay for this because there's no way an insurance company is going to pay for healthy people wearing these things.

We drive those discussions all the time. It's interesting. I had a discussion with a payer once and I said, look, we want this to go to everybody that uses insulin intensively. Tell me what the price is, just tell me what to make it, give me a number. And the response I got was how low would you go? So I don't know what a person would pay out of pocket because all we do is speculate on these kinds of things. Is it $25 for a two week sensor? Is it $50 for a two week sensor? A lot would depend upon the information and the things that you learn from it. There's a whole regulatory process we'll have to go through to get a health and wellness product. For example, our device is a prescription device. Now we've been very clear in our discussions, your patients who use this in its non diabetic state, they have a prescription from you and you pay cash for that.

And we write them a new prescription every three months and they get it.

To make this a non prescription product, there's a lot of steps we'd have to go through at the fda. And one of the things that we look at with respect to our human factors and our software design, if it were non prescription, what would that software experience have to look like?

So let's explain for the listener why that's the case. So right now everything we've talked about, as you said, is still a medical device.

It is a Class 2 medical device.

A physician writes a prescription and I'm only just talking about the cash patients. So this is not about insurance anymore. Physician writes prescription, patient gets it filled and their all in cost is about nine bucks a day to wear this thing. And they are seeing the exact same data using the exact same device with the exact same algorithms that a patient with type 1 diabetes.

And the exact same app. Yeah, the exact same app.

Everything is the same. I am using everything that someone with type 1 diabetes is using. So explain, Kevin, why if tomorrow a little elf jumped out of your desk and said, voila, we can make this thing for a dollar and just say that the dollar was the price. Where like at a dollar a day you could penetrate this new market. The FDA doesn't say, great, go ahead, go start selling it. Like there's a fundamental issue. What is that issue?

We have to go through clinical trials, particularly if we're labeled for use for people with diabetes, to demonstrate the accuracy and consistency of the product across all glucose Ranges. The fda, in all candor, has been very progressive with dexcom. I mean, we're the first company ever to go directly to the phone. We're the first company to share data. We're the first company ever to have a sensor perform at the accuracy levels that we have. Most every first with the FDA in our industry has come through us partnering with them. Most recently, they created a new category for continuous glucose monitoring. And this is in the intensive diabetes world called ICGM versus cgm, where they set accuracy standards, where the products have to demonstrate on a statistical basis they perform, and you have to have a certain number of values in a study in a low range, in the high range, and a certain number of points to statistically prove that that product is capable of doing the things that we want it to do. In our intensive world, that's dosing insulin either through a manual calculation or thinking by a patient. But also with this ICGM category, which stands for interconnected, we can connect to other devices, and they've made an easier path for other devices to connect to our product. So, for example, if you have an insulin pump in an algorithm and would like to run that algorithmic glucose sensor, your regulatory path with dexcom is just to show you get the signal. You don't have to do a study to show that dexcom is accurate. We're done. It's interconnected, and Tandem's recent approval is along those lines. But if you're displaying a glucose value, and that is a real time glucose value, and that is where we've been in our discussions with the FDA, that's a Class 2 medical device, and as of today, that requires a prescription at some point in time. Again, as we look to the future and as you and I have talked, I'd like a device we could sell over the counter, or we could sell through nutrition programs that a patient couldn't use to dose insulin. But what would be the real time feedback you'd give somebody?

So explain why that's necessary. What you just said is the important point, which is if you want to sell this over the counter, the FDA is going to say it cannot be used by someone to dose insulin for today, for today.

And maybe that will change over time, but for now, those are the rules, and those are the rules that we play by.

And that's very important for, I think, people to understand, because that's one of the questions I get asked the most, which is, why can't this thing just be over the counter? Now, I'm willing to pay the full price why do I have to? Because not every patient has a physician who understands the benefit of this. And I know just from what I see on social media, a lot of people go to their doctor and say, hey, you know, doctor, so and so please write me the prescription. And he or she says, what the hell for? Get out of here.

Yeah. What are you talking about?

Yeah. And so now that patient who's actually says, look, I'm willing to make an enormous investment in this because it's my health, and I believe that this is going to matter. Well, they can't do it. So what I'm hearing you say is there's one regulatory path that says, maybe down the road, the FDA says, you know what? This will no longer be something that requires a prescription. If the patient's willing to pay for it, the patient can have it.

I can't speak for them, but they have been so progressive with us so far. What we would literally have to present again is a case as to how somebody would never harm themselves. And remember, there's a needle involved in inserting our product as well. There may be standards and rules around needles, things like that. So I can't speculate how we get there, but I think over time, that's something we would like to take on. But again, it would not be a device used for diabetes treatment. It would be a device used for other things. We'll have to figure out what that looks like. We don't know yet.

And what you were alluding to a moment ago was the other option for making this OTC is not to take the same device and just deal with the FDA changing a rule, but it's to create a device that would fit into the current sort of regulatory environment, which says the device would basically have to be dumbed down. You'd basically have to strip functionality out of the device. Right?

Strip functionality and the user experience. Yeah. Not necessarily accuracy, not performance, but strip down the information that's presented to the individual.

So the ways that that can be done is one, you could make it such that they don't get real time information. Because if you don't have real time information, if you see the perfectly accurate, identical data, a day later doesn't help you dose insulin. Another way is, as you said, you.

Just show ranges, colors, the circles on your Apple watch.

I don't wear one of those things.

But I know you don't. You and I both like to wear our regular watches. I do wear the Apple watch frequently just to see what the user experience is.

Okay, so what do the Circles do.

It's for training. You track how many times you stand up, how many steps you take a day. They have some very simple measures. It's right there. It's pretty easy to see and very easy to use.

This is a totally unrelated question. Does the Apple Watch have a little app or plug in that allows you to put the face of really cool watches on it so that you like. If you really want to have a Patek, you could have like a little Patek Apple watch because I mean that would be easy to do. You just need a picture of the Patek and you could have it like looking like you know, your pick your favorite gmt, you know, or whatever.

See, Peter, we start talking and it gets back to watches and other businesses we'd like to go start and do. I don't, I don't know that that exists, but that would be fun.

Who, why haven't you listened?

Maybe somebody has.

Yeah, someone's got to have developed a plugin that allows you to have any watch you want as your Apple Watch. Apple watches cost what, a few hundred bucks? But you could put the face of a million dollar watch on it if you want.

Well, and what we have found within our company and with our patient base, there's a very high number of Apple Watch users because our device goes from the phone and then the phone there's a watch app also.

I didn't even because I don't use the thing. I've never noticed.

Yeah, there is a watch app and then we are developing a direct to watch transmitter communication protocol. What that would do for a patient. Again, the new Apple watches have cellular capability as well as will some of the Android watches and some of the new Fitbit products. But with that direct sell capability, that watch then can become a patient's receiver and the data could still be shared. You wouldn't have to have it go to your phone. And again, we're thinking about those criteria I talked to you about earlier. As far as convenience. It's a lot easier for some of our people to pull their sleeve up and look at their glucose than to get their phone out during an important meeting or to even take their phone to bed. They could wear their watch to bed.

Well, that's another new thing I like about the G6 a lot. We didn't talk about this with the G5. I had to keep my phone in my room to see all my nighttime data. The G6 seems to store the data so that if I keep my phone in the office, it backloads my file.

There is some backloading if you do lose connectivity. The transmission range of our product, I believe it's labeled for 20ft. And if we've learned one thing about going to the phone, Bluetooth is not an exact science. And I think we've all experienced that where some headphones connect really well, other headphones do not. Sometimes you get your car and it works, sometimes it doesn't. It is very hard to explain, but.

Is that why you went with Bluetooth as opposed to near field communication?

We went with Bluetooth because we didn't want our patients to have to put the phone close to the device. We wanted the continuous feed. I think there is a place for near field and it's quite possible we'd have both chips in a future one. But for now we're very BLE oriented and it works pretty well.

Are there any. And again, I want to be sensitive to what you can and can't talk about publicly. Are there any other partnerships or collaborations that you're able to speak about that are maybe interesting to consumers, especially in this sort of non diabetes, non type 1, non type 2 market for people like me who are thinking about this for quote, unquote wellness?

Well, nothing real concrete. I will tell you that Apple has been a wonderful partner for us in getting the device to the iPhone and getting our apps working on Apple Watch. In fact, at the developer conference one year, we got a VIP invitation. Our head of R and D couldn't go, so I went and Peter and I are dressed differently. I'm total business person and Peter's Peter. And so I show up at the Apple developer conference in my sport coat and my shoes and of course the guys next to me are in shorts and they're way younger than me and they're looking at me like, who's this? Who's this? Nobody dresses like this here. And I'm sitting there feeling pretty uncomfortable and they came out and talked about Apple Watch and lo and behold, Apple's got Dexcom Watch on the screen up there. And I elbowed the kid next to me, I said, do you see that? He said, yeah. I said, I run that company. I thought I was pretty special for the day. Our partnership with Verily includes work with a company that they have called Onduo that is developing treatment for type 2 diabetes and developing apps that combine everything they've learned about diabetes with a lot of Google technology. And they're in pilot phases with various payers. On the type 2 side, we're also doing a lot of work with UnitedHealthcare on type 2 diabetes. And I think in the future with them, we're also going to develop some pre diabetes models as we take this Gen 6 technology out. You know, we talked about going to the consumer, Peter, you wouldn't have taken G5 to a consumer anywhere. It's too hard.

Yeah, I had a hard time getting patients to do G5.

G6 is. It's not all the way there, but it's close. There are things we can do to make it a little bit easier, like pairing the device with the transmitter and some of the other things that have been inherent within our system. But it's close. As we get this thing closer to consumers, I think you'll see us try more things. More and different things. A couple of other applications where we'd love to take our continuous glucose monitoring technology where it's not. I've had numerous physicians ping me on LinkedIn saying, why aren't you in the hospital? Why aren't you in the hospital?

That's a good question. Why aren't you in the ICU of all places? Right.

We tried many years ago. We had a joint venture with Edwards Life Sciences and then the FDA was extremely strict on accuracy and performance. And by the time we built what we built, it just. It didn't work out. Our technology has come so far and we've learned so much through projects like that in the past that we will make a run with G6 in that type of market to help patients. I mean, think about it. You connect the Bluetooth to the nurse's station. I was in one medical center where patients in the ICU are tested every 30 minutes, 48 finger sticks in a 24 hour period.

Not uncommon. Intensive insulin therapy, of course, has had its ups and downs resurgence in the literature, in the critical care literature, but basically there was a paper that came out in 2001 or 2002 in the new England Journal of Medicine that really changed the face of how glucose and insulin levels were managed or glucose levels were managed using intensive insulin therapy in the icu. That has been questioned. Obviously there have been subsequent trials that have suggested that maybe the benefits on the glucose side come at the cost with an insulin side, et cetera. But you're absolutely right. Now that reminds me of something though, which is acetaminophen Tylenol has an effect on the performance at least of the G5, does it not?

G6.

Oh, it doesn't have the G6.

We ran a very, very, very large study and put a lot of acetaminophen into patients to whereby we have no contraindication for acetaminophen anymore.

So that's interesting. But the G5 would over or under.

It would go high, it would overestimate, it would go up a little bit.

Yeah. So one of the challenges, I suspect in the ICU patient is all of the drugs that they're on also they third space like crazy. So their interstitium looks totally different from a normal person's interstitium. It's almost like there's a whole new calibration. Right.

We're going to have to go run some studies. But that being said, I'll go back to what you said your friend told you. You can pay me now or pay me later. If we can get this in the right configuration in the hospital on most every patient, at least every patient over 50 that comes in. Forget whether or not I have diabetes. That hyperglycemia effect on healing, we know is a very difficult thing. If we can get it on everybody and make this affordable and fit within the normal workflow of the hospital, that's a tremendous market for us. Another place we haven't been or been labeled and you're going to be a little bit. You probably chastise me after this. We've never been labeled for gestational diabetes.

We had this discussion once. I didn't realize you weren't actually labeled. But I have a patient whose fiance is pregnant and she had a device in and it turned out she had an old device. So she had the device and then never used it for with one pregnancy, then used it with another and it wasn't working. And we did some troubleshooting and to make a long story short, she said, well, I called Dexcoma but they said it's not approved for gestational use. And I remember saying what would be the difference?

And I'm very proud of my people for saying the right thing. It's just we haven't run a study in gestational diabetes. We'll have to run a study there to get that label. One of my daughters in law contracted gestational diabetes while pregnant with twins. So her OB GYN wrote a script and we procured a Dexcom for her. And he just looked at it and said this is remarkable. We should all be on this. And this gets back to A1C and other measures as we look at evolving this Gen 6 technology. One of the things that we look at is this product is a diagnostic as well. Right now you drink that real sugary drink, go way high, you go Way low. It's kind of awful. What about a blinded sensor on somebody for a week?

Yeah, infinitely better.

And then develop the algorithms to see what we can predict with respect to gestational diabetes. Those are the type of studies that we want to run in the future and the way we'd like to go about that market. And there's others as well. Again, I'll go back to your health and wellness one. Combining this with some of the nutrition apps out there, the weight watchers appreciate combining. If that had glucose data and you ate your points per day and you ate your 32 points today, but your glucose values were still high, maybe we take you down to 26 and vice versa. You can see how that can integrate with it wonderfully and integrate without showing a glucose value that you can dose insulin off of.

I just think in the end it's a much better metric for health. And I think health matters more than weight. You know, weight is. Weight is correlated with health, but the correlation is not exceptional. It's reasonable, but it's so far from great. And my prediction would be when those trials are done, your standard deviation of blood glucose over a three month period is going to tell you infinitely more than whatever the fluctuations were in your weight. And it's frankly going to help you identify probably the type of weight that matters more. Obviously, there's been a big discussion about the difference between subcutaneous fat and visceral fat. You could have two people that weigh exactly the same and you could even have two people that have a similar mass of fat. But where that fat resides probably tells us much more about their metabolic health. So I don't know, like I said, if I could be czar of whatever for a day, I just don't see why I wouldn't want someone to have this information continuously, in real time, every minute of every day under any physiologic circumstance. Because what you learn, and not just someone who's got type 2 diabetes or type 1 diabetes or gestational diabetes, it's going to alter your behavior. It comes back to the airport stories when we're in these environments that are at our worst and you learn other really interesting things. I mean, these things, you get a sense of how much even exercise can transiently raise your blood glucose, but what the benefits are after the fact, which is your ability to dispose of glucose goes up significantly.

Yeah, I get about a 30 point spike in a workout, but for the rest of the day, my average glucose is about 10 points lower.

Yeah, it's so amazing to Think that such a simple biomarker is glucose, Something we take for granted on every chemistry test we do on patients. You know, no one goes to their doctor and doesn't get their glucose measured. But what the utility of that is when you can measure it every five minutes. Kevin, this has been super interesting. I want to be respectful of your time. I know we don't have all day here and you have to get back to work. One of the stories you just told that I love so much that I didn't know was the going to the pharmacy, getting three of these things and poking yourself 60 times. To me, that's like, you know, Dexcom's a pretty big public company. Your market cap's like what, 12 billion.

$12 billion.

Yeah. But yet you're still kind of a startup company because that's a startup CEO move.

It really is. And I've had to learn to be less startup as we've grown. We've all grown with the company. But that culture. And again, one of the things that I manage as CEO here is we've had to bring in skills and supplement our management team from that startup mentality to the midsize company mentality to whereby we have more structure and systems of a large company. So we're trying to mix all of those things together. We just had our employee survey and it's interesting. I read every comment. It's almost 200 pages of comments. I read everything all the employees write. The good ones, the bad ones and the funny ones. I will not quote the funny ones, but there's some pretty hilarious things people say. The most contradicting comments are we all need to go back to being a startup versus we need more structure to be bigger. And both are true. Both are true. The nimbleness of a startup in an industry where you're creating everything is absolutely essential. You've got to remain nimble. You've got to be willing to fail. You've got to be willing to start over. You've got to be willing to do what's right. Conversely, that big company structure where you have systems and, and balances and checks to make sure you're doing the right thing and you start watching dollars More is a different culture. So we're mixing those two together. We're kind of like a mixed family here. We will have added more than 1500 employees in the last two years.

Wow, I didn't realize you were that big.

I was employee about 300 in 2011, I think. We have 2,500 full time employees and several Hundred temps. We do a lot of our manufacturing work. Temp to hire and bring them in and grow and shrink with volume there with a temporary workforce. But no, we have that many people.

Can I add one more question for your internal survey that I think will produce awesome, interesting results every month. Have a. Or every quarter or whatever frequency makes sense. Have a. Tell us your best surprise glucose spike story because I mean, honestly, the grapes, the stupid chocolate covered MMs, whatever, I mean, I think, I mean there's gonna be the obvious ones like I ate a bag of Swedish fish, look what happened to my blood sugar. But there's these surprise ones either in the velocity of glucose escape or the peak. Because I'm guessing most of your employees are wearing these things, right?

For no, no, no.

Really, not all.

There's too many of us.

You'd actually impact production.

There's too many of us now. But, you know, if we run an internal study under IRB protocol and everything, we will recruit volunteers within the company. We have several people with type 1 diabetes that work here because they can lend us a perspective for our patients that we don't have on our own. So that's important to us as well. A lot of wear them and a lot of the things that we learn are through those in house studies and through that in house wear process.

You said something a second ago about failing quickly. You have five kids, right?

I have five sons.

And just before we were getting ready to start, we were talking about our kids and you asked me if I wanted some advice on being a parent, to which I couldn't say no, of course I did. Do you remember the advice you gave me?

I do. And I was recounting a story of how things have changed. There's a big gap. My oldest is 15 years older than my youngest and there's an eight year gap between number four and number five. But what I told you is we can't be afraid to let our kids fail. I know I'm going to sound horribly mean, but everybody getting a ribbon and everybody getting a trophy. I once told a coach to cut my son so he would learn something if he wasn't going to play him. Go ahead, do that. We learn in life as much from our failures as we do our successes. Sometimes we learn more and sometimes they motivate us to be great and motivate us to do great things. But we oftentimes as parents, shelter our kids so much from that, what appears to be traumatic. And I'd given that advice to somebody who didn't have any Children. He came in my office, he goes, give me one bit of advice. And I said, all right, I'll give it to you. Because we just try and manage and regulate everything so much all the time. And look, I will tell you, with number five, I did a lot more of that than I did with number one. Number one would tell you that I was very tough on him, but I let him carve his own way, and it's a good thing to let him learn.

Last question. Kevin, is there a failure that you point to in your professional life leading up to where you are today that has taught you more than the others about what you're doing now?

Boy, that is a great question. I would tell you one in particular. At a corporate level, I'm going to go big picture. I was at one company where I knew exactly what to do, and it was really the only course of action that would have made that company successful. And I presented it to my board, and they said no. And I then rolled up my sleeve and worked hard for several months and several months and several months, and I still got the answer no. And I finally left after beating my head up against the wall. And that taught me a lot of lessons. Number one, to be better prepared in how I give my message. And I attribute fires like that to me. I don't blame the others to be better prepared on how I deliver my message, to be more thoughtful. But if the situation isn't going to work out and what I ended up doing, and my wife would tell you this, my commute was five miles at the time, is the most miserable I've ever been in my entire life. She would look at me and say, what on earth are you doing? I'm going to fix this, and we're going to get this. And I couldn't win, so I left. And that's the one time where I felt like I didn't get done what we could have got completed. But I didn't see all the signs on the wall. So I've looked at ways I can be better from that. When I see something strategic like that, do more homework, we have the people around us do more homework, we're more thoughtful. So that's one of them. We've all had numerous little failures. Sometimes, again, our failures are our biggest blessings. I would say the failure that's been my biggest blessing are all the jobs I didn't take. Because you get opportunities and you get mesmerized with an opportunity. I'm gonna go do this. And countless times in my life, those didn't work out. And then, lo and behold, an opportunity comes along and it's, wow, I'm so glad that didn't work out. And then you learn so much from that now. And I would say the other thing that's important as far as success, you're only as good as those people that are around you. And it becomes clearer and clearer to me the longer I work. This team we have here at Dexcom, they are committed, they work hard. We are all engaged in our business each and every day. I never go to a meeting with another company where their people are as engaged in what they do as ours.

Well, that's an interesting point to end on, because I do think that Dexcom, obviously, I'm very biased. I've been very, very vocal about my bias to Dexcom over the other to Abbott and Medtronic. But I think you guys have an advantage that on the one hand is a disadvantage. Let's be honest. Diversification.

That's right.

Those companies have a million products to fall back on.

They do.

CGM is but one of a hundred things. They do. But that disadvantage is actually your biggest advantage, which is everybody shows up to. And I feel like I know half the staff here. I'm here so often shooting the breeze with you. There's something to be said for. What's the expression? You burn your ships, right?

That's right.

Yeah, yeah, yeah. You guys have burned your ships. You're all in on cgm.

We are.

Well, Kevin, I want to thank you very much for your time, for your insights, and for your friendship. It's been amazing to think that we. We met on that airplane. We met on an airplane three, four years ago. And to this day, we managed to do a good job of not talking watches. This whole thing. Once we turn the recording off, I want to talk to you about the one I'm wearing right now, which I think you're going to love.

It is beautiful.

Yeah. Thank you. I wore it today because I knew I was going to see you. Okay, this is what watch idiots do. We do, like, show and tell.

Does your wife make fun of you as well?

Oh, that's ridiculous. Now I've learned a good trick, which is you start giving your wife nice watches, and she now understands and appreciates, like, why a Daytona is a nice watch and you know, what Paul Newman meant and blah, blah, blah, blah, and all these other things. So now she. She's a little bit more tolerant of my nonsense.

All right.

All right, Kevin, Have a. Have a great afternoon.

Thank you, Peter.

Thank you. So much for your time.

We'll see.

Yeah, you can find all of this information and more@peterattiamd.com podcast there you'll find the show notes, readings and links related to this episode. You can also find my blog@peterattiamd.com maybe the simplest thing to do is to sign up for my subjectively non lame once a week email where I'll update you on what I've been up to, the most interesting papers I've read, and all things related to longevity, science, performance, sleep, etc. On social you can find me on Twitter, Instagram and Facebook, all with the ID Peteratti md But usually Twitter is the best way to reach me to share your questions and comments. Now for the obligatory disclaimer. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional healthcare services, including the giving of medical advice and note no doctor patient relationship is formed. The use of this information and the materials linked to the podcast is at the user's own risk. The content of this podcast is not intended to be a substitute for professional medical advice, diagnoses or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they have and should seek the assistance of their healthcare professionals for any such conditions. Lastly, and perhaps most importantly, I take conflicts of interest very seriously. For all of my disclosures, the companies I invest in, in and or Advise, please visit peterattiamd.com forward slash about.