#328 Ask Scott and Jenny: Facebook LIVE Edition

Answers to Your Diabetes Questions…

Ask Scott and Jenny, Answers to Your Diabetes Questions LIVE on Facebook.

• How do I attack meals that cause spike without crashing later? Is it with a longer pre bolus? More insulin? How to evaluate your bolus strategy.

• Any recommendations for helping with Freestyle Libre accuracy?

• What are the pros and cons of CGMs being used on patients in hospital settings?

• What is the best way to tackle losing weight for a type 1?

• Should I calibrate Dexcom on day one if off and how do you manage that if using an algorithm?

• How do you know if it’s a bad site or another variable?

• What are good tips for managing diabetes when you are trying to get pregnant?

• Is there anything physiologically wrong with a post meal spike if it comes down later without extra insulin? Should we try to master that meal?

• Let’s talk about pod changes and patterns.

• Is it possible to have the opposite of Feet on the floor?

• Let’s talk about female sex hormones.

• How do you manage the inconsistent eating pace of a toddler?

• What is honeymooning?

• Is there a cure on the horizon and near future?

• How do you manage kids and growth hormones? Finding the right amount of insulin.

• Can you explain insulin deficit?

• How do you manage unexpected diabetes variables like unplanned exercise, sudden stress?

• How do you know when to start eating when pre bolusing and looking at the Dexcom arrows?

• What factors affect the hypoglycemic risk value on the Dexcom Clarity app?

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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:01
Hello, everyone, and welcome to Episode 328 of the Juicebox. Podcast. Today's show is the audio from a recent ask Scott and Jenny, Facebook Live. Now the audio is super good. It's clean, clean the way you like it on a podcast. Don't worry, it's not all Facebook. It's not like Jenny's like, I think that we should do this thing with the input doesn't sound like that at all. Sounds crisp and clear. Right? Imagine Wolf Man jack and your house is like, hey, their kids. No one knows who that is. But that's not the point. The point is, it's a good recording for podcasting. And I didn't want you guys to be left out. So I was just trying to do a little live thing on Facebook if people you know, something to do during the day while they're trapped in their house. But then I wanted to get that audio right up here for you guys to listen to, in your ears the way podcasts are supposed to be heard. Anyway, Jenny and I started with one question from my ask Scott Jenny list. And then we let the viewers of the live ask the rest of the questions. I thought it went great. actually had a fun time was nice to hear from everybody. I'm giving you this episode. As a bonus this week. This is the third episode this week. So there won't be any ads on it. But it isn't going to stop me from mentioning the advertisers so that you remember that the good people at Dexcom on the pod Contour Next One blood glucose meter and touched by type one are the reason why I could be messing around yesterday doing a Facebook Live. So I'm gonna put links at the end. And they're going to be in the show notes here. If you'd like to check out any of the sponsors, clicking on the links is very helpful to me. And I appreciate when you do it. Alright, so let's get to it. This is episode one. I say 328. It's a live ask Scott and Jenny from Facebook. And you need to remember while you're listening to it that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please always consult a physician before making any changes to your health care plan. We're becoming bold with insulin. And just like that, you're listening to Scott and Jenny. redirecting to Facebook. Oh, there it is. I'm making a funny face. There we go. We're alive. Oh, that was easy. Okay, so obviously, it's gonna take a couple of minutes for people to get on. Gonna first say that. I'm Scott Benner. This is Jenny Smith. You may know Jenny and I from the diabetes pro tip episodes on the Juicebox Podcast. Jenny also does ask Scott and Jenny and defining diabetes. And today we thought we would do an ask Scott and Jenny live. Now we have a question to get started with that came from one of you. But we're totally willing to see some questions from other people. So first, I need somebody in the chat on Facebook. Tell me if you can hear me and Jenny Say something. See if I can hear you.

Unknown Speaker 2:53
Hello. Okay.

Scott Benner 2:55
Just somebody tell me in the comments if if you can hear us. Oh, hi, Maddie, how are you? Have you never seen Jenny live before?

We already have 18 people? Awesome. 24. We'll start right at three o'clock because you guys are on time. I like prompt.

Jennifer Smith, CDE 3:18
You got a minute or maybe less? I don't know my plaxis 150 or 259.

Scott Benner 3:23
They should definitely be everybody can hear. Cool. All right. They should definitely be rewarded for being on time that people will come later. Gonna have to watch, you know, watch the replay or hear it on the podcast. I can hear both of you. All right, Laura. Thank you. Whoo. All right. So if you guys have questions, throw them in there. And we'll see what we can do. But Jenny and I thought we would start with let's see, I have it here. I have it here. Here it is. Um, oh, you know what, before we start, did you guys know that? I'm Jenny. I'm gonna give your phone a few days here. Jenny Smith is an RD LD CDE T one day. She has a bachelor's degree in human nutrition and biology from the University of Wisconsin. She's a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes a pumps and continuous glucose monitoring systems. Jenny has had Type One Diabetes for how long journey

Jennifer Smith, CDE 4:17
on May 15. It will be 32 years. Okay, so that's a long time.

Scott Benner 4:23
And that is definitely a long time. So any of you who have heard us on the show before? No. This is basically what you know, it looks like for Jenny and I when we record and you guys just don't usually get to hear so we're gonna get started with the first question. Yeah, it's how do I attack meals or times of day that cause a huge spike, but come down eventually. If more insulin is added, I go low later, when I wait longer, like when I Pre-Bolus I go low earlier in the meal. Now by the way, guys, there's a disclaimer here. We're not healthcare professionals. This is not advice in this cause, just us talking and you hanging out so if everybody's okay with that. Cool if you're not jumping, all right, I went, we did not do any problems for you people just get it. You don't like it? Okay. All right. All right, Jenny. So I, you know, I hear this question a lot. I tried to Pre-Bolus. But I got low before I ate or, you know, I tried to shorter Pre-Bolus. And I just got high later, what are some of the reasons that can happen?

Jennifer Smith, CDE 5:23
So to begin with beginning of the question would be your bolusing getting high, and eventually, without correction, it comes down. That initially would be a bolus timing thing, right, where you need to Bolus sooner to stop the rise. It's an indication that there is enough insulin there because ultimately, the Bolus you took does get you down to where you want it to get later after the meal. There's just not enough time between taking the insulin letting it get started, and the food actually impacted blood sugar. But the further part of the question sounds more like if you add more insulin, like upfront thinking there wasn't enough to begin with or you correct, and then you end up going low in either of those scenarios. Clearly, there was too much insulin, right, you didn't need more insulin, you just did it in a different bit of timing for taking it right. The third part of it. So like little segments here. The third part of it really is, if you do take the amount based on your ratio, you end up climbing, or you Pre-Bolus with enough time, and you end up sinking within the time period after you Bolus, but then you still climb up later. That could be especially for those who are using an insulin pump. That could be not only a timing issue, but also a delivery of insulin issue. Okay, right, where you would probably need to use all the pumps have some type of extended bolus feature. Could it be combo bolus extended bolus dual or squarewave. bolus, all the pumps call it something different. But essentially, it allows you to take a certain percentage up front, potentially in this scenario to stop the bump up, gives you let's say you decided to take 50% of the Bolus now and then distribute the other 50% in the back end, what it allows is the 50%, you take now you can Pre-Bolus thus decreasing the amount at the beginning that you get. So you don't have a drop, but you also get the Pre-Bolus benefit of not having that rise up after the meal. And then the later impact is that you still get a finish of that end of insulin, which you knew was enough. You just needed to distribute it a little bit longer to impact, you know, the full content of whatever this meal, I guess, added.

Scott Benner 7:50
Okay. And I like obviously I agree with you. But what I was gonna say is that when when I see that I don't often see a Pre-Bolus It's so like heavy that she crashes before she gets low. And so I think that ends up being a situation where people are like, well, I Pre-Bolus and then I got high anyway. So I'll keep trying longer and longer and longer. But it's not at some point, the length of the Pre-Bolus is just not your issue. You know, and and I hate to I don't want to put a number on it. But you know, if your Pre-Bolus thing, 30 minutes in the future, you're probably coming out of a much higher blood sugar to begin with, and you have issues on the back end that you're not dealing with. I find myself saying a lot that diabetes, using insulin specifically is like time travel, everything you do now is for later, right, right. But everything that's happening to you now is from before. So if you're putting in a healthy Pre-Bolus, like you said on a good site that you can count on, etc. And you're you know, you're still climbing afterwards. I mean, the Pre-Bolus probably at this point isn't the question. And there's little things for CGM users, you can kind of look at the trend, the angle of the trend, right. So if you're, if you're shooting straight up like this, you've either missed, I think, huge with the amount of insulin you're using, or you know, if you just bolus and five minutes later start eating a real sugary thing. You're going to shoot straight up, if you come more on that, that kind of gentle rise that I tried to describe as the it's the minor or no, not the minor, like the the mountain climber on the prices, right? Any guy keeps like rolling back and forth like this, right? Because when you have a Dexcom and you you have that gradual lineup, everyone's done it, they stare at it, they're like it's gonna stop, it's gonna stop, it's gonna stop and then eventually that guy falls off the end and true Carrie says you can't have the money and it's all over right and your blood sugar's 280. And, and then that's sort of the end of it. So like Jenny's saying, there's just 1000 different ways. But in the end, what you're trying to do is manipulate your insulin and put it where it's needed. So you need that nice Pre-Bolus but if an hour later You started having this crazy rise, like she said, an extended bolus, or even coming back and readdressing with more insulin, at some point is the answer you get low later, when you put so much insulin up front, to control that line, that eventually when the impact of the food goes away out here in the future, the insulin still leftover and you crash low. So you've got to, you know, for the lack of a better term, you have to put the insulin where it's needed. I always say when you're about, you know, you have to address your body's need with with the right amount of insulin. So, right, that's cool. That's a really it's a great question. I appreciate that question. And people have left other questions. So dig in here, and see what I can

Unknown Speaker 10:40
love questions, right? Oh, yeah. But I'm

Scott Benner 10:43
on the wrong browser to see I got to get into it. Everybody chill out a second, this is my first time doing this. So a lot of pressure, like running the show, and

Unknown Speaker 10:52
like asking the questions.

Scott Benner 10:54
I was gonna feel under pressure here. Alright, I'm on a different browser. So one browser is sending you guys the Facebook Live? And then I'm going to look on a different one. Where am I looking at? I mean, the wrong I have too many Facebook groups.

Jennifer Smith, CDE 11:16
While you're looking, I'm going to add something extra to that comment. And question from before to it you were talking about, you know, the trend kind of even coming into the meal. And that can definitely determine things, you know, if you were if you were at an excessive insulin coming into a meal, and you are already on this slope headed down, right, and or if that's commonly happening within the same meal time, it could be that your Pre-Bolus thing with a load of extra previous insulin on board. Thus, you're consistently coming down in this time period of the day. And so any Pre-Bolus, it's going to look like that Pre-Bolus is causing you to drop within the first time period of that meal. So you're less likely to Pre-Bolus as much as you need to from previous experience. And thus you're getting this rise up that you wouldn't have if the hours leading into this meal. Again, if it was a consistent problem at this time of day, it sounds like the hours ahead in this setting, could need to be evaluated. Maybe the bazel is too high heading into this meal, okay, or maybe the insulin to carb from a snack three hours ago, is also giving you too much insulin. So you're consistently coasting down into this meal time. So you've got this excess behind the scenes insulin. So are some other things that could be evaluated to cool.

Scott Benner 12:36
Alright. And somebody said I was lower than you. So I just turned my voice up. So if I got if I'm now too loud, somebody told me. All right, Anna asks, I have been having trouble with the accuracy of my freestyle libri. Sometimes there's a big difference. I think I will change Dexcom was I finished? The my inventory I currently have at home. But do you have any recommendations in the meantime? While I'm using these?

Unknown Speaker 12:59
That's a good question.

Unknown Speaker 13:00
Yeah. Is there an answer?

Jennifer Smith, CDE 13:02
Well, is there anything to adjust? There's nothing from our, from our practice, all all of us within our practice. At integrated, we've all used the libri all got our like trial, you know, couple of sensors to try out and I try to as many people often do you make yourself the guinea pig, right, you try a couple products at one time to see what's actually Right, right. So I wore my Dexcom along with the lever a and the three sensors of the libri that I wore, they were all consistently reading lower than my actual sensed Dexcom and fingerstick values were consistently center to center they were all consistently different. And enough that from a blood sugar and a meal bolus and a correction standpoint strategy, it would have been enough of a difference to make adjustments kind of diff difficult to base off of, is there anything that you can do about it? In this setting, what we usually recommend is for the prime times that insulin is going to be dosed based on a glucose value, do a finger stick, get a finger stick and dose off the finger stick don't dose off of your libri what you can know from any sensor system that might be reading a little bit off or different than you know it should be is that while there is a difference in the number, the trend is still a good, it's still a value for you. So you can still tell whenever you're trending up or trending down, and you can use that to your advantage for future planning. Okay, so but you wouldn't necessarily dose off the value.

Scott Benner 14:43
So um, I guess what he's saying is when you find you're not trusting the device, test, but still look for I mean, I guess I've never used the library but arrows and direction and rate of change and stuff like that. And then when you really need to know I guess what we're saying? Is that if it's a pre meal, and it says you're 120, but you think you might be 150. That's important to know when you're making your Bolus, right. Okay. But Hmm, it's still important. I don't want to minimize the idea that a big a big difference is a problem, but at least you can be safe. When you're when you're putting in like more when you're

Jennifer Smith, CDE 15:19
putting in insulin. Yeah,

Unknown Speaker 15:21
yeah. Cool. So,

Jennifer Smith, CDE 15:23
to let her know that that's not uncommon. Gotcha. A lot of people find the variants,

Scott Benner 15:27
it's gonna be hard to keep. See, I want to, we only have an hour, so I need to keep Jenny movie but Jenny will talk and like, get all her knowledge out. And then we're gonna answer one of your questions if we do that. So Maddie, how do you Jenny see CGM being used in patient hospital settings now that we're seeing COVID-19 error How is going to help diabetics? And Maddie, what I'll say to you is, did you hear the episode of the podcast that went up today? Because Dr. Dan disalvo came on and talked about how decks coms are being used in hospitals right now. But so I have something to add, but you go first.

Jennifer Smith, CDE 16:00
That's pretty awesome. Because I have I've not obviously listened. I've been working with people all day. So I'm, so I have I both pro and con feelings to it. Okay, so from the standpoint that great, there's a lot more information, there's a lot more data, it can be beneficial. On the con side, however, there's a lot of data, and healthcare workers in hospital who we already know, have have little experience with type one, consistent glucose information management, they are used to doing finger sticks every several hours, to base decisions on right, whether it's dosing or whatever adjustments in doses. With all of this extra information, the trends, the alarms, the things that are going to be visible to them. Yeah. There's no, there's no quick education that can be done within 10 minutes to the thousands of health care, nurses, doctors, whoever that's looking at this information to help the person wearing it. Yeah. I feel like there's a lot of information, they're not going to know what to do with it. So that's what I feel like I feel like it's good. But it's also, I don't know,

Scott Benner 17:20
let me share with you what Dan said. Dr. salvo told me that what it was really helpful with in the moment was, it was preserving PP for nurses because they were, you know, they do finger sticks on patients a lot. And now you're asking them to go in and out and change their gear every time. So now they're, I guess, Dexcom. If I, if I heard him, right, gave the patients like Android phones. And so there's a cloud service. And now the nurses are able to look at the patients through the share and follow, right? And then they're like, okay, you know, they come down the line. And here's Mary and Mary's blood sugar's this, it seems pretty reasonable. I don't need to go in there. So that was the idea. What I heard while he was talking was a great opportunity nationwide for health care professionals to see how glucose monitoring works, right. And maybe, maybe in the future, things will go better. I told him a story of when Arden had a surgery. And you know, the nurse didn't know anything about it. I just kept talking to nurses till I found wonders like I have a friend who has diabetes, I go, you're my friend. Now come over here and explain to all these people why we need to leave the CGM honor during this procedure. But anyway, that's what I thought of it, Matty, I thought it was I think it's, um, it's great for that saving of the PP. And on the other side, I think it's a good first step in bringing the technology out to people. So

Jennifer Smith, CDE 18:35
yes, yeah. I also think, you know, in that scenario, as if they're using it based on the protocol that they would have used finger sticks, and they're only checking at certain points to see what the values are or responding to alarms. Yeah, it's absolutely valuable. I just hope that I would expect somebody has schooled them in what to pay attention to what not my, my

Scott Benner 18:57
thought was that it was, it was going to be used in a really, I don't know, like a limited way in the beginning. Just to keep you know, from being with people. I saw Donnie ask about managing weight with type one. So and he said, Thank you for being here. So thank you very much, Danny for being here as well. Yeah. Best way to tackle losing weight for type one. Why do why can people with diabetes who are using insulin have trouble with weight loss?

Jennifer Smith, CDE 19:24
The first thing is definitely insulin management. That's that's a huge piece of it. Because insulin is a storage hormone. It's meant to move food glucose out of the system into the cells, either it gets used by your muscles or it gets packed away into fat, right? So from a physiology standpoint, even if you look at a body that doesn't have diabetes, if you out eat what you really need, then overall your body can only pack away that extra calorie, right? Okay, and it does it with insulin. Right to manage the normal blood sugars that should be there. Same thing is happening though. And so person, even without diabetes can gain weight, that that's how they gain weight. Essentially, their body should packing away more than what they needed because their body is managing blood sugar the right way. In a body with diabetes, though, because insulin management is something that we control, body's no longer doing it for us. It's something that we have to, we have to adjust more precisely than people are often given tools to manage. Right. So overall, one, make sure that your baseline dose that bazel is right to begin with, it's in the right place, then the next thing to tackle is the food management, strategizing around meals timings, you're not using more insulin to cover then you actually need to, you're not covering with extra food when drops happen, because you used too much insulin that you didn't really need to have there. And then the other piece, of course, beyond that is, are you eating what your body needs to eat? You know, because if even in this case, if you've got great looking blood sugars, but you're constantly like popping food in and covering it with insulin, you could have wonderful looking blood sugar values, you could still be out eating what you need.

Scott Benner 21:17
Right? So I usually it's funny, I saw john pop in and he said, Don't feed your insulin, which is this is what I was gonna say. I think I think that when people who listen to the podcast have, there's two trains of thought, when you're learning how to use the insulin in the beginning, I will say be more aggressive, you can always have juice later. I don't mean that for the rest of time In Memoriam. I mean, while you're figuring it out, like if you continue to bolus and get low, fix the bolus, don't keep fit, you know, don't keep drinking juice. But it's a great point. Because people with type one can start to think of diabetes first. And instead of health, right, so all of a sudden, an Oreo cookie is not a bad thing, because I need it because I'm getting low, except your real issue is you need to stop yourself from getting low. So you don't have to eat an unscheduled Oreo. And by the way, don't eat Oreos, they're, they're poison. But But you know, like, I really I don't think there's any food in them whatsoever. But my point is, is that don't feed the insulin, but learn the steps so that you can do that. And Jenny, this is a wonderful place to say that diabetes pro tip calm is now open and available to find all the diabetes pro tips with Jenny and I all in one place in case you guys have had trouble finding them in the podcast player.

Jennifer Smith, CDE 22:34
Yes. And we've also gone over that weight piece in there. It's a great episode at least one if not a couple mentions.

Scott Benner 22:42
Yeah. All right. I have. I have one for you. And one for here's a quick one. Yeah, Jenny, you are g six. And so does Arden. Do you ever calibrate on day one? If it's off? No, you don't you let it go?

Unknown Speaker 22:57
Let it go.

Scott Benner 22:58
And how do you manage that with your algorithm that you're using?

Jennifer Smith, CDE 23:02
I manage it by doing finger sticks. Because I have had, as we talked about right away. I've had diabetes long enough that finger sticks have always been a norm. Even once things got approved for not having to do that anymore. I still do that. So that's my thing. And with the algorithm that I use for my insulin management, I can I can populate in my finger stick value for my algorithm to use that value rather than the CGM value. And then I get proper dose adjustment.

Scott Benner 23:41
And you have an apple iphone, right?

Unknown Speaker 23:43
I do. So you go Apple Health,

Scott Benner 23:45
you go into the health kit, and you tell it, you add your blood sugar there, and then that program you're using, yes, the loop app will see it and then it knows what your posture is. Correct. And so my my way of dealing with it is if it's close eye roll, you know to me like if and I test to their their advertisers on the show, but we use the Contour Next One meter, I find it to be incredibly accurate. And so in those first number of hours while the sensor wire still you know, baking in, I will test but I'm going to tell you that if it says she's 70 and she's really you know, and she's really 90, I might let it go a little longer to see what happens. But there are times I do calibrate to get it together. It's not a frequent thing. I probably only calibrate on day one when I calibrate but having said that we don't do it very often law we leave the finger sticks though

Jennifer Smith, CDE 24:42
and there are a There's your so many that trains of thought in terms of that that I've run into in working with people, some people who've got this like system, it works really well for them. Awesome, great, even if it's not what's recommended if it's working for you. I'm not going to tell you this Stop doing that. Right. But from the standpoint of education, you know, we recommend following the recommendations of Dexcom. Don't calibrate in the first 24 hours,

Scott Benner 25:13
you would never do anything like that. Somebody asked for links, I just put them in the comments. And honestly, Jenny and I are not used to being seen we, you know, I mean, for those of you who are new, I have a podcast called the Juicebox Podcast, and Jenny is a frequent contributor to it. And she's not on every episode. So if you really like her, and you hate me, you're gonna be pissed when you like tune in today, and she's not there. But anyway, calibration day one. Actually, that's sort of covered. The next question I had for you. If there's a person who is excited about algo, their algorithm pumping in the in the future, right, but is worried that because they don't always see their CGM rock, you know, rock solid, and they're afraid of what's gonna happen next, what I would say to that is, you know, Arden has definitely done both ways. And it's never been an issue. Like, I've never ran around the house going, like, Oh, my God, everyone's gonna die. Because you know, Dexcom was off and we're using an algorithm, it just, it's a it's a reasonable worry if you've never done it, but once you do it, I don't think it's something you'll think about again, does that strike you like that?

Jennifer Smith, CDE 26:19
No, it does. And it's actually a question that I've gotten more than a number of times from people that I work with, especially parents of kids, you know, wondering, Well, what about those? compression lows? Right? What happens if an algorithm is using that? And now it's not really low? What will have happened? Well, you know what, because the system if you're using one of these hybrid types of systems, whether it's, you know, on the market, or yet to be on the market, um, if you're using one of them, it's going to adjust based on that change in blood sugar, that's being seen, right. But most often, especially in this example, of a compression low, that writes itself pretty quickly. In fact, you can tell it's a compression low, because it looks like your blood sugar is literally like nosedived off of a cliff. Yeah. And then it comes back up very quickly. I mean, you could you can tell it's wrong. Well, yes, the system will have reacted to that drop in blood sugar, it may have taken away insulin where it was supposed to, but within the quick timeframe of it writing itself, that algorithms also going to write what it took away behind that, right. So I've personally, I've had sensors that have been off, thankfully, not very many, my Dexcom, thankfully, has been very accurate for me. In all the years, I've used it. But I have had compression lows. And since I've been using, you know, this algorithm, I haven't noticed that that's honestly been an issue. I've never had any problems of excessive high blood sugars or no problems with like, strange, odd low blood sugars that shouldn't have been there because of this sensor. You know, okay, she being off.

Scott Benner 28:00
Yeah. I hear you. I'm, I'm down. I think it's, it works. I mean, I've I'm not gonna tell you I haven't gone Norton's room been like, She's like, the first thing I do if she's laying on her side, because she wears hers on her, like her body, her hips. So I'll touch her hip that she's not laying on. And if it's not there, I'm like rollover. Just kind of like shutter and, and then you'll wait a minute, it comes back. interesting side note about a compression low with a CGM. The number it's reading is actually correct still, although not indicative of what your blood sugar is. So it's reading your interstitial fluid, which is you know, freely running through your body. But when you press down, it disperses it. So it's dispersing some of the glucose that it's reading. So it might tell you your blood sugar's 60, all of a sudden, the truth is, the interstitial fluid around the wire, the glucose value is 60, your whole body might be 110. But that's why when you roll off of it after it gets to the algorithm gets to think a couple more times, it'll come back and tell you Oh, no, you're one time. And that's it. How does that engineer makes a great point, if that happens, the worst thing that's gonna happen is the algorithms gonna take insulin away, you might get hot, but you know, you might get a little higher, but you're not going to be in a dangerous situation. And that's a great trade off, I think, yeah, you know, Jenny, I'm gonna ask you, somebody jumped on and said that I recently said on the podcast that I don't abide a bad pump site that I get, I get away from a by a pump site pretty quickly. But she wants to know, how to, you know, it's not just your period, or, you know, and so I'll you know, because you and I deal the same way about that we don't stick around for like,

Jennifer Smith, CDE 29:39
I don't stick around. And and I guess, you know, from a female perspective, if you're like, well, gosh, is this my period? Or is it you know, a bad sight or whatever? I mean, most women, most not all, but most women have a pretty consistent timing rhythm to their cycles. Yeah, right. So if it's You know that it's probably coming into that time, or you know that it's that time and your high blood sugars are usually associated with that. You wouldn't necessarily think that this is unless you, you haven't changed your, let's say, your settings or your insulin doses as you needed to for this time period. And if you forgot to do that, obviously the high could likely be associated with that. The best way to tell though I mean, because even in your period, you could certainly have a bad sight. Like two things hitting you at one time. That's not fun, either. It's

Unknown Speaker 30:31
okay, hit from both ends. Right? That's not

Jennifer Smith, CDE 30:33
that's not joyful at all. So, you know, if that's the case, I think, regardless, for anybody, whether you're male or female, if you've got an odd looking high blood sugar,

Unknown Speaker 30:45
yeah, that

Jennifer Smith, CDE 30:46
shouldn't be there. Right? You know, you've done everything you would normally have done. And this is just a weird, all of a sudden, you're like, double arrow up and you're to something. You take a correction, right? In my case, and what I recommend, if it's not coming down within the next 30 to 60 minutes, that's it's done. Yeah, it is done. I don't play with it, even if I pull it off. And I'm like, well, it doesn't look like I don't know, whatever the problem was, that the candle is not bent. It's not bloody, it doesn't look weird. Sometimes it might look a little bit wet, or mediawiki. So maybe for some reason, the site was like leaking up along the canula. And you didn't really get as much insulin as you should have. Yeah, um, but yeah, I don't, I don't play with like numbers that aren't where they want to be. Right. And

Scott Benner 31:32
there's a couple of ways that the way I taught myself so the answer to a lot of these questions ends up being repetition, you do something over and over again. And one day, it just makes sense to you, right? And you don't you lose that checklist in your head, like, well, I said, this is it, this, like you stopped doing that. You just see it, you recognize it, and you go, so before I could recognize it, I would inject with a needle. So if the pump didn't act the way I expected it to, I'd come back with a syringe. Now if there was no reaction after that, then I was pretty sure that my site was over also, last day of a sight, you know, or you just put it on and it just never ends up working. Because I know some people switch their pumps and they, they they'll experience a little bit of a high when they put it on. There's a lot of you know, talk about why that is I part of me thinks in children that it's anxiety. It's the you know, it's the that whole thing kind of gets you jacked up a little bit. That could be it. That's what it used to be for Arden. She's obviously much more relaxed around it now. But we've changed upon this morning, it went on and we did a more aggressive bazel rate for the next hour to try to her blood sugar was good at like 110 but to try to mitigate any kind of arise you know, same thing on the other side, if you think it's not working anymore, once you get it back on, you have to really think about for a second How long has this like not been working? And now I'm just going to slap on a new site and go oh, everything's fine now because the insulin deliveries back it's not because everything for now is for later and everything that's happening to you now is from before I get insolence always from before, go back to the beginning if you're falling late, but that's really it. Now the next one is more for you. Although people are asking follow up questions, so hold on. This is great info inside. Oh, great. Okay. Oh. By the way, there are people in the comments helping each other somebody was like, what's the compression level before we could explain it they jumped in You guys are awesome. Jenny, I drew a picture of a lady with a big belly to remind me that someone asked about good tips for thinking about getting

Unknown Speaker 33:41
everywhere just didn't write down pregnant. But anyway, I'm not showing anybody it's not a good drawing but

Jennifer Smith, CDE 33:47
good tips for getting pregnant. So preconception time. Um, we we kind of define preconception time, the three to six months, potentially even a year up to when you want to start trying to conceive. And the goal there is to aim to get glucose values into the pregnancy target. If you think about and or don't know what the targets are for pregnancy. The goal is to be under 7%. And then in pregnancy and even see more around 6%. Within the fives if lows aren't the big reason for being in the fives. But typically, most practices will say under 6.5%. through pregnancy more around six is the preferred just from the standpoint of health of you and the developing baby. For the preconception time then it's really focusing in quite a lot on what are the variables that you can learn and manage better in your life. And if some of the variables like every Friday night you eat the whole box of chocolate, you know ice cream bonbons And you can't manage around that. You know what, for nine months, you can manage not eating your bonbons on Friday night? Yeah, I mean, that's, you know, those are the things those are the strategies that you sort of learn in that preconception time. I mean, the beginning tips really are, look at what preconception or look at what pregnancy targets for blood sugar should be. Because aiming to get those as close preconception will make it so much easier. Once you're pregnant, as you don't have to shift this whole mental. Oh my gosh, now my blood sugar has to be 90, and it's been riding at 150.

Scott Benner 35:36
Just count on, I'm going to get knocked up, and then I'll do this better. Right, right, just and that probably wasn't the right way to say that. But you know what I mean, thoughtfully and through love, make a baby and then trying to get better at your blood sugar, get better first, prove it to yourself that you can do it over and over again, Jenny, if you had to say to somebody, how a way they could get better at this, what would you tell them to do?

Unknown Speaker 35:57
What would I tell them to do? Like a web address? Yes, well, they can call me

Scott Benner 36:03
just put Jenny's email address in the comments.

Jennifer Smith, CDE 36:05
They could. They could also i we've got, I wrote a book with a good friend of mine, Ginger Vieira, who's written a couple of her own books. It's, it's pregnancy management for type one diabetes. You can find it on Amazon. And we actually have a big preconception, month to month guide for pregnancy management, postpartum lactation, we've got all of the information in the books, I would

Scott Benner 36:31
also bet that sometime later this year, there might be a pro tip episode about being pregnant with somebody too, because that just sounds like a good idea. And I typed it into our running list of ideas for the podcast. Awesome. Yeah. Okay, that's a great answer. I wanted to just say that.

Unknown Speaker 36:48
I think

Scott Benner 36:50
I think that once you figure this all out, you get pregnant, you keep your blood sugar, super stable, and you're a onesies nice and low forever. It's gonna be difficult, but try not to lose track of it after the baby comes. Like, just you can do it. If you did it, then you could do it forever. You know what I mean? Like, you know, it's interesting, as I interview more and more people over the years, to see that some people who have trouble managing their diabetes, for themselves, don't have trouble managing it for someone else, you have no idea how many people have come on and said, I met somebody and I fell in love. And I got married, and I wanted to be healthier, so that our relationship or I had a baby, and I realized I wanted to do more. That's not specific to diabetes, by that it's a very human idea. But yeah, keep putting yourself at the top of your list of things to worry and be concerned and

Jennifer Smith, CDE 37:38
he can take care of you. You can take care of other people.

Scott Benner 37:40
100% I think and Wait, do you see having a baby? It's It's wonderful. Nothing like having a kid my wife and I were just sitting on the other night going, we think having these babies was really, really good idea. No, we were choking, because they were both being annoying at the same time. People are thanking us, which is very lovely. Thank you very much. We really appreciate that. You guys listen. evany asks a question back about bolusing. That I feel like I have something to say he said, Is there anything physiologically wrong with a post meal spike? If it comes down later, without extra insulin? Would you try to master that meal? I think you probably can. I mean, unless it was, like you said, Well, you know, I can't even say unless it's cereal, because I can get cereal, right? Sometimes, too. So yeah, I have an In my opinion, if you're going up, hanging up, coming back and leveling out again, and never getting low, there is a way to get more insulin up front. And you know that and we talked about it earlier that really Evan should go back to the beginning of the live, right.

Jennifer Smith, CDE 38:44
Yeah. And I also think, you know, from the standpoint of that kind of management, what it also leads into longer term, if you consider, for the most part, you're looking at your day, let's say you're using a CGM, and you can see how much of the time you're in range and where you want to be. And you're only, let's call them problematic times are these spikes above where you really would want to be after a meal. Yeah, but the end result is that you're back in target. And that looks awesome to you. Right then, one managing the timing, again, it's all about timing the insulin right, but to that peak is still leading into your overall a one C, okay, it's still leading into time out of range. And those post meal spikes also lead towards things like some of those many things people don't want to talk about, but the complications, more of those microvascular complications with these peaks that come into play, the more you can minimize and have more gentle roles, the better long term, so right.

Scott Benner 39:57
To do your best and keep messing around little sooner, a little later. Little more or a little less in there somewhere is the answer. It sounds like he's got the amount right and the timings off. Listen, even if you don't listen to podcasts, I maintain that most of managing insulin is timing and amount, it's just about getting the right amount in the right place where the need comes in. If you can get more up front to stop that initial spike, it might not have to be that much more, you'd be surprised it could end up being a couple more minutes of a Pre-Bolus or another half a unit of insulin or something random like that. That's still because that momentum from the food is so great. At that moment, it'll eat up that insulin, it won't leave you extra on the back end that will make you low. Right, hopefully. Julia asked, What do you consider a gentle roll? Did you just use the words gentle roll? Okay. Do you mean like one of those little Pillsbury things with the?

Unknown Speaker 40:47
Oh, no, no, no.

Scott Benner 40:48
Julia, I can I can talk Jenny as a matter of fact of Jenny's husband ever leaves her we're perfect for each other. what she means is not like, not like sharp, sharp down. She means like, it's cool if you go like this a little bit. By the way, this. So much of what we do is, is easier when people can see our hands moving Jenny and my hands move a lot while we're talking.

Jennifer Smith, CDE 41:11
And the funny thing is, nobody can ever see like our expressions or anything because it's just all voice. There are times when Jenny goes, I wish

Scott Benner 41:17
people could see what we're doing right. And I'm like, Yeah, they can't so Oh, Rachel, it is the best podcast ever. Thank you for saying though. I asked if the group earlier forgot. I would ask here. I had been pumping on the pod for six months. And I've just noticed the pattern. Day one runs high. Day two, good day three low. Any ideas how to combat this? More or less insulin? She's heard of the opposite problem. Brittany has a day three being a little higher. I would say that's if I see anything. It's day three higher Ardennes pumps either work, right out to 80 hours, or right around

Unknown Speaker 41:55
two and a half days.

Scott Benner 41:56
Yeah. 70. I was gonna say right at 70 hours ish, then I have to start paying attention more.

Jennifer Smith, CDE 42:01
I've actually personally noticed that when it does, it's not a time factor. It's more of a when my pod gets to about the 20 unit mark, I can almost guaranteed if I continue to use it after that for boluses or anything. Yeah, I will ride higher. Even though the pump tells me I've delivered the insulin. And it's the same way it's the same factors ratio is everything that I've used. It's it's a, it's a dose amount from what I and I've used Omnipod since 2006. So I got a lot of experience of yours.

Unknown Speaker 42:35
Yeah.

Scott Benner 42:37
I was telling Jenny the other day Arden's been using it since 2006. And it's, it's amazing. Like, I have nothing bad to say, uh, you know, a number of people asked, they said, they have the opposite of the feet on the floor up, they have a feed on they wake up in the morning and their blood sugar drops pretty drastically. Have you heard about that? from anybody?

Unknown Speaker 42:57
I've actually not.

Scott Benner 42:58
So so then would we consider maybe that the bazel leading up to their wakeup time is too strong?

Jennifer Smith, CDE 43:05
The question would be first, which is always my question to people are is your wakeup time the same? Please, it is the same. And you're noticing that drop, as soon as you get out of bed in the morning, okay, then the next thing to do would be try to sleep in and see if the drop happens. Because my guess would be the drop is there. Because you're getting up at the same time you think it's because you're getting out of bed. But it's because as you just said, the bazel in the hours preceding that are probably too high, and the drop was going to happen anyway. Um, so If, however, you find that when you wake up in the morning, and or sleep in completely different, let's say the sleep in stays totally stable. And when you wake up and get out, that's when the drop happens. Yeah, that's it. I mean, it's the complete opposite of what a good majority of people see. I'm not saying that it's not your personal experience. I've got friends who have a drop in their blood sugar with adrenaline rather than the typical peak in blood sugar because of adrenaline. So it could be the case, it, I would say that it's going to be a little bit, it'll be a little bit harder to maybe manage a drop. Because if it's related to when you get out of bed and not really wanting to like eat glucose tablets, or drink some juice just to stop the drop, though only a couple of options would be, well, if you can get up at about the same time, you could technically decrease the bazel leading into that time. So the drop doesn't happen. The only thing there is if you if you get up later, then you're not really going to need that

Scott Benner 44:48
decrease higher than listen because of this whole Corona thing Arden has been she shifted her life drastically. She's staying up way later and getting up way, way late. Yeah. And so I know if by 6am, I don't take away the power of her bazel by half, she's going to be low by eight o'clock. Like, because her daytime numbers are, you know, the insulin we use during the day is just different than what we use at night at night. She needs far less. I don't know, I hope that was helpful. Let's say I know I have a drop because I'm not waking up at the same time. Every day when I had a normal work schedule. There was no drop when I wake up. So then Laura, look is did you do you have a stronger basal rate in the time you're supposed to be awake? Because if so then that's it. Your bazel is just building up and building up and you have nothing going on inside of your body that needs resistance from extra insulin, then, at that point, a bazel. could act like a bolus eventually. Yeah, right. Okay, cool. I like the way I said that. Well, Melinda, thank you for loving the podcast. Thank you. This morning, I was 111. Justin says when I woke up later in bed and read the news got up 45 minutes later and went to 72. Hmm. And that's not Justin, it's tough. I can't have a conversation. But was that not bazel related. Somebody here said they have a new bazel program that's called pandemic. So that's a good point, too. Don't just change your settings, you can make a new program so that when this is all over, you can switch back to the way it was. I've had to you know what, I have a question for you, Jenny. This happens sometimes when we do the podcast. Let's do it now. And then I'm going to get to a question about kids and growth hormone. I was interviewing someone today who talked about when they got pregnant, they suddenly needed much less insulin. And I was saying to them, it's interesting, because for three days before Arden's period, she almost needs no insulin to and I'm wondering what hormone we're going to figure this out, I know this isn't going to something you're going to know now. But we're gonna figure this out and talk about later in the podcast, there must be some hormone that's released. For oscillation. That must also exist while you're pregnant. And maybe I'm wrong. But I'm going to find out if that's true. Because those two things like a bell went off my head as Ooh, maybe this is it. Because Arden Will you know, Jenny and I've talked about it privately, Arden will use like almost no insulin for a number of days before some of her periods. Not all of them, you know, just to keep things interesting. But do you think? Did I just say something you've never thought of before?

Jennifer Smith, CDE 47:25
No, it's well, and typically, oops, some reason went off my screen. There you are. Hi, hi, sorry. Um, I was gonna see the horrible and that's present in the lead up to your cycle, as well as the horrible and that's present very heavily prevalent in the first part of your pregnancy in that first trimester up to about like, six weeks is progesterone. Your body is having this ramp up, almost up a hill climb. And when you get your period, because your body's like, hey, you're not pregnant. So then the progesterone kind of like falls off the cliff, right? You come back down to this normal level. So most women, not Arden, but most women have a right up in blood sugar in the days before their cycle starts. And then it calms down. Same thing in those early weeks of pregnancy. Typically, women will actually see a heightened need for insulin in the first about six to seven ish weeks. And then around eight weeks of pregnancy, there is a bit of a dip off for a couple of reasons. Um, you know, hormonal II and what the body is doing, why there would be a dipped in blood sugar prior to the first day of a cycle, or maybe in the first part of pregnancy, when normally most women are experiencing a rise, the hormone, hormone drive there, I can't say that it's different. I would have to research let me give

Scott Benner 48:56
you a number another variable for this story. And I guess this is me ruining an upcoming episode. But what if the pregnancy didn't last much longer than eight weeks? Maybe there was something else going on? Sure. Yeah.

Jennifer Smith, CDE 49:09
In fact, that is if you've had a normal increase in insulin in early pregnancy, and if prior to that eight to 10 ish week point where usually your insulin needs at least stabilize and or dip down a little bit. If that dip happens sooner. Oftentimes, it can potentially be an indication of like miscarriage only because the hormones are not staying steadily, you know, there's not a steady climb. There's also you know, an early pregnancy. If you've ever had miscarriage before and or you're just worried. You can always get this the HCG hormone tested, which is the early pregnancy hormone that's released that actually gives you that positive result in your pregnancy home pregnancy test. So that hormone should add Actually, mostly double, sometimes triple in those early weeks of pregnancy, which is, it tells you is that your pregnancy is progressing the way that it's supposed to. Okay. Um, so those hormones, you know, that might have some indicative factor too. But that would be something I'd had, that's a great way to look into

Scott Benner 50:20
a little more research sound like there's more in there for to understand, hey, I want to go back to Justin for a second talking about getting up and getting low. Justin, I just had a thought maybe you should do a bazel test day, maybe you're eating enough to feed a basal rate that's too strong. And that way you sat in bed, you looked at the news and everything, maybe that is what's happening, maybe it's not, but if you bazel test and find out you're always low, maybe, you know, like, when I talk about, like, you know, manipulating bazel rates, sometimes when you manipulate them too much, Justin, you're in some belong somewhere else. So you can you might be I could be wrong. But you could be in a situation that a lot of MDI people find themselves in where when they switch to a pump, and they realize that their basals way wrong. But you know, people are like, Oh, I switched to a pump, my blood sugar started going up. Well, it's possible, your bazel, you know, before was too strong or too weak, you know, one way or the other. And so, I guess the way I like to talk about it is, so then what's happening? You can't draw a parallel to the things you think they're attached to. So I don't know, Justin, that's maybe worth a shot. Somebody here said I've been diabetic for 31 years, Melanie. Hi. And you guys have changed my life. That's lovely. Isn't that nice? Thanks, Jenny. I feel nice.

Jennifer Smith, CDE 51:33
And they can see a smile.

Scott Benner 51:35
Yeah, because we really do smile. Yeah, cuz I read those two jenine. And you probably think we're just all like, just jaded and like a doesn't matter. But no, it makes everybody really happy. It does. Sabo. Can Type One Diabetes go into remission, I can answer that one. No. That it definitely can't. Oh, what's the proper way to bazel? test? Caroline? In my opinion, that's a long conversation. It's not an easy conversation to have. But Jenny and I have had it in the pro tip episodes. So find the link, go to diabetes pro tip comm and look for the Basal testing episode. I listened to all of them If I was you, but at least to get to that one. Justin says, like, maybe we're onto something. All right. You're good to go for a little longer. Yeah, Caitlin. My toddler has decided to wait, we're gonna go somebody else said something about Caitlyn disappeared, my toddlers decided to pace himself differently during meals resulting in dipping down into the 60s mid meal. I'm concerned about our low percentage has hiked to 6%. and wondering if we should make changes.

Jennifer Smith, CDE 52:43
So if your toddler is now decided to like, pick it things like he'd rather he or she graze like over the next one and a half hours instead of like slamming it all down within 15 minutes. That was the case. You know, kids are different. I've got a three year old, they sort of roll and change without telling you they're going to Gee, sounds like the dose is probably not wrong. It would be again, the timing of the insulin distribution. So if the picking of the food he he or she ends up eating everything, but it's in a slower timeframe. If you're on a pole and extended bolus,

Scott Benner 53:27
yeah, so extended bolus you could do two different boluses if you wanted if that's get that idea scared you. Kenny says try to get them to eat the carbs first or the shorter to help it there's a you can manipulate the food. You know now you're going to get me into my my coma when I'm on stage and I start talking. Too often with diabetes, we think of just one thing, how does the insulin impact the number, but you should be wondering about how the food impacts the insulin, how the food impacts the number, how the insulin impacts the food, like there's all different sort of perspectives you can use to think about it and one of them in there is the answer. And Marcel makes a good point. Maybe the person who asked if diabetes could go into remission maybe they were asking about honeymooning and, and so, so back to that some people really can. Maybe we should go over honeymooning real quick, but honeymooning is a spot where you have Type One Diabetes you have this insulin need. And then sometimes for a day, three days, three months I've spoken to people it's gone on for years for suddenly it feels like their pancreas is shouldering the burden a little more again, and then they call that a honeymoon. Well, I think that's a fairly good explanation of what honeymooning is so it does eventually for most people go away.

Jennifer Smith, CDE 54:45
Right and you're eventually you will return to using insulin completely

Scott Benner 54:50
right for right. If I go away, I mean, your pancreas is gonna, it's gonna give up finally poop out go down like Bugs Bunny eventually. And then for those

Jennifer Smith, CDE 54:57
who are diagnosed as adults or What we call often call ladder. Some adults, it can actually have a very long honeymoon Yeah, where they may very well be able to control even without insulin for months at a time after they're initially diagnosed with just lifestyle changes before they actually start to need to use a basal insulin and eventually a bolus insulin, etc. So

Scott Benner 55:27
let me address this one question. Then there's another one here. I like that I want to go to back to Sabah because he's asking, Is there a cure on the horizon and near future? I don't know that there's any cure on the in the near future. I have a very simple concept around this. I live with a lot of hope for advancements, but I make decisions day to day like they're never coming. Because far too many people I see ignored thinking, Oh, this will be over soon. I can my body can take bad management for a little while. I that's how I feel about it. I act like it's not gonna happen. I hope I'm hopeful. But, you know, somewhere in the middle there i think is the answer. And Jenny, do you know of any cures on the horizon?

Jennifer Smith, CDE 56:08
I don't there's, as there have been long term, there's a lot of research, there's a lot of animal based studies that show some warrants some benefit. But you know, 32 years with diabetes, I explicitly remember my doctor telling my parents not to worry that within seven years, it was seven years when I was diagnosed within seven years, right? You won't have to worry about this anymore. And, you know, even into my teen years, then my team brain even started to tell me, this is like lifelong, right? Just the hope has always continued to be there that maybe there will be some grand discovery, and it'll get through and everybody will benefit from it. You know, I am, I'm hopeful more in technology, and where the technology piece is going for helping management. But I am hopeful, but I don't see it.

Scott Benner 57:06
I agree. I hate saying that. I know it sucks to say it, but I'm on the same page with you. And not for any nefarious reason, just that if you really if you go look, I think as a species, we've cured like eight things. And a few of them are just inoculations. They're not even really cure. So I'd live like, I'd live like it's not gonna happen with my actions around diabetes, but I'm always hopeful. I and here's another thing not to make light of it, though. But somebody said on the podcast recently, no one's going to cure diabetes, and you're not going to know about it. It'll be on the news. You know, you'll figure it out or turn yourself into a mouse because it seems super easy to cure them from type one diabetes. Maybe that's what we should be doing. Looking how to turn people into mice. Hmm, now we're getting somewhere. Yeah, I'm sorry. I feel bad about that. But all right, Mallory says, No, wait, Mallory. I'm sorry. That's not the one I was gonna read. And I'm like, Damn, they almost got the mind. A Kelly said nearly every night after my son falls asleep, he shoots the 300. I've increased bazel by as much as 95%. But once he's there, I can't bring him down. When he wakes up, can I answer first?

Unknown Speaker 58:13
Sure.

Scott Benner 58:16
Hold your thought, I'm just gonna put something on that you can come through with Trust me. Just because your kids bazel rate is I'm going to make up a number here, a half unit an hour and 95% puts into a unit an hour doesn't mean that's how much insulin he needs in that time. So you may have to extend on your pump, the amount of bazel you're allowed to use to get to the point where you can keep him down because there is an amount of insulin that will stop that kid's blood sugar from going up and hold him steady. What were you gonna say?

Unknown Speaker 58:46
What I said, You're so funny. So

Jennifer Smith, CDE 58:48
pretty much along that line? Yeah. One is, you've got data that shows you that this is happening every night, right? You're not like, Oh, this is only two days. And now it's not happening anymore. This is it sounds like it's every night. So one, you know, insulin needs to change to right along with what you said. It's in very low level bazel rates, especially in many kids. If you're turning Bayes a lot by 95% at a bazel. That's point one. You're not hitting the mark, by any means.

Scott Benner 59:21
Remember, you're not going to

Jennifer Smith, CDE 59:23
write it. That's that's not hitting them. You can even look at it a little further if you take into consideration. What what's the climb in blood sugar. Let's say the child is starting at a blood sugar of 91 at bedtime and climbing up to 303. Right? That's a huge increase in blood sugar. You can also take a look at Well, what is your correction factor? Most little kids have correction factor somewhere around like one unit changes their blood sugar by 150 points or by 200 points. If your kid is climbing 200 points, that little notch up 2.2 When your kid really needs a whole unit to correct a 200 blood sugar climb, right? That's how much you need to change the base and why

Scott Benner 1:00:08
Yeah, here's the thing, you'll hear me say this a lot. If you listen to the podcast, you need more insulin. That's it. If you have more insulin, it wouldn't happen. And by the way, for the person who asked about the group, and by the way, too, for a little kid, that could be growth overnight. Right? And for the person who jumped in and said, their kids in the teens and going through growth, and they can't keep their blood sugar down. Here's my answer to that to use more insulin. Because there is an amount that will stop it. Trust me, there's an amount like, now the question is, how do you get to that amount in a way that doesn't feel frightening? Especially for somebody who's now talking about Look, it's supposed to be point five, I made it one, how am I possibly going to go higher than that? That feels frightening. I've told the story in the pious, long time, so I'm not going to waste it here. But there's an amount you can do just find yourself being more aggressive cover with a fast acting is used if you've gotten too much, but the truth is Peters bazel up a little too high. He's not going to go from 300 to negative 10. Out of nowhere, you know, and keep in mind too, that if you see arise at midnight, that doesn't mean change the bazel at midnight, it could mean change the Basal at 11 o'clock even or it could be a little earlier a little sooner, depending on how his body or her body reacts to the increase of bazel. Just like you putting in a bolus doesn't start working right away. Putting in a bazel doesn't start working right away. There are more thank yous in here. Those are nice. Thank you. Jen, do you have to go at the top of the hour?

Unknown Speaker 1:01:34
Oh, no. I've got about 15 minutes.

Scott Benner 1:01:37
Jenny's giving you her personal time. That's lovely. The takeaways more instant mirror it always is. Kara? I'm glad you think this is awesome. Okay, so she got correction factors thinking about it so that way. Jeff is saying protein and fat that are hitting around dinnertime. Okay, Scott. Jamie said, Scott, I've heard you say things about being an insulin deficit. From overnight, I'm pretty sure I understand what you mean, I suspect it's a reason why some people go higher than expected in the morning. It was a lightbulb moment for me. So I'm sure others may find it helpful. Anyways, I love you guys to explain what you meant here. I'll let Jenny explain what I meant. So I can drink something.

Unknown Speaker 1:02:27
Yeah,

Scott Benner 1:02:28
I see what I mean, afterwards, just you go first, relax.

Jennifer Smith, CDE 1:02:32
So if you're at a bazel deficit, essentially, you're coming in to a time period when first thing in the morning most people are trying to put food in right away, right. And if you're coming in at a deficit of insulin behind the scenes, then the impact of that food even with potentially a Pre-Bolus, it, you're still going to rise because there wasn't enough behind it in the hours leading up to that meal time. If you're at a deficit of insulin as well, you're likely seeing that you're writing in at a blood sugar that's higher than you want to be or it's higher than the target, you've had your your pump set to keep you at. And that's a telltale sign right there. And that's only then going to lead into that real time, also causing more of a rise up than you want. Because you're already starting higher than you wanted to begin with.

Scott Benner 1:03:26
I would and I think of it, if you want a different way to think about it, it's like eating a meal without a Pre-Bolus. Right, because there's just you, if you don't Pre-Bolus a meal, you start eating that foods gonna win way before the before the insulin starts working. Same idea, like Jenny said, people jump out of bed and they eat. And you know, we just explained to the last person that you turn, you put a basal rate on at, you know, not at midnight for a jump up at midnight. So if you're getting up at seven in the morning and beginning to eat right away, your blood sugar's jumping up, it's possible your basal needs to be stronger, starting at 6am. And you still have to Pre-Bolus it's not all the base, or you're gonna have to Pre-Bolus and you're gonna have to have the base. All right, it's all just the timing and amount. Everything you see with Type One Diabetes, in my opinion, is about the balance of insulin and using it when it's needed. And you have to be able to step back sometimes to see the bigger picture. People get hyper focused on what's happening in the moment. I get up in the morning and my blood sugar gets high. That's it then they stop there. It's not about that. It's about before I've now this is going to be the third time I send everything. Everything you do now with insulin is for later, but remember now is always some other times later. Ah, that's how Arnold Schwarzenegger tried to kill those people in that movie. Right. Time travel time travel.

Unknown Speaker 1:04:47
Okay. Yeah, that's all. I think

Jennifer Smith, CDE 1:04:50
the other part of it too is that there is a very there's a very emotional level to managing your diabetes. Managing somebody that you love. Diabetes, yeah, right. And so, as hard as it can be, sometimes you have to step outside of yourself. And you have to kind of say, especially for the person who's managing their own diabetes, you kind of have to step back, take the emotion out and say, Okay, um, hi. I love being high, but I'm high. Let's, let's look at the information and see what I can do to fix it. Right? Um, sometimes taking that emotional piece out of it also makes you think a lot clearer about what you want to do. I mean, that's, that's the big reason for baseball maker.

Scott Benner 1:05:40
I maintain, I maintain that I'm as good at this as I am, because it's not happening to me. If I had type one diabetes, I wouldn't have this podcast, I'd be a mess. I'd be on the floor with my 10 a one See, God, I gotta know what's happening. You know, but it was for my daughter, right? Like, no, I don't know, like I you know, it's for her. So that I'm able to, I'm able to be more aggressive because I have a bigger fear of letting her down than I would have letting myself down. I think. So a lot of the things you'll hear about on the podcast, which by the way, you can listen to on any podcast app, absolutely. For free, just search for Juicebox Podcast, there's over 325 episodes, the podcast has been up for almost six years. You know, if you don't have a podcast app, they should be free. If you can't find one, go to Juicebox podcast.com. Scroll to the bottom there are links to all your different phones to get you on. And someone just asked a question here, how to manage unexpected activity, but a bunch of people just jumped in and said have a snack. decrease your bazel Yeah, that's it. Now listen, something somebody said was amazing. I'm gonna assume it was me and we'll just move on.

Unknown Speaker 1:06:50
I don't really know what she's talking about.

Scott Benner 1:06:53
Yet, so they're talking about that they're talking about activity around all this. Also, I want to bring up around you know, a lot of people stress, anxiety, or all of a sudden sedentary lifestyle because you're not going to work anymore. All those ideas somebody in here asked about they said their blood sugar's jumping up at night, not always, since the pandemic has started. And I wonder if when your brain slows down after your days over, do not find yourself thinking or worrying about Coronavirus because stress, anxiety, pain, there are a lot of things that can make your blood sugar go up. So I would I would look into that a little bit.

Jennifer Smith, CDE 1:07:30
In fact, there's it's really funny that you bring that up because, uh, somebody that I work with, she actually just emailed me. It has nothing to do with diabetes, but my brain was right away, like bringing diabetes into the picture reading it, it's all about dreams, since Coronavirus became the thing that it is, yeah. And the fact that dreams are, they are the way that our our mental self kind of manages through things. And we can learn some things, you know, if your dreams are kind of scary, or if they're really scary, or if they're just sort of like hinting at weird things. You know, I mean, it's the way that your body manages to sort of work through some of the thoughts that it didn't have in the daytime, right? Or that were sort of in the background. And with diabetes in the picture. Some of those can be very stress inducing in the overnight time period. So you know, if you're looking at, you know, many of your overnight values and you're thinking Whoa, why is this weird? This night was really weird. I had this strange rise and I woke up high and that's usually not happening for you. Maybe you had a horrible dream about

Unknown Speaker 1:08:37
something that you know, and it's not about never hugging another person again.

Jennifer Smith, CDE 1:08:44
Could be I had a I had after all this started I had a horrible dream about zombies. Did you? Horrible like I woke up in like a panic. And I usually I don't remember many of my dreams. I usually see sleep pretty soundly. Yes. Dream had me like, I was like all levels.

Scott Benner 1:09:03
When Natalie just jumped in and said playing video games makes her teenage son's levels go up. That's adrenaline, I would imagine. And Natalie I bet you they come back down again. Right? And because that's that's another thing. So stress, anxiety, those sorts of things are always going to well always have the ability to impact I'm sure there's some people get stressed out in their blood sugar's don't go up. But it does happen to a number of people enough that it's worth paying attention to.

Unknown Speaker 1:09:27
Yeah, and

Jennifer Smith, CDE 1:09:28
sometimes you can address the rise. If you know that it's not going to come down sometimes sometimes you have to correct for it. Many times adrenaline rises, though. We often don't have to touch oftentimes once that stress factor or the adrenaline like surge sort of passes. You'll see things come back down.

Scott Benner 1:09:46
You know it's funny somebody jumped in as you were making this and said a bedroom could make your blood sugar go up at night, mira said and there people my daughter's goes up with Xbox so if you know, listen, it's not the easiest thing to to Guess schedule. But if you know, Xbox time is going to be in a certain place, you probably could do with Temp Basal increase. Right. And that would

Jennifer Smith, CDE 1:10:08
that would definitely kind of like weightlifters if you know, you've watched enough to know how much blood sugar typically rises during Xbox use, you could technically take an amount of insulin as a bolus to offset the typical rise that you see based on what your correction factor is.

Scott Benner 1:10:23
Let's see if we can get one more thing in, because we have to go so somebody asked about their Dexcom user, and they're talking about Pre-Bolus. And when do you know when to start eating. So for my daughter, in a perfect situation, I like to see a diagnose Down Arrow before she starts eating. And you also have to get right in your head what's high and what's low, too, you know, for me, I don't want my daughter, I try very hard for our not to go under 70. That's my goal. And I try for not to go over 120 do we always do that we do not always do that a number of times a day, she ends up higher, it just happens sometimes. Okay, all the things that you just heard about happened to us to my daughter's a one C has been between five two and six, two for almost six years. But she got out of bed didn't have enough insulin going because she slept in try to eat something with a lot of carbs and her blood sugar's 200 right now. And it's and we're going to get it back down as fast as we can without it getting well it's not you're not shooting for perfection. You're just shooting for as much time and range you can get in there. But back to the initial question, I like to see a diagonal down arrow. But now I know how fast the food is going to hit or just you just have to practice right like, started 100 put in the blood sugar when you get to 91. Diagonal down, eat, see what happens? Did you go up to 150? But then level back out? Cool. Maybe you could have waited till 85 diagonal down. Maybe that would have taken you do 130 c? It's just trial and error. You have to go over and over again.

Jennifer Smith, CDE 1:11:53
Experience teaches you? Yeah, a fair amount.

Scott Benner 1:11:57
JOHN, I don't know that. Jenny knows this answer. But I'll ask before she goes john wants to know if you know what factor? What factors affect the hypest hypoglycemic risk value on the dexcom clarity app, you know what it takes into account to come up with that? I don't,

Jennifer Smith, CDE 1:12:13
it I don't, but my assumption is that it calculates the percentage of time that you've been low, within the timeframe that you're looking at, to classify what your risk is, you know, if you're, you know, 1% of the time low, I guarantee that your risk factor for most is not high. Whereas if you're pretty consistently at 10%, low, even if it's not really red low, it's just that pink low, right? Because there's a different designation. There's a 55, red low, right? But I mean, if you're really low, pretty consistently, that risk factor obviously goes up. I don't know exactly what parameters they're using to establish that percentage value for you. Um, but

Scott Benner 1:13:09
Alright, so let's roll through these last three, Jamie brought up that if she waits for a diagonal Down Arrow for her credit goes lower, so it's gonna be different for everybody. Yeah. Lisa is saying hello to us from Sweden and said, we've both been very helpful in her first six months of being a type one mom. Hi, Sweden. That's cool. And Sue asks, do we recommend the in pen which I think we both though?

Unknown Speaker 1:13:29
Yes,

Scott Benner 1:13:30
yeah. If you can't pump, you can get a lot of the knowledge that a pump has from in pen pairing with their in pen app and your your glucose monitor and even a meter. Not as much luck and Jenny's holding one right there.

Jennifer Smith, CDE 1:13:42
I've got the pink. You can get them in different colors.

Scott Benner 1:13:44
Yeah, I've got blue in here somewhere. But it's a demo. So. Yeah. Okay, so listen, Jenny was only supposed to be here for an hour. It's 409. She got to go back to her life. I want to say that at one point. This was up to 120 people and it never got below 80 even 15 minutes after it was supposed to be over. So awesome. Really appreciate all you guys. Thank you so much for listening to the podcast. If you enjoy the podcast, please share it with somebody else. It's the only way it can grow. I do not have money to to do any kind of meaningful. You know, advertising for the show in the last comment here again is Jenny's email address. You can hire Jenny. She works at integrated diabetes services. You can have one on one calls just like this with her. Check it out. See if your insurance has covered it or if you want to pay cash, whatever you want to do. Jenny is very cool. She is 100% my diabetes spirit animal. I've never heard her say one thing that I was like that's wrong. But as I've mentioned on the podcast before, that might just be my narcissism because she agrees with me. I think she's terrific. But who knows exactly, you know, this will be available on the podcast soon. And it will be running on Juicebox podcast.com as well. And it stays here on Facebook. So thank you everybody very much and Hope you guys have a great day. And Jenny, I really appreciate you doing this. Thank you.

Jennifer Smith, CDE 1:15:02
Yeah, no, this was great. Thanks to everybody who commented back and forth to each other as we were answering. It's a great way to help each other. Yeah.

Scott Benner 1:15:10
Very cool. All right, guys. Wash your hands. Stay safe.

Unknown Speaker 1:15:15
I why.

Scott Benner 1:15:19
Don't forget even though this episode was not sponsored, the podcast does have sponsors like Dexcom. The Contour Next One blood glucose meter, touched by type one and Omni pod. There are links to those sponsors in the show notes of this episode, and at Juicebox podcast.com. If you're not looking for those types of things, go into your podcast app and leave a glowing review of the podcast. It would make my day and Jenny would smile about it too. Alright, let's turn off the music and we'll dance our way out of this

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This is a bonus episode and was not sponsored. That said, these are the show sponsors.

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About Jenny Smith

Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com

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