#899 Diabetes Pro Tip: Transitioning
Diabetes Pro Tip: Transitioning
Scott and Jenny Smith, CDE share insights on type 1 diabetes care
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Scott Benner 0:00
Hello friends, and welcome to episode 899 of the Juicebox Podcast.
My diabetes Pro Tip series for type one diabetes began in February of 2019. Today I'm adding another episode. Jenny Smith and I are going to be talking about transitioning. We're going to do an overview of transitioning from your blood glucose meter to a CGM, from MDI, to pumping from pumping to algorithm pumping. And at the end of the episode, I'm going to add feedback from Juicebox Podcast listeners about all of these topics. While you're listening today, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan are becoming bold with insulin. If you'd like to help type one diabetes research, all you have to do is complete the survey AT T one D exchange.org. Forward slash juicebox. The T one D exchange is looking for US residents who have type one diabetes, or are the caregiver of someone with type one to complete a very short and simple survey. The answers that you give will help move type one research forward T one D exchange.org. Forward slash juicebox.
The diabetes Pro Tip series from the Juicebox Podcast began on February 25 2019, with an episode called newly diagnosed restarting over after that episode 211 was all about MDI episode 212 all about insulin, Episode 217 Pre-Bolus Singh, Episode 218 Temp Basal 219 Insulin pumping to 24 mastering a CGM to 25 Bump and nudge to 26 the perfect Bolus to 31 variables 237 setting Basal insulin 256 Exercise 263 fat and protein 287 illness injury and surgery episode 301 was glucagon and low blood sugars episode 307 Emergency Room protocols episode 311 long term health 350 Bumping nudge to 360 for pregnancy 371 explaining type one episode 391 was glycemic index and load 449 postpartum 470 weight loss 608 Honeymoon 612 female hormones and today episode 899 transitioning, you can find these episodes in your audio app Spotify, Apple podcasts or anywhere you get audio. You can also find them at juicebox podcast.com. And at diabetes pro tip.com. As always, these episodes and the entire podcast are absolutely free for you to listen to the information inside of this podcast. And more specifically inside of this Pro Tip series. This information is at the core of how my daughter has kept her a one C between five two and six two for over eight years without diet restrictions. Myself and Jenny Smith Jenny of course is a CDE who works at integrated diabetes.com Jenny and I we go over the topics go over the ideas in easy to listen to and digestible ways you can apply this information to your life whether you're an adult with type one who's been living with it forever, or a parent whose child was just diagnosed, I implore you to check out the entire series. It really will help. This episode of The Juicebox Podcast is sponsored by cozy Earth cozy Earth sells sheets and towels and joggers and comfortable things really that's what I should have said cozy Earth has comfortable things whether it's sheets or towels or clothing. It is soft, it is warm. Unless you don't want it to be warmed I don't even know how to describe the sheets or they keep you cool or they keep you warm. Depends on what you want. I don't even like I don't know if there's a word for it but your body is temperate in it is temporary the word. I looked it up it is a word it. How do I put this? I wear my cozy Earth gear on an airplane the other day. I wasn't too hot. I wasn't too cold. When I got home. I got my bed with my cozy Earth sheets. I wasn't too hot. I wasn't too cold. Everything is soft. It feels terrific. Check it out at cozy earth.com where the offer code juice box will save you 35% at checkout The podcast has a number of long term sponsors, Omni pod Dexcom contour G voc, US med touched by type one, athletic greens. Of course, you heard about the T one D exchange earlier cozy earth. All of these sponsors are prominently displayed at juicebox podcast.com. Or in the show notes of the podcast player you're listening in right now, when you support those sponsors by clicking on my links or typing in those web addresses, you are supporting the production of this podcast. So please, if you have the need, use my link. What I would like to talk about today is transition. Just a an overview concept for this one, but transition from just finger sticks to CGM transition from MDI, two pumping, transition from pumping to algorithm. Sure, can we do that? Yeah. All right. I thought we could all thank Isabel here for having her finger on the pulse of the people in the Facebook group and knowing exactly what people ask about, and what they seem most confused about. Why don't we start with MDI, because everybody starts there, right? After you're, you're doing it for a while, like, let's put ourselves in that place. We've been doing MDI for a while it's working pretty well, or at least at a baseline. We're shooting a Basal insulin once a day, and we are shooting a meal insulin to correct blood sugars and to cover our carbs. That's the basics of MDI. Okay, correct. So then we're in a doctor's office, but I'm gonna make up some numbers. Let's, let's say our basil. It's like, I don't know, let's say our basil is 10 a day. And let's say were, I don't know, one to 10 for carb ratio. Okay. All right. Let's say our correction is one to 100. Let's keep it all very like, like that, so that it's easier to talk about. Okay, round 10 numbers and numbers, we're gonna do that. So the math makes sense when people are listening. So we're in the doctor's office, and the doctor says, you know, you might like a pump?
Jennifer Smith, CDE 7:24
Is he gonna say it just like that?
Scott Benner 7:25
I mean, if it's a lady, she might be like, You made like a bump? I don't know, like, people are anywhere in between. There's some women have more masculine voices, Jenny, this isn't the point of what we're talking about. Yeah. So they see, you might like a pump. You are. I'm guessing, gonna have a couple of different reactions. I see a lot of people scared. Oh, no, don't change something. I see a lot of people are like, yes, please, because this isn't working. And maybe this will they don't know why they think that just right, they're hoping for a change. So the first thing that's going to happen is the doctor is going to translate your Basal insulin to this pump. So Jenny, you do that math for me? I correct I get 10 units a day injection, what are they going to do on the pump for me
Jennifer Smith, CDE 8:13
most often on a pump, because it's expected that your Basal insulin which and this is kind of outside of it, but within your Basal insulin will now be given by the pump as rapid acting insulin. So that's the first thing to understand is that you're injected Basal insulin, which is a specific long acting kind of insulin will now sit in your refrigerator as a backup in case of pump failure, right? So you don't put Basal insulin into a pump. The only insulin that goes in the pump is your rapid acting insulin of any of the brands, right. Depending on the pump, company, they all have a little bit of different kind of recommendations for type of rapid insulin, but it's a rapid insulin and to translate your Basal dose of what we said 10 units into a pumped Basal delivery, you would essentially take 10 units into a 24 hour day. Right? And that translates into a a dripped amount, right? Because insulin pumps drip drip, drip drip consistently to deliver that total amount of basil that you want.
Scott Benner 9:32
Okay, so let's clean it up for people who get lost very easily. You may be injecting trusty Abba love Amira, Lantis what are the other ones,
Jennifer Smith, CDE 9:43
Basil Glar or these are all based in jail.
Scott Benner 9:46
These are basil insulins. These are now gone. You don't use those anymore, because as Jenny points out, you're going to take your mealtime or your fast acting correction insulin, put it in the pump, and it's going to split it up. Those 10 units are going to get split up Over, not just over hours, that's how the settings the pump work, right? You're gonna come up with what is it going to be like point four, maybe an hour if you're 10 a day about like that, right?
Jennifer Smith, CDE 10:10
Right, depending on your pump, all of the pumps differ in their precision of a single drip of insulin. Some pumps can drip as little as point one, one, some can drip as little as point oh, two, five or point oh, five. So it just depends. But if you broke this down 10 units a day into 24 hours a day would be a rate of about point four, two, if you do rounding, right? Yes, some pumps, you may have to round that 2.4, because they can't deliver the point oh two.
Scott Benner 10:42
And you're, you're gonna hear that if you're MBI. and think, oh, at the top of every hour, it's gonna give me point 14 incidents on but it's not doing that it's going to break the rack to wait for Twos Up over the entire hour
Jennifer Smith, CDE 10:53
over the course of the time. Exactly. Now, the other step to this calculation is that we expect that your Basal insulin you've been injecting I'm trying to think how to say it. So people don't think their insulin is not working. But when you inject Basal insulin as its type it, it will not be absorbed as efficiently I guess is the better way to say it as it would from a pump where it gets infused in those little tiny drips over a very precise amount of time, a very precise dose. So your rapid insulin in your pump gets infused out of sight. And so we usually take your base Basal dose down by about 10%. Some, some physicians even go down by 20%. But the general idea is taking your base dose down by 10%. So 10 units a day taken down by 10% is one unit less, so nine units instead of 10 units. So if you do the math there, nine into 24 gets your rate down instead of point, let's call it point for an hour, down 2.37 an hour, which again, we'd probably round down to point three, five.
Scott Benner 12:05
And you're going to want to keep an eye on that because I've seen it go either way. I've seen that be right. And it's amazing. I've seen that be now not enough insulin, and people are getting high blood sugars. And they immediately like you hear them say like the pump doesn't work like well, you gave yourself less insulin and turns out you need right. So pay close attention to that.
Jennifer Smith, CDE 12:27
It also translates into the next step. Once you've been making some notes on this 24 hour dose of let's call it point three, five units an hour. And you can say Well, it seems okay here. But then at this time of the day, I'm always high no matter what I can skip eating and I'm high I can eat and I go even higher. Well, that's when the next step is Basal testing. Right, we need to really look at it and say, where is that point? Three, five, sufficient and where is it not? And where might it be too much.
Scott Benner 13:01
And you might notice, and this, this might sound a little heavy if you're thinking of switching but you could put your pump on your belly and have a different reaction to the insulin that is if it's on your hip or your thigh, you know, there's reasons like Arden's thigh doesn't work as well as her stomach does,
Jennifer Smith, CDE 13:19
you know, neither does mine, I don't use my thighs anymore. Yeah, back of your arm might
Scott Benner 13:23
be better than your, the back of your butt. Or who knows, like right and with
Jennifer Smith, CDE 13:27
with this being new from coming from MDI, to going to using a pump, I would suggest initially utilizing and testing out within an area of the body, you know, we talk a lot about rotation, not only should you be rotating, if you're doing MDI, your injection should be going multiple different places, not just the same site over and over. The same goes along with pumping, those sites need to be rotated. If you're new to pumping, however, you really want to get an idea if your settings are fairly good. Stick with rotating around your abdomen, right? Get an idea. And then once you have that fairly well set, you can then move to upper body or the back of the arm or maybe your thigh or you know your lower back and see if you notice any difference some people do and some people don't at all.
Scott Benner 14:19
No, right? No. I mean, there's it's your body composition, hydration, how you know where it's actually going inside of you. Is it subcutaneous Is it very close to a muscle? We don't overwhelm people, but the muscle can kind of I don't know what the term is like what a large muscle group can. It kind of lessens the impact of the insulin but for the life of me, I can't think of why right now. Do you know what I mean?
Jennifer Smith, CDE 14:44
lessons? I know I don't know what you mean.
Scott Benner 14:46
I always thought that's why the thigh wasn't a good spot because it was a large muscle.
Jennifer Smith, CDE 14:51
Well, it might have more to do with how well the insulin at that site is getting absorbed. Like that's a big reason that I don't use My thighs is because whenever I tried using it, either I got a clusion alarms because the cannula was bumping into muscle or potentially that I had nicked, like a small vessel under and it had been clouded kind of near that site were was trying to infuse. And so that backs up into the pump and the pump tells you hey, the delivery of insulin has stopped. It gives you nice alarms. Right? So I think in some cases that may be part of the issue is the proximity to muscle, yes. But also I it was either painful or I got occlusions like it just never worked on my thighs.
Scott Benner 15:41
Okay, I'll say, Look, I'm learning from the podcast. Finally. Finally, I learned about this every day, you learn a lot. Okay, so now we've, I think here's a good place to insert that it is possible that there are some people on MDI who are achieving reasonable lower blood sugar's some how do I say this? Sometimes your doctors over baseline you because they don't think you're covering your food correctly. And
Jennifer Smith, CDE 16:12
or they may not have looked at your records enough to know why they've you know what I mean? Like, it might just be easier to backup with enough Basil with what they're seeing in your data. Yeah. And it may as you're saying, it might be wrong,
Scott Benner 16:26
right, right. So like, imagine if you're a person who has been getting more basil than they really technically need, but you kind of forget meals, sometimes you don't cover all your food. But now all of a sudden, you have this pump, you're like, Oh, it's so easy. Now, I just push the buttons for my foods, and now you're covering your meals well, and you're like, why am I low all the time? Right? It might be because you're using more insulin than you have been in the past. So those are things to look for that I see people struggle with the beginning with a pump. And I do want to say I think there's a, I think there's a period of transition there. It's not going to be like if you're nervous. It's not unfounded, you know, like you are starting a whole new way of doing something. But it really is just another way of delivering insulin to you. It's not that complicated.
Jennifer Smith, CDE 17:16
And I can say personally, when I switched from MDI, having done MDI, a long time before I started using a pump. By the time I started using a pump I was already doing. I was already doing somewhat of a Pre-Bolus. But it wasn't the same once I switched to a pump, there was a definite time difference between my Pre-Bolus with injections, and there still is, yeah, I can take an injection and my Pre-Bolus Time is not as long as it is on a pump. Right? Again, and of one. But that's what I noticed. And so those are some things to pay attention to between MDI and what you're doing along with what you said about maybe the doses you were taking on MDI, were covering a certain way for your rapid insulin for meals and corrections. And now that you're on a pump, your meals, the food hasn't changed, your strategy has stayed the same. And things are looking
Scott Benner 18:14
weird, right, right there, you do have to step back a lot and try to see what's happening. One reasonable reason for that could be reasonable reason why it wasn't right. But anyway, you use an omni pod and delivers insulin a little slowly. Like it doesn't just like you take a needle and you go Yeah, the pump is pumping over time. And I don't imagine you use very large bonuses, but larger bonuses take longer. I've seen I've sat at a restaurant with Arden and, you know, you forget you've done it and you kind of still here like that, like think like click clicking. It's still giving her insolence feels like it's been five minutes, you know, and yeah, so that's, that could be part of it. Anyway, these are things you're going to learn along the way. They're new lessons, but they're not a reason not just try, because you're going to gain what you're gonna gain so much, right? Like if, to me a pump is at its core, I've always thought of pumping as a way to be able to manipulate basil. Whereas on MDI, I shoot it in, it's in there, nothing left to do. If it's too much, if it's too little, it's what it is, you know, with MD with a with a pump, you know, you can go back and listen to the Pro Tip series. I think about like, wow, if we sit down to a meal, that's all of a sudden much carb heavier than what I usually eat, I could do a Temp Basal increase, they try to help me with this. You know, I was thinking a minute ago when we were talking about breaking the 10 units down into point 4.35 That if you think about putting a sprinkler out on a dry, dry lawn, right, and you need to give your lawn 10 Guys gallons of water, you could come along and dump it on all at once, it'll just be there, that'll be it right, or it could break it up into a little point three, five gallons every hour and go back and forth. And just a light covering, covering, covering, covering, you're never gonna soak it down, you're and it's just I think of basil like sort of like that. Sometimes you're just,
Jennifer Smith, CDE 20:20
and that's a good way to think about it too. Because if you consider that slow Basal drip that you are getting from a pump, when you inject your Basal insulin all in one clump, right? You can, depending on the kind of activity you like to do, you may have found that you have to pay attention to Gosh, I'm doing like a really heavy arm workout, I'm probably not going to inject my Basal insulin into my arm today, I might inject it someplace else, right? Because there's this whopping dose sitting underneath your skin. And any kind of insulin, whether it's rapid, or Basal can get enhanced in action, the more active you are, and especially if you're using that site. So, you know, those are the kinds of things that having those tinier doses that you can manipulate and adjust, especially with the variables that you know, are coming in the day.
Scott Benner 21:21
If somebody's listening and thinking like, well, they have spent the first 15 minutes talking about Basal insulin, it's because it's really important, and nobody tells you it's important setting. So if you listen to this podcast, like while I do MDI, they're always talking about, like, their settings on their pump or anything. This is still settings, you know, if it's MDI, it's your settings, it's, you know, these Basal carb ratio, correction factor, they're all settings. So it's just very important to have them. If they're not accurate to your needs, then everything else is just going to be a mess. And especially Basil, basil is wrong. The whole day is confused. So okay, so we've translated our basil, our insulin to carb ratio, does the doctor keep it the same? Do they usually like what is common?
Jennifer Smith, CDE 22:06
They may keep it the same, especially if your records prove to show that it seems to be for the most part working fairly. Okay. Right? Could there be improvement somewhere, possibly, or whatever, maybe that's also part of the reason that they feel like a pump might actually be better. Maybe you're the kind of person that just eats really slow digesting food. And so you've had problems with taking your insulin and having these big drops in your blood sugar too fast, and then it ends up catching up with you. And then you end up high later, and you've treated low blood sugars, right? And there's not a timing thing that you can really get quite right with MDI. And maybe the doctor says, Well, why don't we try a pump, because hey, you're eating these types of foods more frequently, we could actually use some of the smart features on our conventional pumps that allow you to take some insulin for food, we're calling these extended boluses. And you can just kind of like basil. It's almost like a secondary use of basil. But for a Bolus, where you drip drip, drip drip drip a Bolus in over a certain amount of designated time, you
Scott Benner 23:13
know, there's just, there's so much you're gonna get out of having a pump there, there's also going to be some things you need to know, sites can, like they're going to tell you whatever pump you have, they're gonna say this pump you can wear for X amount of days, or X amount of hours. But sometimes sites go bad. You know, sometimes new sites don't work as well in the beginning. Those are little things that you'll learn along the way. There's, if depending on Arden's blood sugar, she might put on a new pod, and we might just Bolus a little bit to get the site working. This morning. I woke up in the morning, I saw that artists blood sugar was trending up overnight. And listen, for those of you just switching like Arden is looping, but I can see how much insulin is left on a pod remotely, which most of you aren't gonna be able to see. But I can see she was down to like 30 units. So this is the end of her sight, right. And I just spent the weekend with her. And doesn't matter. But we were in a lot of restaurants this weekend. So Arden got a lot of insulin this weekend. And in my heart, her blood sugar is drifting up because this site is kind of done. So because you have experience, yes, I can just tell and you will be able to one day as well. So I sent her a text and I said I wouldn't go to class with this pump one. Because if she does, she's going to spend her whole day with blood sugar around 150 And she's going to be fighting with them constantly. And bolusing and they're not going to work and and by the way, if that happens, and then all of a sudden she gets crazy active out of nowhere. She might experience a low blood sugar from all this insulin kind of sitting in this right over us. Yeah, getting this pole right. And so like that's Here's the thing you'll learn along the way, you'll learn, you know what people worry about so much like, well, you know, do you travel with pumps? If we go too far from our house, we do. If it's a 15 minute turnaround, we don't like, you know, what, I'm gonna have to have insulin with me now, like, I don't know, we don't travel with insulin that frequently, as long as we're in your home base, you know. But if we go far, you know, half hour, 45 minutes, and it's not something we want to turn back from, we'll take insulin with us, you know, you just you, my point is, is that it becomes all second nature at some point. Just like everything else about diabetes, you're gonna have experiences they're going to teach you, you'll learn from them and move on. Speaking of moving on, you'll think I'm gonna go from MDI to pumping, to pumping to algorithm pumping, but I want to do CGM is first. So you have a meter. And that's how you check your blood sugar. And that's all you have. When you're in the doctor's office. The doctor is like, you know what you want to do?
Jennifer Smith, CDE 25:59
It must be the same doctor.
Scott Benner 26:01
I got one of the drawer here. Take this a sample you try. You'll love it. They're gonna try to give you they're gonna say to you, hey, you might want to leave Ray, you might want to Dexcom if you're on a Medtronic pump, they might ask you to do whatever the Medtronic CGM is called. And you're gonna say I don't need that or you're going to be newer. You're gonna Yes, please.
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Wherever you fall on that you do want it. Your insurance covers it you want it? That's for sure. Right? Tell me why.
Jennifer Smith, CDE 28:49
And I think it applies in all realms of diabetes as well. Right? Not just in type one diabetes, but also type two diabetes and even worthwhile and gestational diabetes. I know there are some rules in terms of when it can be prescribed whatnot. But I think it's beneficial all around what you miss with finger sticks are all of the little dots in between. So where things are trending, right, so if it is something that your doctor does bring up? Absolutely say yes. Right. You may not know how to look at the information or what you're getting from it initially. But it's so worthwhile.
Scott Benner 29:30
You want to know what you don't know. And with finger sticks, especially if you're newer to diabetes, or if you just been doing them your whole life and this is how you tend to think of it. You do the well i i test before I eat or I test before I go to bed or I test before I drive. And right. And I know you've asked yourself what's happening when I'm not looking right like and if you haven't asked yourself that. I wonder how do I go from two 50 to 50 in an hour, like how does that happen? And you'll learn you'll start seeing the impacts of activity and the lack of hydration, and different foods that you eat. The age of your, your insulin pumps cite all these different things that have a huge impact on the way your blood sugar moves. And now suddenly, it's there. A CGM is going to show you minute by minute. I think it's every five minutes. Right.
Jennifer Smith, CDE 30:32
And I think there are there are some people who have been using it long enough that can say, there can be some frustration around the amount of data that you get. And I wouldn't disagree with that I but I do think it's how you interact with the data, right? It's how you actually take a look at things and what you do with it and what you learn from it. And you'd have to, you have to expect that in the first month. Let's call it of using a CGM, you're gonna see a lot of stuff. And so rather than being so very emotionally reactive, again, taking a step back and kind of looking at the data to be able to make better decisions about what you felt like was probably happening, and now you can actually see it
Scott Benner 31:21
right. Well imagine you have your sprinkler out on the yard, and you have to keep the dirt moist because you've planted grass seeds, except every time you look out, it's kind of dry. That's the CGM. You look at the CGM ago Oh, from 3am till 6am. My blood sugar's 140. It's pretty stable, but it's 140. I wish it was lower or moister. I can turn up the sprinkler a little and put on a little more insulin and make it where I want it to be like push that number download
Jennifer Smith, CDE 31:48
and the CGM can show you that if you're really looking at it. That way the CGM can show you where did it start to lose? Right effect? Where do I start to need to add more insulin? It's not once you get stuck higher or once you get stuck lower than you want. It's before that so any drifts up or drifts down. You can see that very clearly on a CGM I, you have a really good example I think from when Arden first started using her CGM, it was like that overnight thing that you were constantly missing was at Lowe's when you had finger sticks, and I would put all you could see them.
Scott Benner 32:27
I thought I was a genius. I've said it before I would put Arden to bed at 180. And she'd wake up at 90. And I was like, Look how good I am at this. And what would happen. We put a CGM on her. She was 180, she'd go down to the 50s sit there for hours, I'm assuming her liver would be like, hey here, try not to die. Here's some, you know, here's some, here's some glucagon, I'll give you a little bit. And then she drift up to 90 overnight. It was happening constantly. So the reasons for that are mind numbing is not for this conversation. But we were bad at bolusing for dinner. We were her basil wasn't like there were so many things that weren't right.
Jennifer Smith, CDE 33:03
But you didn't know it because you couldn't see what was happening unless you really did a finger stick even an hourly finger stick, it would have caught a drift. But it still would right? But it would have still been confusing unless you've sat down and you connected all those dots. And you could say, well look, look at this. And you probably I mean not necessarily wanting to see your child sit at 50 for three hours before your body actually reacts and gets you the glucose that is needed to bring it up. But you'd have on a first finger stick probably under 70, you would have ended up treating so you also wouldn't have had the information to show. Well, how much do we need to take away? And what do we need to do differently?
Scott Benner 33:45
I can't I can't say how valuable it is to be able to see a graph and to enter look at it every three hours or you know what's it look like over six hours, like Jenny's point is great as the you you don't know why? What happened happened? It's um, if you're married here, it's nine o'clock at night. And you're now in an argument. Right? And you think I don't know what just happened. But mostly this is guys like they're like what? They searched the last five minutes their brain and I've not done anything wrong in the last five minutes. But if you could step back and see a whole graph of your day, you'd realize that at 630 at dinner, you said something really stupid, and now it's hit me at nine o'clock. So I think that that can be similar. You could have cheeseburger with french fries at dinner at eight o'clock at a restaurant and hit it with a great Bolus. And you're like, oh, wow, my blood sugar's still where I want it to be it's 140 After dinner, that's not bad. And two hours later, it starts to jump up. And that doesn't make any sense to you because you haven't listened to the Pro Tip series. You don't know about the fat and the French fries and the slow digestion and how your blood sugar is gonna go up afterwards. But at least if you see it on a graph, and then you go have those French fries and that burger again. You see it happen again. You can go Oh, I could get get ahead of this, right? Yeah, I could not say that stupid thing at dinner. And now we'd be watching television and she wouldn't be yelling at me.
Jennifer Smith, CDE 35:06
Right. And if you have a pump, you can also address it a different way than waiting for it to finally start rising and getting too high, you can offset it ahead of time knowing what is coming, because you've had the experience that, oh, it always hits around two hours. So I'm going to start doing something about an hour and a half before that. So that it actually doesn't happen. Right. So I mean, yeah, it's million
Scott Benner 35:32
ways to handle that if you're Yes, right. For for art in an hour after she has french fries, we have to Bolus for the fat. And there's a calculation you can do. And there's that heads off that secondary rise and doesn't cause a low later. That's the other great thing is the everyone. When you don't have enough data, you think, Oh, if I just keep throwing more insulin here and there, it's gonna be it's not true. Like you can match the need up with the impact of the insulin and never cause a low, right. And that's something you're going to learn looking at a CGM that, that uh, that a stable line on a CGM is really your insulin, your insulins pulling down and your food and your other impacts are pushing up. And neither of them are winning, like so if you can kind of imagine that line going off into affinity nice and stable. There's invisible lines. cables attached to it. One's trying to pull it up. One's trying to pull the line down, and neither can win because you have a great balance between your insulin and your knee. Yeah, so that in the CGM, like, seriously, like, I don't care, like there's Dex comms and advertiser, it's not like I'm saying that like, get a CGM. It's of any,
Jennifer Smith, CDE 36:43
right? Absolutely. I mean, I've said before, many times if somebody was going to take my technology, I would fight for my CGM. Before I'd fight for my palm. Yeah, no 100% would keep my CGM.
Scott Benner 36:58
I'll throw this here too. Even though it's about like, leaving quote unquote, finger sticks, you're never going to leave finger sticks by the way, you're going to need them. You're gonna test when you're not sure about your CGM. You're gonna test when you're making big decisions. I listen to my daughter's blood sugar looks high on her CGM, and we're gonna make a big Bolus. I said, Look, you gotta test we got to know this numbers, right? We can't just start throwing insulin in here. And you're actually 40 points lower than this, or whatever.
Jennifer Smith, CDE 37:23
And I think it's also really important to acknowledge what you know about how you feel around certain blood sugars. Because again, technology. It's wonderful. And it's so much better than it was years ago. But it may still not be accurate at certain points. So always those finger sticks are important to continue to use. Because if your symptoms or how you're feeling doesn't go with what your CGM is reading, I guarantee a finger stick isn't gonna lie to you not unless you still have like, apple juice on your fingers.
Scott Benner 37:58
I was gonna say and I didn't get to it just an accurate meter, just a blood glucose meter. Yes, they're not all the same. They don't all work as well. Don't just take the one that doctor handed you from the drawer, do a tiny bit of research use the one that I that advertises here because that's the one we use and it's amazing and, you know, like or do what you can do your own research and find out I will throw out a little story here. Because I did spend the weekend with my college age daughter, which I haven't done in a while as a visitor at school. Second night she was with me. We replaced her CGM. Okay. So at five o'clock at night, I said, Hey, your Dexcom is going to expire one in the morning. You should switch it now. It's before we're going to eat dinner. We'll get it back online. It will have it we can do some finger sticks through dinner. And then it'll be rolling and working well by the time we go to sleep, because it does take a little while for some people where to look right. You know, she does. I don't want to do that right now. So then when do we change her CGM? 10 o'clock 11 o'clock, you know, like, oh, so then it's done. So then it's wonky for the first couple hours. And for Arden, if her Dexcom is wonky, it's wonky low when she first puts it on minus two. Okay. So like, I mean, it'll be like you're 42. And she's 10. Like that kind of thing. Yep. So there's a lot of consternation in what you should do. I'm a fan of letting it be on for a little while and calibrating it to help it get along a little more. But now we're asleep. And it's like BP people. All I could think was I told I know I said this. Nobody listens to me. But that's fine. And I'm like, and I know she's not that low like and but it's worrying. So now she's, she's asleep. And I get up and I'm checking her blood sugar and she wakes up. She's like, What are you doing? I'm like, your CGM is going off. She goes, I'm fine. It's like okay, so I tested her and she was 130. And I was like, okay, so she's right. And I did a calibration and it came together. Other pretty quickly. And that was it. Having said that, we could have done that at five o'clock. There. So there is a way to time, your technology. Now the new g7 is going to have a shorter warmup period, which will help overlapping you'll be able to soak your sensor, which I'm not going to bother explaining here. But yeah, but as the technology gets better, so should those things. But that is not to say it's not, like hands down. The most valuable thing that's happened to people who have any kind of diabetes. Since I've since I've been aware of diabetes, so absolutely. Okay. All right, Jenny. Now we got our CGM. We're using a pump. We're looking online. And we're like, see, this isn't that the doctor is not gonna go you know, you got to do. That's not gonna happen now because this stuff's also new. Maybe Maybe you're really in tune doctor might say, why don't you get an algorithm? But for the most part, I don't think I think that's the thing you're gonna figure out on your own a little bit. So all this stuff we're talking about about, you know, the Bayes will be incorrect. And you might need a Temp Basal here. You might need an extended Bolus for fat you might need all this. There are pumps that make those decisions autonomously. Yeah, you have to be wearing at this time, you have to be wearing index calm, because it works with that correct. But
Jennifer Smith, CDE 41:19
or med tronics. Um, CGM? Yeah. Because they're their system also works with their pump.
Scott Benner 41:25
Yes. So there's a Medtronic version of this. There's a tandem version of this. There's an Omnipod version of this. All their algorithms are proprietary, they work slightly differently, but long, and the short of it is they're going to give you insulin when you need insulin, and they're going to take insulin away when you don't need it. They're going to endeavor to stop you from getting low, and endeavor to stop you from getting too high. You
Jennifer Smith, CDE 41:48
still know how they do that it was with targets. Yes. Right, right, specific targets in each of the different pump systems. Medtronic newest one was just approved, which is really nice. But they all have specific targets. So how that algorithm works is based on when and how to give you more or less based on a target and based on what the system is projecting off of your current CGM trend. So it's a very interesting, like the algorithms don't just willy nilly deliver or take.
Scott Benner 42:24
Like, I think maybe now more,
Jennifer Smith, CDE 42:26
right? Yeah, exactly. There's a map to the algorithm right
Scott Benner 42:29
Gremlin inside of your pub flipping a coin going, Oh, my God heads. Let's do it. So but it's it's it's stunning. Now there's another version. There's a number of other versions there are Do It Yourself versions. There's Android APs. There's loop. I think, Jenny, you loop. Right. I do. I think you would
Jennifer Smith, CDE 42:48
have been looping for five and a half years.
Scott Benner 42:52
And Arden has been doing it. I think since 2019. Maybe? So yeah. And you're Arden's using loop three, as am I and you just switched to it as well. So like, they're all just different versions of an algorithm making decisions about insulin based on your CGM trend. That's Yep. They're astonishing. They work incredibly well. They are not magic. I know in all settings, all knowing how to Bolus for certain foods, understanding the impacts of things, your digestion, your hydration, like all the things that are important about MDI are the same things that are important about pumping are the same things that are important about using an algorithm.
Jennifer Smith, CDE 43:38
And you made I know, people can't see you, but you were very in a line going from MDI, to pumping to algorithm. And I think that's, it's a really important piece. For those who are listening to understand if you're kind of listening to this, because these are not pieces in your life already. Right, and you want to get an idea. There is 100%, I'd say 1,000% value in learning on MDI. And then moving to a conventional pump, that does not do anything for you, meaning it does not use an algorithm. There's absolute value in that, you know, we talked about testing, and evaluating settings, and learning about all the variables, food and activity and everything and how to adjust your pump or your insulin doses to accommodate for those variables. I think as you mentioned, when you said you owe your pumps, like, hey, let's start on algorithms. I can't go as deep as you. So it's a totally different doctor, right? But in that sense, there are I think more doctors today who are thinking algorithm, but in my personal and professional In all opinion, I think some of them are thinking that too fast. Okay? They are they are moving somebody to, hey, you're MDI, let's move to this algorithm driven system, whatever the system is, whether it's Omnipod, five, or tandem or Medtronic. There is, there's a missing piece in the middle there, that if for some reason, and we talked about CGM is potentially not being always accurate or technology failing. If your pump fails in its algorithmic dosing, and you have nothing to step back to, you're at a loss. And it's important to understand that, you know, so I can't emphasize.
Scott Benner 45:42
It's incredibly important. Jenny's been talking to me about this privately for years. Honestly, she's like, people can't just be put on the machine, the machine does the whole thing. And they don't understand why it's happening. Because, you know, the general argument is, what if the machine stops working? I don't even think that's the need for that. No, I think the need is, is that this is a thing you have to understand. Like it, no matter what none of this machine stuff is at the point where you don't need to know how to how it works. It's not AI, it's not even a computer like you know, used to have to know how to fix your computer, because it would break all the time. Nowadays, you buy a Mac, it'll just do the thing you want it to do, you'll never have to touch it, and it'll die. At the end, you're like, Oh, my Mac doesn't work anymore, you get another one. And you don't need to understand how a computer works. To use a computer. You need to understand how diabetes works. To have diabetes, I don't care what version of care you're using, I don't care what the next one is. Now, if someone magically comes up with something one day, where it just works, no matter what, like a, like a laptop from Apple, okay, then then okay, then God bless. If you want to skip it, then skip it. But I'm still gonna say, that isn't happening anytime soon. Because of not just the things we've mentioned today. You know, your insulin pump site might not work on time, like your CGM might not be right right away, like all the other things, it just not happening anytime soon. So you don't want. The worst thing I can imagine is that you put an algorithm on a nine year old who it works for. And then five years later, the kid hits like puberty hard or something and you have no idea, like the algorithms doesn't know you just became a completely different person, you're gonna have to change your settings to make that work, right. And that takes experience. And if you I think if you ever find yourself listening to Jenny and I talking and thinking, How come whenever something comes up, they just fill the next space with something valuable. It's because Jenny's been living with diabetes for over 30 years. And I've been staring at my daughter for 15 years watching her have diabetes. And I have a never ending supply of experiences and answers in my head because I learned through them. Yes, that's why and that's why you? Yeah, like you didn't go to like diabetes University where they told you something secret that they don't tell everybody else, right?
Jennifer Smith, CDE 48:14
No, no, no, not at all. I mean, I have valuable behind the scenes, like information about disease states and those types of things from a medical knowledge base. Absolutely. And understanding them helps me to understand some of the navigation of that with diabetes, but the lived experience and the work that I get to do with so many people, that's the valley that you can't teach that. In a university, you you can't teach, there's no degree and diet.
Scott Benner 48:47
And for your situation, you've been helping people for so long it professionally. I tell people all the time, like, it's, it's gonna sound self serving, but it's not like it's that I was able to get advertisers for the show. So I get to turn the show into a job so that I could put this much effort into it. Because I learned every day I talked to people, like you'll hear me say like, Oh, I was talking to a guy the other day, he said something about this. That's me. hearing something I'd never heard before and right and retaining it and being able to apply it to a situation go, oh, you know where that'll help here. And then you get to keep expanding those conversations. I'm going to get to something here and you get to keep expanding those conversations till they help other things. We did fibroid episodes. Now we hear from people are like, Oh my God, my life is different. Because I got my thyroid managed well, I'm getting a lot of my I didn't realize about my iron and my ferritin like a lot of women especially are getting back to me like they're feeling so much better, because it's something they heard on the podcast. They heard it on the podcast, because I was able to focus on this because this is what I think about And now and now it's coming to digestion. And that because we had to figure out a problem with my daughter's digestion. And then we shared Get on the podcast now I've seen that help other people. That goes for little things about diabetes too. Yes, that's how this stuff spreads. This is a repository of information, but you're gonna build that in your own mind. Correct. But not if somebody slaps an algorithm on you and tells you don't worry about the thing. I'll take care of it.
Jennifer Smith, CDE 50:18
Right? Because it one that's such a, that's such a big thing that I hear well, shouldn't it be helping me with this shouldn't be doing this shouldn't? The one word I hate is learned, shouldn't have learned that I don't need this much insulin at two o'clock in the morning. Nope, your system isn't learning. I promise you it's not learning. doesn't keep track of two o'clock in the morning, gosh, I gotta give less insulin for this person. It's not that's it's not smart.
Scott Benner 50:44
Now. And Jenny, do you know oddly enough, as we make this episode, I put up an episode today called Rise of the Machines, where a guy comes on to talk about his Android APS system and how it he does believe it's going to learn in the future. Correct is so exciting, but not now. Like, what's one of his examples? He said, location services. So if you say I'm having pizza, and it realizes you're at Domino's, okay, and you have an experience with insulin, at some day, it will remember that experience. Yeah, if you go to a different pizza place and have a different experience. It'll remember that if you go to a pizza place, it'll remember that if you head back to Domino's, it's gonna go Oh, we're back at Domino's. This. That's not happening right now.
Jennifer Smith, CDE 51:33
No, in fact, there is there are some. There are some apps that actually you can track that way. Like you can take a photo of something and tap the location indicator. And the next time you come back to that location, you'll be able to see what your dosing looked like what your CGM trend looked like. So you can learn from Bob's pizzas, Friday night, last week to this Friday night, maybe I should change my strategy, it looked like this. And I want to improve this right or do it differently. But those they need to be married right into the pump so that not only do you have Okay, now I'm at Bob's pizza, this is what I had. And hey, let's the pump then can acknowledge and I'm going to do something different for Jenny.
Scott Benner 52:17
But for that happening just automatically, that's not here yet. 2023 on the pod five doesn't do that. Tandem T slim doesn't do that the control IQ doesn't do that. The mechanic doesn't do that. Now, it may have happened one day. Sure. But the other I think the other thing is, I know you want your days to be easy, and they can be they can be much easier than they are now they can be more your intuition can come into play as you grow. But this is a lifelong thing. And what you want is you want to get to the point where I saw Arden get into this weekend, where we sat down to this meal, there were 16 different things. And she just looked at it and picked up her phone and went and pushed the button. Yeah. And I was like, how much did she give? She was I don't know, I told it was like 85 carbs. And it was and she and I was like, okay, and then she was okay. And it was okay, just looked at a table at a restaurant. And she's like, I think about this much. And and that's boy, forget this podcast and everything else. It's that's where you want to get to where just where you wake up at two in the morning, you see a high blood sugar and you go, Oh, I know what this is. And that does come it really does come. So anyway. But you're gonna transition along, by the way, I think algorithms are amazing. And
Jennifer Smith, CDE 53:42
yes, they are. Absolutely I I love my algorithm. Absolutely. But I've also learned to work with it. And I've learned what it can do and what I still need to tell it to do. I think that's the big thing about algorithms is knowing that you still have a fair amount of action to put in to it so that the algorithm can work with you.
Scott Benner 54:04
Yeah, yeah, I wouldn't want anybody to think like, oh, you're using a do it yourself loop. It's magical over the other comp there. It all is about the same. Like they all need your help. They all need your intuition. They all need your knowledge. There's nothing if you think you're going to just put a loop on or on the pod five, and it's just going to be perfect. Like you don't have to do anything. Like that's not going to be the case. No. Yeah. So but don't be afraid. No, like I I'll say something here on the hall, save myself Saturday, make a beat and make myself sad. Yesterday was my friend Mike's would have been my friend Mike's birthday. And I don't want to bring all this down. But Mike had diabetes. Type one when we were teenagers. He's not with us any longer. I believe that one of the reasons Mike's not with us any longer is because Jenny alluded earlier that I was stepping along with my hands while I was talking about things like Mike Never came along. He just somebody gave him regular and mph. And he used it long, long after he should have been, you know, didn't have updated meters and didn't you know, he didn't do the little things that you do to come along. I mean, I guess what I'm saying is you don't want to be managing your diabetes like it was 10 years ago. Right? I don't think so.
Jennifer Smith, CDE 55:25
I think you're also bringing something in here. That's really important to consider, because you've, you've talked about, you know, practitioners bringing up hey, why don't you try a CGM? Hey, why don't you try a pump? If, if you're the one always going to your doctor asking for what's new. I don't know. I you know, and your doctor is very willing and can talk about it then with you. Maybe they didn't bring it up. But they're very, they're knowledgeable about it. Once you do get on it fine. But if this is someone who's never really brought it up, and kind of like, shrugs their shoulder and like, sure you could try it, whatever you may need kind of like your friend maybe didn't have a doctor who was keeping up with what could have been better for him.
Scott Benner 56:10
Yeah, yeah. Yeah, you don't you have to take this as a, I don't know, if you want to call it a disease or like, some people don't like that word. But this is a way of living, that it begs you to be involved in it? Yes. Like, it just, it just really does. You have to be aware, you have to take some time to learn what is happening with technology, what's happening with insolence, you know, and you need to move along with it. Because if you look back 50 years, I still interview people who are like in their 70s and have had diabetes forever. And they don't even understand why they're alive. Like, like, you don't want your life to be a coin flip. You don't I mean, like there are things you can do to to, to give yourself better health outcomes. And those health outcomes are not just health outcomes, their quality of life, they're your they're your psychological state of being like there's so much good that comes from just understanding. I know that sounds silly, but how to set your basil right? And make sure your correction factors, right. And you know how to cover the foods you eat?
Jennifer Smith, CDE 57:16
Absolutely, I think and on a bigger scale. We're also we're all supposed to be a participant in our life, right? health in general, you may have been given good health to begin with, but you're the keeper of that health. Right? It's just like, you're the keeper of the car. If you continue to let the salt buildup on you never wash it off, you're gonna have a rusty car. Well, you're your body's the same way, right? You're the keeper of your health, you got to do things to maintain your health, diabetes, it stepped up a level it is
Scott Benner 57:50
absolutely. And so prepare to transition by getting as much good information as you can, but then at some point, just have to do it. You have to just dive in and do it and then learn a new thing. And then once then you'll be surprised at what else comes from that. And anyway, listen, it's also not to say that you couldn't get an algorithm pump right now and teach yourself backwards. I actually think you can. Sure. I think some people have a harder time with that than others. And I don't want you to be in a position where you're lost and something's happening. And you don't understand why because it won't be any different than a person that gets over Basal on MDI and thinks they're doing okay, but it's not really covering their meals well, right, you know, and then doesn't get hungry one day, and then it's up low all afternoon doesn't understand what happened. Like diabetes. There's no reason that if, if you have an if you have enough information and understanding diabetes doesn't have to happen to you. And I think that's maybe the most important part like I would if it feels like it's happening to you, instead of you are doing something and then something's happening. I think you have to have to look and get a deeper understanding, because it shouldn't just be happening to you. That's all. Okay. Awesome. Thank you Jerry.
Huge thanks to Jenny for helping me once again on the Juicebox Podcast, you can learn more about what she does for a living at integrated diabetes.com Jenny might be able to help you. Thank you very much cozy Earth for sponsoring this episode of The Juicebox Podcast get 35% off your entire order at cozy earth.com By using the offer code juice box at checkout. And don't miss the rest of the diabetes Pro Tip series and the other series within the podcast. If you give me a little gifts, give me two more minutes of your time after the music and I'm gonna tell you a little more about this series and the others But first tips from other listeners. I want to thank everyone who left their tips for this episode on the private Facebook group Juicebox Podcast type one diabetes and the people who left their tips on the public group bold with insulin. This first one is for going from pumping the algorithm test your basil and your ratios before you move to an algorithm. The first few weeks may be frustrating, don't give up. Reach out to people online for advice. They probably have been doing it longer than you. This person leaves a little bit of advice from going from MDI to pump says the first night they kept getting low and didn't remember that they could turn their basil down. We talked about this in the episode having access to your Basal insulin. Next one says Oh, I love this one. Listen to the diabetes Pro Tip series from the Juicebox Podcast Take notes. Here's another one from this person. Some sites have dramatically different absorption rates. We talked about that in the podcast. Here's one for Dexcom. Learn to look at the dots instead of just the number in the arrows. This person says when you're going from just having a meter to a CGM. Remember the CGM is just one of the tools in your arsenal, it's not a full replacement for a blood glucose meter. Use both tools effectively. Don't get overwhelmed. They are just numbers and data. It's not a grade for you. It's good advice to this person says no matter what you're doing, whether you're changing from MDI, to pumping pumping to algorithms, your ratios are likely going to change. And that takes time to figure out. This person says not all algorithms are the same. So make sure you understand which one you have and how it works. Their example here is if you're having trouble with a T slim product, don't use someone's advice from the pod five, it won't be the same. Don't assume that your CGM is always correct calibrated if symptoms aren't matching the number, use finger sticks to make sure other person preaching patience, and says not to make perfection your goal, just shoot for shorter peaks, and more shallow valleys in the beginning and over time, your skills will get better. And those peaks and valleys will flatten out. This person says be prepared when your technology doesn't work. And please don't expect perfection. Another person basil testing, there's a great episode about Basal testing in the Pro Tip series. Here's one that just says don't give up. I like that one. I like this one here. Don't use too many new or different foods when you're trying to figure something out. So stick to meals that you are good at bolusing for that way you remove variables, right, like you know, on MDI knew how to cover this food. So I'm doing the same thing on pumping, what's not working, then you can look at your settings and see what's different. I'd say that's a great one. I like that a lot. Educate yourself on how your pump works. Don't just trust that your rep set it up correctly. It's a lot of settings in there. It's a good one. We were used to coasting high no matter what this is an MDI, person to pumping. And we rounded up way too much on our carbs. When we switch to a pump, it took a few weeks of lows to get out of that habit and trust that the pump knew what it was doing. Interesting. So if the settings are good on the pump, I see what they're saying their settings on MDI weren't great. So they were always just, you know, doing more. But when the pump was set up, well, they didn't need to do that anymore. It's interesting. That's a good one. Here's a great one. Don't just put in settings into your palm, write them down somewhere. If something happens to the pump, you need to have them to put back into a new one. And keep a pen or needles handy in case you need to do manual injections. Even on a pump, you might have to do that sometime. That's very good to your settings in a manual pump may not work in your algorithm. This person talking about a CGM says when you start a sensor start at a time of day when you haven't eaten for a couple of hours. And you're not going to eat for a couple more hours if you can. Evening is good, especially for kids in school so the sensor doesn't run out at school. Oh, that's a good one. So he like you don't want to like put it on. I think what they're saying is you don't want to put it on at nine o'clock in the morning on Saturday. Because then at nine o'clock in the morning, you know, on a weekday it might run out. That's a good one. Don't feel bad about removing a sensor if something's wrong, whether it's causing pain or discomfort because you can always call the company and they'll respond with a replacement. You may have heard leaders or readers, that's not always the case. This person says if you haven't heard that phrase, you will eventually take pictures of your CGM sensor codes and transmitters put the expiration date into your calendar with a reminder and that way it won't sneak up on you. Here's one for going from MDI to pumping make sure the correct factor is calculated using the number, the pump shoots for not the one you were shooting for on MDI. Interesting. So what she's saying I think is if the pump gets set up in the target is 100. But when you are MDI the target was, then your correction factor won't be correct. Interesting. This is funny, I can't read you the whole thing, but it says, eventually, something's gonna go wrong. And your tech savvy husband is somehow going to push the wrong button and deactivate everything. I don't think that's as much advice as somebody who wanted to tell a funny story. Going from a blood glucose meter to a CGM. Don't look at the thing every five minutes for me that led to me overreacting to blood sugars, that may not have warranted a reaction at all. Set your alarms at a useful level. This one's terrific the person who sent this one and use that to guide your decisions rather than checking constantly on CGM. I'm a big believer in this by the way, if it doesn't beep, I don't look, there's a person here echoing this sentiment that blood sugars can be fluid, and that it's possible you can overreact and be the reason it's jumping up and down. I think that's worth repeating actually. When you're going from MDI to pumping, you don't need to wait to do a correction Bolus, make use of the insulin onboard information that the pump has great one, that's a great little tip. There's a comment here with a ton of information for the Omni pod five, I'll tell you there's actually an omni pod five Pro Tip series. Definitely listen to that before you go to Omni pod five. But I do want to add a little bit here from this post. Fluid insulin delivery, like an algorithm has to do suspending and increases and decreases and that demands a different approach than a static Basal. So in a regular manual pump, where you might just say, um, one util an hour all day long. You're making a lot of adjustments throughout the day that you don't realize, because there are times you don't need that insulin at a unit an hour might need it more may need it less. That's why the initial settings on these are so important and you kind of stepping back and watching it work for a while to see where your settings may need to be adjusted. Or maybe the way you use your insulin needs to be adjusted Pre-Bolus etc. This person says that a pump was not a cure all for their problems. And they found it very deflating when they went from MDI dual pump and it just didn't make everything better. That's important, Jenny and I definitely went over that in this episode. But keep in mind, this person says here that your doctor's office might say we don't give a pump till one year or you can have a pump till after you've been on MDI for six months or something. That'll sound like a rule to you when they say it. But that's not really a rule. You can, you can push. This is a reiteration of something we heard before. But when you're going from just a blood glucose meter to a CGM, you might want to take some time to just absorb everything. You don't want to just jump in and start tinkering right away before you know what it is you're doing. You know why you turning this dial on that dial really kind of lived through it for days, maybe weeks, even before you just say, alright, I see a trend here. I know what's happening. This is an interesting one. This is for somebody going from MDI to pumping. They don't want you to forget the tricks, you know, brain like if you see a blood sugar, and it's kind of stuck and it won't move and back on MDI, you want to inject it in a unit, there's no reason why you can't give a unit with the pump. Just because the pump says, Hey, there's still insulin onboard, it doesn't mean that that insulin was calculated correctly, and is really about to make an impact. I think they're saying trust your gut. This one's a little long, but the person says everyone's experience is going to be different. So roll up your sleeves, go into it with an open mind and be ready to dig in and do some problem solving. And don't forget to listen to the podcast, they go on to say when going from MDI to a pump, you really have no idea what to expect, you can only kind of hope that you start out with great settings. But that may not be the case. So many people end up having a poor experience when they switch and then they share that online. And then this person was like scared. That's what was gonna happen to them. But then that wasn't what happened at all.
It was incredibly easy, she said, and his numbers got much better very quickly. So I think the I think the message here is, sometimes people just share bad news online, doesn't mean everything's bad news. Here's a little tip. A pump company puts their pump through the FDA for approval, and they choose a couple of insolence to use in the pump. Those insulins are then approved in the pump. It doesn't always mean that the ones that aren't improved in the pump won't work in the pump. It just means they didn't put it through FDA testing. I want to thank everybody who share those tips and remind you that those people exist in the private Facebook group for the Juicebox Podcast. There are so many other management based series within the podcast. You're listening, of course right now to the diabetes Pro Tip series diabetes Pro, tip.com, juicebox, podcast.com, and in your audio app, but there's also the defining diabetes series, diabetes variables defining thyroid, bold beginnings, ask Scott and Jenny. And we have collections of episodes about algorithm pumping, which we talked about a little bit today, you can find out way more in the algorithm pumping episodes. There's the after dark series where we talk about all the things that people don't usually talk about about diabetes, how we eat mental wellness, there's so much to choose from. And if you happen to know somebody with type two, there's a brand new type two diabetes series for people with type two or pre diabetes. Check them out at juicebox podcast.com. Here's a little feedback from other Juicebox Podcast listeners. After devouring the Pro Tip series, I got my daily average down by 30 points. And I'm excited to continue learning from this all in one resource. If you're struggling with insulin, this is the place to figure it all out. I am so thankful that a friend recommended the Juicebox Podcast to me, and I wish that I would have found it at the beginning of my journey. I have been binge listening since I found this podcast. My son and husband both have type one man, I wish I had this when my son was still living at home. I'm learning and sharing how we're going to get our agencies lower. I've had type one diabetes for 20 years, and it was never well controlled until I started listening to the Juicebox Podcast. I've become bold with insulin. And this podcast is unlocked the solutions to so many issues I've struggled with for years. I can read you these reviews all day. But I would prefer to stop because it seems it's tricky to do this right? I just want you to go listen to the Pro Tip series, find the defining diabetes. If you're new, go check out bold beginnings. All of the information that you could possibly want and need about managing your insulin is in the Juicebox Podcast. Subscribe now in a podcast player like Apple podcasts or Spotify, Amazon music or wherever you get your audio. And don't forget to check out the private Facebook group, which is also free Juicebox Podcast type one diabetes 37,000 members and it grows by hundreds of people every week. What a resource. Please don't miss out on this community.
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#612 Diabetes Pro Tip: Female Hormones
Scott and Jenny Smith, CDE share insights on type 1 diabetes care
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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 0:00
Hello friends, and welcome to episode 612 of the Juicebox Podcast. This is also the next episode, the diabetes Pro Tip series.
On this episode of The Juicebox Podcast, Jenny Smith and I are going to be talking extensively about hormones, female hormones, about getting your period about riding the won't say that about shark week. You know that time of the month where your baby box is trying to kill you. And we're not going to just talk about your period, but we're going to talk about the lead up. And afterwards, the entire month really, and what you can expect as your hormones fluctuate and change. Please remember that nothing new here on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan. We're becoming bold with insulin. Right now I'm considering putting a ton of euphemisms for a period at the end of this episode. Not sure if I will or not. It's all kind of up in the air. Hey, if you'd like to help out the podcast, head over to t one D exchange.org. Forward slash juicebox. If you're a US resident who has type one, or is the caregiver of someone with type one, I'd love it if you'd fill out their survey. It'll help people with type one diabetes, and it supports the podcast. This episode of The Juicebox Podcast does not have a sponsor. Not that I don't have a sponsor I could put on the podcast that I certainly have. But I just wanted to take this opportunity to remind you about the other diabetes pro tip episodes and some of the other series within the podcast. Can I do that? Will you give me a second? Thank you. At this point, the diabetes Pro Tip series consists of 25 episodes. This one of course, is female hormones. But there's also honeymooning weight loss postpartum, glycemic index and load. Explaining type one diabetes, pregnancy bumping nudge one bump and nudge to long term health emergency room protocols glucagon and low Beegees. Illness injury and surgery fat and protein exercise setting your Basal insulin variables the perfect Bolus, mastering a CGM insulin pumping Temp Basal Pre-Bolus, all about insulin, all about MDI newly diagnosed starting over actually listed them in reverse there for you. But you can find them right now at diabetes pro tip.com. There are 1,000,000% free, they're not paywalled. You can get to them and start them and stop them or listen to them as you would like. I'm going to tell you that I think if you listen through those pro tips, they're a pathway to an A one C stably in the low sixes or even fives. Everything I know about type one diabetes management to be important is in those episodes. And along the way, I always have Jenny Smith, there with me having those conversations, I'm going to tell you at the end of the episode all about Jenny, but for now just know, she's had type one diabetes for a very long time. She's a CDE. And a lot more. So head on over to Juicebox Podcast comm or diabetes pro tip.com. Or you can just go back in your podcast player to Episode 210 and start right there. I really hope you do. There's a ton of information in these episodes. I think they're very easy to listen to and even easier to understand. I hope you take advantage of them. All right. Okay, give me a testing. Hello. Alright, you're there. I'm there. Okay. Yeah. All right. So I've spent, not my whole life, you know, but the last number of days and weeks looking into all of this, trying to get ready to make a pro tip episode about female hormones. And it's a very scary proposition. There's a lot going on. I'm not scared, scared, but I'm overwhelmed. And then the last kind of piece of it was that I went on to the Facebook page and you know, said to people look, you know, throw out your questions for this episode. I want to be clear, I almost didn't think I needed their questions so that we could talk. I wanted to see if there was repetitive need, like, what are people like same questions over and over. And my goodness, I mean, it's kind of obvious, right, like so. The questions ranged from like, just God, is there any rhyme or reason to this to what about menopause? What about Hurry menopause. What about the time where my kid isn't getting their period yet, but it's starting to exhibit, you know, symptoms and having hormone fluctuations, talking about puberty and then pregnancy and then and then
is your head spinning post pregnancy? It's it's listen nature. God, I don't care what you think this is there's got to be a better way to do this. Someone, someone, this was an afterthought, like like someone at the end was like, oh, you know, here's what we'll do, we'll throw some eggs in here and then you'll have to throw in some estrogen to get the eggs really roll and then one egg will come out. And if they don't get pregnant, the whole thing will just bleed out of their vagina. Perfect. Like, I don't know who what. Oh, my goodness, PCOS keeps coming up. Is that polycystic ovarian syndrome? PCOS? Yes. Now I know those words. So already, Jenny, I want you to tell me what you just said before we started recording about the inequities of diabetes management from men to men to women,
Jennifer Smith, CDE 6:11
or from an education standpoint to begin with. I mean, it was not something that was ever discussed in my presence, at least and I don't think my mom had outside of visit conversations with my peds and know at all about hormones. Right. So I learned all of this as I was having this like, typical cycle, you know, that should happen after a certain point in the sort of teen years. And education today. It focuses on diabetes, in general, right? Not on if you're a woman with diabetes, versus if you're a man with diabetes, these are the differences that you will definitely see. So you're a woman with diabetes, you've got all the female hormones pumping in your body. Let's discuss diabetes from the angle of being a woman. Right? I mean, especially for my like, I would even say, when I start working with somebody, if they're from about the age 1011, all the way into wellness, even the women they work with into the perimenopause and menopause age, that's something in an initial visit, I always ask about, because if even if it isn't yet visible, it will be at some point. And people need an idea that they need to like, see out into, if I see this and this and this, I'm clearly not a crazy person. This is body function.
Scott Benner 7:44
Well, I guess especially given that, you know, because we talk about things in general terms, like the cycles, 28 days, that's in general, it's not, it's not for everybody, and it might not be for you from month to month as well. So if you can imagine when you hear people talk about like diabetes, like just when I thought I had it, it changed or you know, those memes, there's meat is it memes? Oh, my God, I'm old, you know, where it's like Monday, two plus two is for Tuesday, two plus two is seven, you know, Wednesday, two plus two was zebra like that kind of stuff. If that's already how diabetes feels to people in general, and then you put this on top. I mean, you really are kind of creating two different spinning layers of confusion that can impact each other, or show up on their own. And I don't know how you're supposed to make sense that I actually after going through all this, I have an idea I'll share at the end about how to get a handle on this. But I just don't know. Well, I guess to give people some context, Arden 17. So this is the depth of my understanding of this. My understanding of this is I'm married, I've lived with a lady for a couple of decades, and, and my daughter has diabetes, and she's been getting her period for a while.
Jennifer Smith, CDE 9:06
And I bet you never paid as much attention as when it really was in reference to diabetes management.
Scott Benner 9:12
Only thing I used to pay attention to was there's this what I call the nice day, there's like this. There's this. There's this literally one day a month, where my wife is a 1950s. Like, I'm making quotes perfect mom wife, Glover. Like it's that day on that day. I feel taller, more handsome. Like, you know, like she is so incredibly
Jennifer Smith, CDE 9:41
kind of like Leave It to Beaver mom, sort of at that age have an idea of what a Mom was right? Yeah.
Scott Benner 9:46
100% and I and I, I bask in that day because the day that comes after it. I can't even look her in the eye. Because if I do something wrong, she's the different like and then I Know that the the event is coming in about five to seven days. Like that's how it works for us paid enough
Unknown Speaker 10:07
attention to actually like I can tell you many, many spouses or partners.
Scott Benner 10:13
I thought I was gonna die. I was defending my own life, you know. And so for years, that's the only way I've ever thought about it. And then Arden starts to get her, you know, and then we're kind of rocking along taking care of Arden's blood sugar. Like, it ain't nothing some days, you know, it's just like, I do really have this all figured out. And then one day, she started getting her period. And it was all fine at first. It actually almost it got more difficult at some junctures. But it was, it was very structured. So I didn't have any trouble with it really. Right. And then all the sudden her periods got heavy. And you know, people listening will know that, you know, Arden went through a year or two of like us not understanding what was going on. She got anemic a number of times, she had to have iron infusions. This was all ended up being because of her period. Right? Yeah. So Arden would get her period for like, 11 days, like she'd have like a 11 day long cycle, and then only a couple of day break before she started to bleed again. It was just ridiculous. Which led us to put her on birth control, hoping, like, you know that she wouldn't bleed to death. Because she was, I mean, the impact on our life was insane. Sure, you know, and so first go round with the birth control they gave her it wasn't strong enough, didn't really do anything. But they still ask you to be on it for 90 days before they consider changing it. So you, you struggled all this time you think you have an answer, and then 90 more days struggling. And then they moved her up to another, I guess strength and that has, you know, straightened out her. Excuse me also, the first indication of that problem was nosebleeds. Oh, really bad out of nowhere. nosebleeds, right? That only happened once a month. And it took us a while to figure it out. It was literally happening on a cycle. I never was able to connect it to her periods. But the minute she went on the birth control and the second round of birth control, and it straightened out her periods. The nosebleeds never happened again.
Jennifer Smith, CDE 12:34
That's really interesting. Well, and I mean, again, a symptom that if you're paying enough attention to your body, there are lots of things that your body is trying to tell you. Yeah, right, if we just pay attention to.
Scott Benner 12:47
And it's why I bring it up, honestly, because part of what I figured out, Jenny, part of what I figured out being a man who doesn't get a period, and a person who doesn't have diabetes, as I considered talking about this with you today was was that you kind of have to, you got to kind of have to Jane Goodall it a little bit, right, like you got to take notes and step back and see things and keep wondering what's happening until you can build some some idea of like, I keep seeing this thing over and over again. And where does that fit on the calendar? And how does it work in relationship to, you know, bleeding or pain or insulin resistance, and then sort of start making sense of it, you have to track your period, maybe for six months before you'll be able to wrap your head around it a little bit,
Jennifer Smith, CDE 13:37
especially if your cycle is not regular. I would say for women who especially women who are considering maybe you're starting to track things and pay attention because you are planning a pregnancy, or maybe you're really trying to prevent a pregnancy. So then tracking things becomes just as important, right. But then along with the lines of even planning a pregnancy, the goal in diabetes is to have pretty optimized management prior to conception. So yes, I mean, you really should be tracking things for a fair amount of time, if you don't have them already nailed down because you've paid attention, right. And there are a number of really good period apps out there. I mean, there's some that are free that do just as well as some of the ones that have all the 1000s of bells and whistles for tracking everything else. But I think the ones that are the best actually have a place where you can keep notes. Because the tracking app that I like to use, I actually track month to month, how my insulin changes have looked this month. So I can go back last month, the month before and actually see, has it been consistent enough? Is it going along with what is normal for me? And that helps.
Scott Benner 14:52
Well, even very recently, in the last couple of months, Apple added a period tracker to their health app, which So interesting, robust, and it's free, and a lot of people use Apple phone. So I wanted to throw that out there.
Jennifer Smith, CDE 15:06
I didn't even know that was an option. So thanks. Yeah. So
Scott Benner 15:09
because Arden uses one that's third party, I don't even know what it's called now. But as I looked at people's questions, and I thought about Hold on a second. The gods are coming after me for talking about periods when I'm not a lady. That's right. As I thought about how I figured, like, like, step back and look at what we had to go through to try to figure this out for Arden. And then I looked at people's questions. The real fear, when you see fear is around the unknown portion of it. And all I could think over and over again, when I saw their questions like, How do I know if it's gonna fluctuate? When do I turn up my Basal insulin, if I can't be sure when it's gonna start? I kept thinking, you're gonna have to track it, you're going to have to pay attention, you're going to have to put like, work in. And I know, that sucks, because it feels like diabetes has already worked. But it really made me think about like, kind of what we talked about another pro tips, which is, you know, some upfront effort can save a lot of heartache, right, over and over again,
Jennifer Smith, CDE 16:13
or a lot more micromanagement than you really should need to be doing?
Scott Benner 16:17
Yeah, yeah, you get stuck in that situation where you're constantly constantly constantly adjusting your blood sugar. In the moment, which I'm, listen, I'm a fan of if you're lost, to stay flexible. But in this situation, where what was the number I saw the average woman's going to have how many periods like 400, and something or I was like, oh, like,
Jennifer Smith, CDE 16:40
hold on a lifetime? Well, I guess if you expect an average age of a period starting at the age of 12. And there are 12 months in a year, right? So you would have, let's say one cycle a year. And then the average time period of a cycle, completing would be about, let's say, age 12, all the way to maybe 55, let's say maybe even 60. And that's a good amount of time that you would be having cycle.
Scott Benner 17:15
I'm using your math 55 minus 12, is 43 times 12 months, is 516. There you go. So I'm saying
Unknown Speaker 17:24
that's a lot of tracking.
Scott Benner 17:28
I'm saying put in put some like real, like, it's gonna be honest effort, because you're gonna have to track you know, your insulin use every day. And, you know, just giving yourself I think, what helped me was just simple words. Difficult, easy. You know what I mean? Like, referring to my management, you know, meals were, what I expected, easier than I expected, harder than I expected. Yes. You know, my Basal seemed to work. Well, not Well, today, like just kind of keep it keep it like that. You make a little note for yourself. And I'll tell you to tracking your period is going to help you get better at taking care of your blood sugar, too, because you're gonna see all kinds all around. Yeah, yes, yeah, all kinds of things that you didn't, didn't see before. To begin with. You're
Jennifer Smith, CDE 18:13
gonna learn a lot of things too, in that time tracking for all of those other variables that we have to adjust around, right? Because I for one, know that my sensitivity, once I've gotten to about day three of my period, after that point, and until about ovulation is a really sensitive time. But it's more sensitive from day three to about like day seven ish. And in exercise, I have to be more aggressive and adjusting my insulin for exercise. Or I will go low. Despite my other tools and tweaks working outside of that. I will go low if I don't adjust more than I normally would, is that
Scott Benner 19:02
a progesterone period in there.
Jennifer Smith, CDE 19:05
So you're essentially when you're looking at progesterone that is typically like peaking at certain points, right? And then there's also the luteinizing hormone, there's follicle stimulating hormone and there's estrogen and a lot of hormones that are coming into play. So progesterone kind of starts to really kind of like, fall off essentially, once your period is started. It has really climbed in the time of you coming into potentially having a period and part of the reason for that is in the anticipation that you in sort of that Avi LaTorre time period, have actually conceived right. progesterone levels will stay high and continue to climb in pregnant See, when you don't have conception happen, and you start to have your period, that level falls, because there's no reason to have that elevated. I mean, again, other hormones at play here as well progesterone being one of them, but it doesn't need to remain where it was because you're not pregnant. Okay. And so then it fluxes
Scott Benner 20:21
right. And do do we let's try to think about this. Do we count the the beginning of the cycle is considered when the period starts, right?
Jennifer Smith, CDE 20:32
Day one of your period is day one of your cycle.
Scott Benner 20:36
Okay. In that moment, estrogen at that point is lower. Is that right? And then it starts to,
Jennifer Smith, CDE 20:45
and then estrogen starts decline coming into ovulation. And then in that next phase around ovulation and potential like conception, again, progesterone is sort of like climbing into that time period. Right? So, you know, again, all these fun hormones doing different things. I mean, if you even looked up a simple like just Google, a graph of like, what your hormones should look like, you can tell why. One Basal for 30 days in a row, if you're a woman who has a monthly cycle, doesn't work. Yeah.
Unknown Speaker 21:27
It doesn't,
Scott Benner 21:28
you know, what else I learned by digging into all this is that not that I wouldn't expect this because it's a physiological thing. But it's incredibly complicated what's happening. It's not just like, you know, your your eighth grade health understanding of it, which, you know, in my mind was, an egg gets released, you use it or you don't use it, if you don't use it, you know, the uterine lining and the egg come out in a period, which I know is high level what it is. But the idea of like the ramp up, right, like the gosh, like you start talking about like follicles, and like, there's this process that's happening in there, where your body's trying to locate the strongest egg to be released. It's not just like the next one on the assembly line. It's like it literally anyway, it's mind boggling. Even the TED talks on it are confusing. Even when even when nice girls sit in front of cameras in front of YouTube and try to talk to you right in your eyes, you're like, I don't understand, there's so much happening. But I think for the case of but for type one for using insulin, is it is it as easy as saying that there's a time when you're bleeding, there's a time when you're ovulating. And there's a time when your body is trying to make your body a hospitable place for sperm to live. So that the process of fertilization can happen well, is that basically like there's I mean,
Jennifer Smith, CDE 22:52
that's basically the simplified and I think, sort of along the same line of what you're getting at is, if you, if you're having a cycle, whether you're on birth control with a cycle or you're not on birth control with a cycle, you can expect the times of your period to show similarities for you in insulin need, right? One person may experience during this phase of, you know, hormone release, or this phase of their cycle, that they always have higher blood sugar's now that they've been tracking things, they can say yes, I'm always getting higher here. One of the first places that that commonly starts is the fasting blood sugar, or the overnight blood sugar. For whatever reason, in the hormone dance of the human body, that's the first place that commonly women see things are running higher. And if you start to pay attention to your calendar, it will most likely coincide with that's going to be somewhere about like, three to maybe seven days prior to your period, starting. Some women experience really short lived higher insulin needs. And whether they may have missed a slight nudge up maybe a week sooner. Most of them notice, gosh, the first you know, day and maybe the two days before my period, I'm just high I can't take enough insulin, I dump it all in and I still sit high. Well, next month, you know, if that's the case, and you start seeing higher blood sugars, and you do and you are maybe somebody who doesn't have a regular enough cycle would probably expect that this is what's probably on its way as long as your site isn't bad and you know, all the other variables that it could possibly be
Scott Benner 24:42
Yeah, so it's going to be incredibly important for you not to throw your hands up to the diabetes ferry and go it's just did diabetes. It's happening to me again, like after it happens a couple of times. You gotta say like Jenny saying, like, this is what happens. Whether or not I can tell you that it absolutely happens on day. I don't know 30 Have my cycle or not? It becomes unimportant like you, you sort of see, you know, it's not any different than like, as you're talking about all this and about when people see higher blood sugars, like Arden has this too, but because my mindset is, like more insulin push back, don't let it happen. I can't see it. Sometimes I can tell you that we're bolusing more or that I'm running a higher Basal like profile. But I'm so accustomed to just being in the fight and fighting the fight. I sometimes don't think about why it's happening. I just, I just adjust
Jennifer Smith, CDE 25:35
to get it back to target. Yeah. And I and I think that's, that's okay, as long as you're okay, adjusting that way. And if that works for you, then great. I think that more women especially again, those who are planning a potential pregnancy, are really wanting to track well enough because they're also in ensuring that their blood sugar's are really optimally managed for possible conception and that thereafter, you know, so if you really do want more consistency, rather than saying, Well, I know how to do more insulin, I do it all the time. I just, you know, adjusted here and take more, they're adjusted back here or whatever. But if you have even those that have irregular enough cycle, it could take some of the like headache out of the arm Hi again. I know I need more, I'll take more. But gosh, is this happening regularly enough that I could actually figure out how much more do I need on an average monthly change time? That is less guesswork in the moment that
Scott Benner 26:38
and the reason I brought it up is because the process of getting ready to make this episode with you made me realize I'm gonna set up three different profiles for Arden because she's gonna go to college. Yeah, know what to do her blood sugar's gonna go up and she's gonna be like, this never used to happen before. You know, and and she's, you know, not gonna realize the thing she's missing is me. Texting, texting or going yo Bolus, what are you doing? Cuz because for people who don't like really understand, I know it sounds like micromanaging to some like newer people but for people listening the podcast I don't imagine it does. Like, I don't like to see a blood sugar over 140. And I act like like, you know how some people might act when your blood sugar's 300 is about how I start feeling at 140. I'm like, yo, what are we doing here? Because in my mind, I'm targeting back to 80 in my mind, 140 60 points too high. Like, get it get it, but the the amount of insulin that it takes to get it has climbed since Arden's been on a birth control pill. So while yes, the birth control pill has regulated Arden's period, and she's not bleeding to death anymore, her diabetes has gotten more difficult. Yeah. Because and now if you go look at graphs about how insulin like listen, what I know about birth control is probably not enough. But you're getting you're getting a pretty regulated amount of these hormones every day. And and that birth control is literally tricking your body into not releasing an egg. I didn't realize that. That the bleeding
Jennifer Smith, CDE 28:16
keeping you on a one cycle of hormone akin to not needing ovulation.
Scott Benner 28:22
Yeah, right. And so you're not nothing's happening and ovulate. Like the whole process isn't happening. Actually. I think what confuses people? Is that the bleeding that happens when you're off the hormones and you're on the the placebo? CBOs is not your period. It's got it's actually got a name. It's, uh, hold on a second. I have so many browser windows open. It's called withdrawal bleeding. Yeah, yeah. It's not your it's not the same thing
Jennifer Smith, CDE 28:51
I never heard. I've never heard it called that before. Okay. Well,
Scott Benner 28:55
I was schooled, I recorded an episode about this with a different podcast. I'm gonna be on a vagina podcast pretty soon. And that's funny. Oh, it was hilarious. And as I was being asked, I was like, why is this happening to me, but um, but people who really take birth control? I don't mean seriously is the wrong word. But but see it as stuff that maybe, you know, there are people who think you shouldn't do it. There are people who think you shouldn't tell people how to live their lives. There's a lot of consternation around birth control in some circles. And it's important for those people for you to know you're not actually getting your period when you're on birth control. So and I have to be honest, I don't want Arden to be on birth control not because it's birth control, but because I don't want her to take anything she doesn't have to take right but she's she was going down. You don't I mean, like Yeah, we were looking at a real like, I guess this is it. Like you know the money with the money we save for college. We could buy a house with now or something Well, and
Jennifer Smith, CDE 29:56
that's I mean, those there are I think really there really good reasons to utilize birth control all around, there are. But in a case like this, it's almost a necessity in order to get containment of something. Now, the other thing is, you know, is this something that's just, it's just the way that her body is going to continue to work even into like adulthood, where she continued to have to have this level of birth control, you know, management, so that she doesn't have this problem. That question, you know, I
Scott Benner 30:29
had constantly like, when do we just like, stop at once and see what happens? You know what I mean? Like, right, but I don't understand any cause and effect reasons why using birth control for a while, would you know, quote, unquote, regulate things? And then you would need it anymore? Were? Or was this just a cycle of her life, and it was going to pass on its own. And we're never going to know, as long as she's on the birth control pill, right. I keep praying, I keep thinking maybe, you know, a few months before college, maybe we like, would try Bella bail on at one time and see what happens, because you've
Jennifer Smith, CDE 31:06
done enough work already to know. I mean, she's used several different types of it. So you also have an idea of what works, what really did nothing good. And what does actually work because there are so many kinds of birth control that are available, and so many mixes of hormones that you could use, or some are single, single hormone and some are a mix of hormones at different levels. They're taken different ways. I mean, there are
Scott Benner 31:39
one point are our pharmacy benefits changed or over to a generic things were going great. And then they change the generic a went right back to where it was again. Oh, and then we had to swap her back to another one.
Jennifer Smith, CDE 31:53
So funny, right? I mean, if it was the same thing, only a generic what's different, right?
Scott Benner 32:00
I have no idea. This is the this. Jenny in one way or another vaginas are the bane of my existence. Just there. They're torturing me from different angles and different perspectives all the time. And, and on Arden's period has been, I mean, a roller coaster, it has not been fun for her for the, you know, people trying to help her.
Jennifer Smith, CDE 32:24
Well, and I think you see it from a perspective of, you want the best for her, you want her to be healthy and enjoy life and everything. So you see it really as a it's problematic, not from a physiologic standpoint is problematic and what it brings into the picture of her management, you know, you may have a very different look on it. If she didn't have diabetes.
Scott Benner 32:50
Yeah. Yeah, I guess I there's so much about I wouldn't even understand or pay attention to her. Right, sir. So I, I'm basically having this conversation to tell people that I'm going to start doing what I think you should do, like I'm gonna, I'm gonna set up my own tracking app. And I'm gonna track Arden's like insulin inputs, just Jenny's making a face because I don't do
Unknown Speaker 33:13
I'm pretty yummy. Yes. Like, you don't do things like that, because I don't
Scott Benner 33:17
She's gonna leave for college and either bleed to death, or have a one see in the aids like one of the other. Like, it's just one of the others gonna happen. So And typically, I
Jennifer Smith, CDE 33:27
mean, that is, it's also another piece in the mix, too, because you brought a lot of things in that could be happening in periods that are mismanaged, right? Someone who has excessive bleeding can bring in a lot of other health risk problems that can also make the diabetes management piece even harder to figure out and manage around. So it's really important. I mean, on average, you know, quote me, but I think I read at one point, like the average woman with a normal healthy cycle length, and not excessive bleeding, really only loses about a quarter cup of blood through the whole period, which is it's a tiny amount, right? I mean, if you know what a quarter cup measuring cup looks like. So I mean, if you're saying gosh, excessive, clearly excessive is like, lots and lots that shouldn't be happening.
Scott Benner 34:22
Here's the one measuring stick for you. Arden's ferritin gets down to like the teens. She gets an infusion. They tested again, it pushes it into like the 130s. It gets pretty high when you get the infusion. Yeah, within three months of not being on the period. She was back in the teens again, teens again, yeah. So and just I mean, for people who don't know an email, low blood, low iron, whatever, you know, however you get to it. I mean, just can't hardly pick your head up. Oh, freezing feels horrible. You feel like you're dying, the whole time, shortness of breath. You can have heart palpitations. Like it's not good, you know, you get pain in your, like muscles and joints and like it's it's terrible. So Arden's gonna stay on this as long as she needs to but, but it's funny while she was home, Arden's chill at home, like when she was going to school from home, she needed less insulin. As soon as she went back to in person I knew her needs, were going to go up again. And I did the thing, where I was bolusing too much and didn't adjust settings for a little while to like, it happens to everybody, it's sure doesn't not happen to me, because it's my podcast, like, you know, like, you're so used to managing one way, and then this big piece of your life changes. And you don't even realize it for some reason. And that just made me sadder when I realized that thinking about this, because basically, on your period, your life is changing. Like every couple of weeks, you know, like there's this impact and the end, it might not happen to everybody, there are some women who will listen to this to go, oh, that doesn't happen to me. Or if this is, you know, just like, Oh, my God, well, in
Jennifer Smith, CDE 36:07
fact, I've got, you know, some women that I've worked with, you know, even outside of like preconception planning, just in terms of diabetes management. And obviously, the cycle is a piece that we talk through and talk about, and some women who actually have the higher blood sugar levels during their period. Not before. It's more really an onset while they're actually having their period, which is not the typical of what I've seen. But again, I've heard it enough that it's also not odd or rare.
Scott Benner 36:38
Yeah, no, no, in the questions that I sent to you that that I found online, it was almost like people were like, hey, during these days here, my blood sugar is incredibly easy. And then somebody would come along and say, well, in those same exact days, my blood sugar's incredibly difficult. And yeah, I'm sure if we could, you know, Doctor House, every person in the world you might find, but I don't think that's gonna love that show. I mean, right. sarcoidosis usually. Right? And I don't even know what that means. But, but so did you see anything in these questions that you definitely wanted to go over?
Jennifer Smith, CDE 37:16
I was just gonna go back to because
Scott Benner 37:21
because at some point, too, there were a number of questions about menopause to, and some women are asking about what about when they take hormone replacement? Is it going to happen, then? And I don't know. But it seems like the same as taking birth control to me, right? You're, you're adding hormones to your daily intake.
For the longest time, I believe that one of the sticking points of getting people good information about managing insulin was that it was hard to put it in one place, or to hold people's attention or for them to realize it was there so they could keep coming back. You know, there might be an article here or there or a story that would be helpful to you. But how do you condense it all into one place. And it turns out that this podcast is the perfect way to accomplish that, I would notice that even if somebody understood Temp Basal was really well, they might not have thought about pregnancy, or if they understood, you know, extended boluses, they might not have talked about how to use your Basal well, and that you were going to be lost if you didn't have all of this information in one place. But most importantly, this information needs to be easy to digest and easy to understand and listen to. Right, like you have to want to listen. And I think that we I think we've done that with this podcast. Well, now in my eighth year, with over 600 episodes, there is a ton of information inside of this podcast. It's a it's a compendium, it really is of how to manage your your insulin and live well. So I need you to look for the defining diabetes series. It might seem overly simplistic, but it takes the terms that you're going to be using every day and boils them down into easy to understand explanations. They're not long, they're fun to listen to. And you'll leave with a real understanding of what the terms mean. The podcast also has these diabetes pro tips, which I think are absolutely I think there's they're amazing, honestly, like it's not just because I made them. I see feedback from people every day about them. And I'll actually leave some at the end of the podcast for you. But listen to the diabetes protests, but you need the tools, right? You can't just you can't just look at the instructions to build a bridge not understand what a wrench is. So listen to the defining diabetes and then move on to the pro tips. Now there's also things like how we eat where people come on and talk about all the different ways they V carnivore, gluten free Bernstein FODMAP keto intermittent fasting ton of them, because I think that everyone's eating style should be represented. I don't care how you eat, I care that you know how to use insulin. That's all it matters to me. Once you know how to use insulin, you go ahead and eat any way you want. I just want you to be able to do it doesn't matter what you do. It matters that you can. That's how I feel. There are special episodes, me and Jenny Smith answering questions from the, from the audience, you know, they're called ask Scott and Jenny. In those episodes, we talk oh my god, we talked about so much how to combat the morning rise. How does carb absorption work? How to handle a high blood sugar? What is standard deviation advice for using Basal IQ, just so many different things. There's entire episodes that are just about mental health and type one diabetes, I have afterdark episodes that handle everything from heroin addiction to being a sex worker and having type one diabetes to smoking weed and everything in between stuff that other people don't talk about. But we talk about it here on the Juicebox Podcast. I also have over 10 episodes about pregnancy, an entire series just about the variables that may pop up while you're managing your insulin. You want to learn about algorithm pumping, we've got that covered to the Juicebox Podcast is much more than the diabetes Pro Tip series. I hope you take time to check it out. There's something in there for everybody. And there is a path to the A one C and the stability that you want. So whether you're looking for community or answers, check out the Juicebox Podcast, subscribe now, in an audio app, it's always free.
Jennifer Smith, CDE 41:49
And hormone replacement therapy is usually for the most part centered around like the menopause kind of time perimenopause, menopause kind of time, it's supposed to help to ease much of the hormonal transition that's creating some of the symptoms, things like the hot flashes, and the energy swings and the insomnia and the, I guess, level of irritation one woman may experience versus another. Right? So that's supposed to technically, even things out more. And it's a good question to actually ask, if you haven't, and you're considering are already taking the hormone replacement therapy, you know, asking your physician if they know anything, really about that piece in terms of what they should expect. My expectation would be that with the replacement therapy, if it's going well, then dose is well managed. Technically, you should have actually more stability, then in how you're feeling, which should also bring more stability to your glucose management,
Scott Benner 43:01
right? Well, I guess while we're in this area, what about somebody who's had a hysterectomy? Do they lose all of those, that the cycle is just gone? Right? So that is, but is all the horror or all the hormones gone to?
Jennifer Smith, CDE 43:15
So although I mean, there's a good question, because quite honestly, you could have a partial or you could have a like a total hysterectomy, right? I mean, so there are hormonal imbalances that can definitely happen with partial hysterectomy. It does, for the most part, from what I know causes less dramatic change in hormone levels than a full hysterectomy does. So in terms of that, you know, your hormones definitely shift because obviously there's nothing there to cause that trend of hormones change, right, there's a period right disappears. So, you know, overall, while there may be some initial management that needs to be done, I wouldn't expect that there would be as much I haven't worked with many women who have had hysterectomy. But I wouldn't expect that there to be as much fluctuation as they probably usually had. I mean, when the menopause obviously is kind of similar in that when that happens, obviously your ovaries stop producing enough hormones to continue the menstrual cycle. Right? So if you've had a hysterectomy, which includes removing the ovaries, you would then be essentially moved into sort of like a premature menopause kind of time. Right. So
Scott Benner 44:45
all right. Well, you know what, there's one person that asked such as a detailed question that I think yeah, the way they broke it down might be valuable for us. So her first question was, why does the body become more insulin resistant during different phases of the mess? cycle just laid out for you. And not that I think we haven't. But is the answer just simply there's more hormones at different parts?
Jennifer Smith, CDE 45:09
Right? And so that's, you know, initially when we're talking like what is the surge of the different hormones through the course of pregnancy or through the course of a menstrual cycle, right? So in terms of that rise up in insulin need, you know, there are a couple points of time for different hormones, one of them progesterone, as its kind of rising, in terms of, are you going to find out you're pregnant? Or are you now you don't know that you're pregnant, or you're not going to be pregnant, so you end up having a cycle. So then that climb in progesterone is, again, that typical time period before your cycle starts, that you would have insulin resistance creep into the picture. It may creep slowly, like seven days before you start to notice you've got that rise in blood sugar, okay, maybe you change up your overnight settings, or, you know, whatever it might be, as you get closer to your expected first day of cycle, you're going to see a lot more resistance. I mean, many women find 20 to even 40% more insulin need in that time period of climb in hormone. And then that most women experienced the most significant and resistance the day before their cycle starts
Scott Benner 46:21
the day before the cycle starts, which is the day Yes, leading to
Jennifer Smith, CDE 46:25
day before there, yes, there before their period starts. There's they're bleeding the event here, but in the event, there you go. Um, so you know, that could be, you know, a visual point of saying, Well, I'm not crazy, I didn't need to change my pump site and change to new insulin or nothing was really wrong. I see that this is the pattern and this is what's always happening. So how high did my blood sugars go? How much more insulin did it look like I continually used in the past two or even three months, so that you can expect it now. And you can make a I guess, a wiser shift in your insulin rather than just sort of like completely guessing. Right? Oh, I'm gonna take three units today because clearly two and a half yesterday did work well. Okay. But if you have some back knowledge, you can say okay, this is definitely how much more I needed. And I can adjust better here. Now,
Scott Benner 47:19
do you know there are months that Ardennes period doesn't begin on the first day of the placebo, it happens sooner. Which doesn't make any sense at all. She's definitely kooky and her belly, like like something's, something's going like when that happens. So is yet two days ago. I saw as much resistance from her as I as I had in the month. And I said to her, like something, you're going to get your period. Soon. She goes, I have like four pills left. And I was like, okay, so then yesterday, do all day. Like we had to cut her insulin back. Crazy yesterday. So when she got home from school, I was like, did you get your period? Because No, I still have a couple of days left. But her body acted like her period started yesterday starting and I'm like, I wonder if the bleedings now adjusting back to where it's supposed to be. I also wonder sometimes like Kelly's, you know, still still match traits, my wife still fertile.
Jennifer Smith, CDE 48:19
That's a good thing. The longer you actually have your cycle, the healthier for you. It reduces a lot of the risk of female related cancers. The longer you have your cycle, and the length of the cycle matters to not that this is diabetes specific, but it's a piece in the mix of bad cycle regular cycle and the longer you have it in the life the better for you. Yeah,
Scott Benner 48:43
well, that's good news. But what I was wondering was is you know how you kind of sync up the people? Yeah, like I I've often wondered if Arden and Kelly even being near each other is messing with Arden.
Jennifer Smith, CDE 48:55
Very likely because in college I had three other roommates. And at that point, we we all within a week had our periods at the same time. Yeah, like it was not a house
Scott Benner 49:14
buying a bigger trashcan. Okay, so this person's next question was, do insulin needs change? Only when premenstrual or does it happen around ovulation as well? I think yes. We've pretty much gone over that right.
Jennifer Smith, CDE 49:29
Yeah. And ovulation for some just in clarification, some women notice more significant insulin resistance around ovulation than they do in the pre cycle or like period start time, and it's often much shorter lived have a is a swing up, more noticeable rise. Post meals often tend to be impacted more if you're going to notice a change around ovulation, but it's only going to be like 24% 72 ish hours around that ovulation that you're going to notice such significant resistance. So again, we've got this like roller coaster of hormones going on. Making people feel
Scott Benner 50:14
crazy. Also, I watched a video about how to know when you're ovulating getting ready for this. And there's a lot that you can watch. Oh, geez, I learned a lot about discharge and cervix ripening and feeling sexual, and that it sometimes happens. And sometimes, to some people doesn't happen to others. Some people get many of the symptoms, some people get fewer none. You know, it, I love it when something spelled out to you like this. Here's what could happen, unless it doesn't. Or maybe it won't. But it could and you're like, This is not helpful, like, say something concrete or stop making videos. But it was really, I don't know, it was interesting. Anyway,
Jennifer Smith, CDE 50:59
here's a really good book I got actually years ago, before we even plan to start trying. It's called taking charge of your fertility. And it goes through, it's really, I think, I think that it should be given to women in general. Because even if you never plan to have children, it gives you a really good idea of how the female body works. Yeah. And it can, from just that standpoint, make you feel less like. Like, I've always kind of hated when people are like, Ah, she's getting her period. Like, that's the reason for all of these mood swings and whatever. Well. I mean, that's, quite honestly, it could be true. I mean, it's somebody meaning it in kind of like, not a very nice way. Yeah, but it is true that hormones change and flux a lot. But for you to know that as the person living with it, you don't feel silly about that. That's your body. It's supposed to be doing that.
Scott Benner 52:00
I'm 20% more feminist than I was before I started paying attention to this. And I was already on the lady side. And so I mean, listen, I've never once been given medical direction that began with start with a clean finger. But I've heard those words a lot. Now since I've been paying attention to this. And I just thought like pork girls, like you don't even like cheeses and seeing it happen to my daughter, like firsthand. It really does. I mean, if you're if you're not moved by it. I mean, I don't tease my daughter or my wife about like, Oh, your periods come in, you're acting. But I tell you when I was younger, I probably said it. But now, now that I've lived around it, I'm like, it's not. I mean, they should just say you should you should be thanking them, not telling them. Yes, sir. You know,
Unknown Speaker 52:45
I know, to some degree, and I'm very happy that I have two boys. Like, you're gonna go to your dad. This is Dan's department.
Scott Benner 52:54
You go to your father, whatever he says it's not gonna start with begin with a clean finger. I can tell you, nobody asked Bobby about that. And you you're lucky too, because you're not gonna ever be in this situation that Arden and Kelly are in where your periods are like, No, it just jerking you back and forth. On timing. Right? You know what I mean? Right, right.
Jennifer Smith, CDE 53:12
Because I have like I said, I have experienced that like in college. But I don't think at that point, I was even while I did a really good job of management as well as I could. I that technology at that point was not I mean, there was no CGM. I was still doing, you know, a lot of darn finger sticks a day to see where things were going. But I don't think I was as a two and two even wanting to pay attention to why something I was just like, Oh, I didn't even at that point. I was like, oh, it looks like I just need a little bit more. I
Scott Benner 53:48
mean, maybe we're a decade into having the technology where you can break this stuff down. Versus next question. I really want to thank them for this and I don't have her name here, I apologize. Is you know, she brings up what are ways to track it. Um, you can track it on a paper calendar, you can track it in an app. It's my intention to just like I said earlier, to in a quick, easy way, maybe even colors would work. Honestly, you know, green, yellow red for insulin. I would track insulin needs I would track when the period starting I would try to figure out as much about ovulation as I could. So you can kind of find that window in there about where it is. And I'll tell you to like it sucks but you could track your mood. You could track your you know, your sexual desire, like you can make all those little like clicks there. It's like yeah, you don't I found thinking sucked for women the whole time, is that things that from an outsider's perspective seem like choice can be driven so harshly by hormones, which could make you feel like you're not doing things purposefully like it's your body. Doing it
Jennifer Smith, CDE 55:00
telling you to do you telling you to do
Scott Benner 55:03
Yeah. Like, like, I would hate the idea of, I'm on a date, and I'm open to having sex tonight. Not because I want to have sex or because I like this person, but because my hormones are in a state where it's telling me
Jennifer Smith, CDE 55:17
they're kind of telling you to feel this way. Yeah,
Scott Benner 55:20
do this now. Because sperm will live in you for five days, and then we can get you fertilized and give you a good chance to, you know, bring in this egg along. That's, I mean, it's kind of which brings
Jennifer Smith, CDE 55:33
in a lot of interesting fact, especially for the teenage. Right? Yeah, where I mean, the majority of teenagers, this point are not considering conception. They're not they're beyond that, you know, for many reasons, but those are some of the things that your body is supposed to be telling you to do. And, you know, what's the reason? Well, eons ago, people were getting married when they were 1415 years ago, old and having kids at that point, in fact, you know, if you weren't married by the time you were like, 25 was like, over four
Scott Benner 56:15
are window. Yeah, right. We're five years away from dying, probably it's. Well, I mean, I listen, it's beautiful, like, you know, in a nature kind of naturalistic way. Like, it's amazing. I just found myself feeling badly that you could be having feelings or thoughts that aren't the ones that you decided to have. But then I kind of brought it out larger. And I thought, when my iron was lower, I wasn't who I was. Right? I mean, we're all just, you know, some dialed up level of different chemicals and hormones and impacts and everything. And, and I yeah, I think that I hate to say that I think this episode could have been like, Hey, you should track your period, and then make better decisions about your insulin. Like, I really think that could have been the end of it. And it Well, I
Jennifer Smith, CDE 57:03
think there's other I checked, there were a couple other questions in here that I think that do go. I mean, they they kind of go into, yes, that's the base, track your insulin, see what you need, and then make the decision on how to make your insulin delivery system. Do what you want it to do for you, right, but there were a couple of questions. One of them was on MDI changed my Basal in a certain point of my cycle to deal with increased or decreased physician resistance. And I should I also focus on adjusting my boluses I can say that, absolutely, you'll need to adjust at least your Basal insulin, even on MDI. I mean, when I was MDI, and had caught on to the fact of needing more, based on what my blood sugar was doing, I knew that I needed a certain dose, that was three units, I still remember it was three units higher than my baseline dose for the time period of resistance that I needed. So you know, in terms of that, I could always adjust and unless something shifted and changed, you know, I would have maybe used a little bit more, or a little bit less. But overall, it was, it's funny that I still remember, three units, four was always what I used when I had my period. So yes, you could use more. And if your doctor isn't directing you to do that. Our doctors don't direct us to do many things that we end up doing. This is not advice or recommendation to do that, but discuss it with them. But it definitely and bring in maybe some of the logs that you've kept and say, Hey, I'm noticing this, would you agree? I'm thinking I need this much more insulin, right? I mean, always check with somebody, obviously, if you feel that you need to Bolus is could they need to adjust? Absolutely, they could.
Scott Benner 58:58
Well, you know, I just did the math real quick three units is only like point 125 an hour if you're on a on a Basal program for a pump, so right, but but, but it might have been significant for you. Do you remember what your Basal was back then?
Jennifer Smith, CDE 59:14
Yeah, I do my Basal and overall was sitting at 12. And I needed 15.
Scott Benner 59:22
Okay, yes. Okay. So it's a big jump, even though it doesn't look like a big jump per hour. It is a big jump percentage wise,
Jennifer Smith, CDE 59:29
it was a big jump percentage wise and it was a bit I mean, it looks like a big jump like Gosh, going from 12 all the way up to 15. Oh my gosh, like, that's a lot more insulin right, especially when you talk about like adjusting things. Okay, we're going to add one unit more of your Basal insulin and we'll see how this manages things over the course of that whole 24 hour time period. Right. Um, I the other one that I thought was good to focus on would be using algorithm driven pumping systems as a female, the algorithm was not it wasn't built for this to deal with hormones. It was not it wasn't built for hormones, it wasn't built for pregnancy, you can successfully use it. If you know how to manipulate settings, right? I, I personally find that it's better for me to just adjust my baseline profile in my system. And then on the months that I am more resistant on top of that, then a temporary adjustment up using a temporary Basal or an override or, you know, whatever your adjustment is for the algorithm that you're using. I adjust up using that. Yeah.
Scott Benner 1:00:48
Is this whole conversation really similar to what you would have if you were talking about like, a teenage boy who's going through a lot of growth and hormone changes and stuff like that, like just it's just not on a cycle that you can see as well? Right?
Jennifer Smith, CDE 1:01:05
It's not on a cycle. That's as I mean, it doesn't seem to be from the team guys that I've worked with, it doesn't seem to be as cyclic.
Scott Benner 1:01:13
Yeah, predictable, right? It Right, right. This really is predictable, though, within reason,
Jennifer Smith, CDE 1:01:19
within reason, yes. And I can even say, if you're the person with the irregular cycle, let's say 25 days, one month, 29 days, another month, back to 30 days, and then back down to 25 days. Despite that, the things that you're seeing happen to your blood sugar, in that time period, will continue to happen for you. Yeah. Right. So even if your cycle length isn't about the same, if you start to see those in a time period, that could be soon enough to be close enough to like an early cycle. Or maybe you're gone back beyond that. You haven't seen changes yet. And up now I see changes.
Scott Benner 1:02:03
Okay, right. Yeah. Well, I was just thinking that you're talking about like variables and inside of variables inside of variables. You can, you know, you know, food, food cravings are not uncommon, right around hormone changes. So you could you could have forever thought, why is it sometimes I'm really good at nachos. And other times, I'm not really good at nachos. And maybe it's because once in a while you have nachos when you want them? And sometimes you want nachos? Because your hormones want them. And you're already in a situation that's more difficult. And then you add in food, because what was the question here is like, should I eat differently or exercise differently through different phases of my cycle? Which is a great question. And it may be think, you know, I'm not into telling people how to eat. But there are definitely foods that are easier on you that take less insulin that you might want to try eating, while you're having an increased need for another reason, because now otherwise, you have to increase needs correct difficult food and your hormones at the same time.
Jennifer Smith, CDE 1:03:05
Right? And the hormones are driving a desire for things that otherwise you may have very, you may have very easy management around, right. You may love nachos, but your typical serving of nachos is appropriate and and find. And if it's a hormone driven time, you know, you might eat much more
Scott Benner 1:03:24
of your doctor. You know, while we were adjusting Arden's birth control pills and getting it right, she couldn't stomach meat. Hmm, she was not a vegetarian kind of person. And for a while she couldn't stomach meat, like just getting away from me. She couldn't smell it, she definitely couldn't even think about eating it. And then as her as the pill, we found the right pill. And it got kind of like set in stone. Now that's come back a little bit.
Jennifer Smith, CDE 1:03:51
It must be something to do with the hormone levels in the birth control she's using because it's actually not uncommon for just thinking about hormones in general. Many women have some aversion to meet during pregnancy. Yeah, many women can't stomach red meat specifically. So I wonder if it's something hormonally? Well, similar. That was weird happening for her before it got regulated.
Scott Benner 1:04:18
I'm running around the house pointing to that my wife's like, that's crazy. Arden's like you don't think Arden just thinks I paid too much attention to her. So she's like, stop paying, like caring I brought up to the OB the OB is like, I don't know, I'm like, god dammit, I'm right about this. Like, no one's watching these people more than me. You know what I mean? Like, um, they trust me they don't be dead without me, Jenny. Like, in one way or another? My wife like, you know, like with the thyroid stuff like I'm the one who's kind of like stepped back like you guys hear me talk about on the podcast like being micro and macro. Like on my family on macro. Like I step back, I look for big picture stuff. And I don't worry, but when I start seeing stuff over and over again, I don't know. It's just who I am the guy just don't know, I worry about people. So
Jennifer Smith, CDE 1:05:03
that's not a bad thing necessarily bad
Scott Benner 1:05:05
for me. It's great for them. You've ever noticed me worrying about myself? But
Jennifer Smith, CDE 1:05:12
was this I think this kind of me answers some of the question I see and hear about age. Do How old was Arden when she had her first cycle? Do you remember? Of course you remember?
Scott Benner 1:05:23
No, I don't know if I do. It was a little later than her friends. Okay, maybe,
Jennifer Smith, CDE 1:05:31
as was, as was I? And a couple of questions here, you know, just relative to, like, when should I expect this in my daughter? Honestly, could be as early as age 10. Wow. Honest. And it could be I mean, I was, I was definitely late. I was definitely late and getting my cycle comparative to all of my friends. But I also think, in terms of that, my, my management wasn't then what it could have been if I were diagnosed in today's age, right. So I think that the management style that I had at that point was not managing well enough to allow my body to actually be consistent enough to start my cycle at the time that it technically should have started. Yeah,
Scott Benner 1:06:24
this is Jenny's third attempt to let you all know to go back and listen to all of the pro tip episodes. You can do a really great job of getting your settings right understanding how to make changes for yourself, how to Bolus for meals, how to keep high blood sugars from happening, like she is very artfully telling you, that's the ability and understanding is the is the firm foundation of living with diabetes. She says she's so nice about it when she says I'll just say what Jenny's saying y'all aren't doing a good enough job. You got to get in there and try a little harder. You know, it's funny, I think Artem was 14 Having just turned 15. And I don't remember the date. I remember the situation we we, along with a number of her friends. Were on our way to go swimming. And this was Arden's first time swimming with a period. And a bunch of little girls disappeared upstairs in my house, and came back 20 minutes later, disheveled, sweaty, rocked, and the end, the one girl goes, we couldn't get it in. And apparently, this is apparently at one point like a mechanic
Unknown Speaker 1:07:34
and how funny that they actually like. I mean, well enough with you that they actually announced it to like a guy. Oh, my God, I would have been like mortified, telling my dad something Oh,
Scott Benner 1:07:45
no, no, no, he was described to me as Arden was a car on a lift, and the girls took turns trying to change your oil and couldn't figure out how to do it. So.
Jennifer Smith, CDE 1:07:56
Oh, that's interesting.
Scott Benner 1:07:58
So that's about what happens around here usually. And well. Actually, I gotta say that's not usual. But but it didn't work out. And so I'm thinking it was the end of her 14 right around her 15th birthday. If I'm okay, I'm guessing right? If I'm wrong about that, then it's end. It's not 1516 She's been at this for a while. I think it's 14 to 15. But yeah, like this could you could have kids getting their periods, all kinds of crazy ages. Like what what they used to hear like the hormones and cow's milk or making girls develop sooner or something like I don't know if any of that's true. But you know, there are girls walking around sometimes where you're like, are they 20 or 10? Or like what he can't tell? Yeah,
Jennifer Smith, CDE 1:08:36
I know. Yeah. The I mean, I think that that's like a rabbit hole of we could dive in there. But it would be a long, long discussion.
Scott Benner 1:08:45
We should make euphemisms about holes while we're talking about periods. So. So I mean, do you think, let's see, do you think there's anything else like I mean, I feel like this is a good conversation, I mean, perimenopause, people are asking about different kinds of birth controls, like there are non hormonal birth control, like, ways, right. So, I mean, there's, I'll tell you, more than two people asked about Plan B. Whether as an whether or not that would have an impact on blood sugar's and I wasn't able to find that out.
Jennifer Smith, CDE 1:09:21
You know, I that is a really good one. I can actually ask my, my or my, my MFM. I can actually ask them if they have any reference to that having worked with enough women with type one. I don't know. I mean, the goal of that, obviously, is to not conceive. So it has some level of hormone shift to prevent pregnancy.
Scott Benner 1:09:49
You would think it's an overwhelming of hormones to kind of stop
Jennifer Smith, CDE 1:09:53
whether it has an impact on blood sugar. I don't know that's it's a really good question.
Scott Benner 1:09:59
I don't know enough about how that works. works? How about IUDs? Do they impact blood sugar's that I'm sure you've seen in practice, right?
Jennifer Smith, CDE 1:10:06
Right, those more they seem smoother than other birth control methods from what I have seen. So do they have impact? They probably have an impact in terms of initially having one. And then the outcome of what now your sort of monthly cycle if there is still one remaining, what does that look like? Do you see any shifts? I've, I've seen women who don't actually have any visible cycle whatsoever, right? Who have noticed a minor shift that appears to be cyclic, but most of them tell me that they don't even adjust around it. They just end up taking like a little more corrective at the next mealtime the correction seems to work well enough, kind of gets them, you know, back to where they want to be. And they never make any shifts in their insulin at all.
Scott Benner 1:11:03
I have to say that Ardens OB was pushing, pushing, she was pushing, she was saying if we don't find some stability with blood with birth control pills, she wanted Arden to consider an IUD now Arden's like a little young, like we walked out, she's like, the first thing she said to me is like, I'm not doing that. And I was like, gotcha. But it was, you know, she's like, you know, in the future, we might have to keep this in mind. Yeah, I don't I you know, that is another thing I don't know much about. But you look like you have something you want to say. What did you find?
Jennifer Smith, CDE 1:11:32
No, I was actually just looking up a little bit about whether I could find anything on the plan B and blood sugar specific to type one, but I don't really see anything at all that documents that
Scott Benner 1:11:48
Okay, how about so is PCOS somehow related to diabetes? And or no? Like, why is it just because I only apparently at this point in my life, I only talk to people who have diabetes that I I start thinking things are more common or
Jennifer Smith, CDE 1:12:03
right PCOS is more common in those with other metabolic shifts that include insulin resistance and PCOS can bring more resistance into the picture, right? Other metabolic things being have more difficulty with weight management, they have higher cholesterol levels may already have higher blood pressure, despite potentially doing all of the healthy lifestyle things to manage those. But PCOS is more common with the type two. But interesting. In the past, I would say five years, I have had more women more normal, like healthy body weight and healthy lifestyle who have actually been diagnosed with PCOS. And part of the part of the reasoning in terms of like sending them to their back to their doctor to say, hey, I don't understand I am doing everything in the picture of management. And I need so much insulin to keep things where they are. Something else has to be in the picture. So a mine is always Why don't we look for PCOS, because if that is in the picture, one of the long term even in women without diabetes with PCOS is a medication that's very common and uses Metformin. Okay, it helps to dial down the resistance and from the PCOS level, it helps with some of that cystic nature in the ovaries and it helps with evening some of that out in terms of hormones and everything. So Metformin is definitely a heavily used additional medication that could be you know, beneficial.
Scott Benner 1:14:02
Yeah, somebody mentioned Metformin in in one of those I forget where it was. I didn't bring that question over for some reason, because they were like, because they were talking about like, can I could I just use Metformin during certain times of resistance around my you can't stop and start it right?
Jennifer Smith, CDE 1:14:22
That's no that's not the way that Metformin is meant you know, if you're going to use it, we started a low dose, evaluate tolerance I mean, it's one of the older oral medications it typically for most people is well tolerated after you get over some initial like first week or so of like some stomach upset and as long as you're tolerating it, it increases to like more of a therapeutic level. And then you continue use of it you
Scott Benner 1:14:48
don't stop at use Advil during one section of your Yeah, I only got I brought it up here because if somebody was thinking maybe somebody else was thinking, I did not think that was a good idea. So okay, I don't know, like, there's this moment where I go, Are we good Johnny that I do we do it or?
Jennifer Smith, CDE 1:15:08
Yeah, I think, you know, I was looking at more of the questions just to make sure that P A mean in terms of talking specific like cycle, I think yes. Um, I mean, I think discussion around things like menopause and that kind of stuff are it's such a transitory time in terms of
Scott Benner 1:15:37
that ever, right? Like menopause can go on for years.
Jennifer Smith, CDE 1:15:41
It can go on from very long time. Absolutely. I mean, and that's really perimenopause. Right. Once you're fully in menopause, you have no longer had a cycle for a year's time. Right, then are you are menopausal. perimenopause starts with many women notice a shift in their cycle. Let's say you have had a regular 30 day cycle consistently, you kind of getting into the age of and what age in general about 50 ish, but women with diabetes have from research sort of proven to start earlier than the typical like age of 50, let's say. So any shifts in your cycle, without any lifestyle changes or anything like that, you know, now you're having 25 day, the next month, it's 30. Day, this month, you have three days and a really light cycle next month. It's really, really heavy and painful. And it's just not your typical, it could be very likely that perimenopause is kind of in the picture and there aren't any many women would say, Well, can I you know, get hormone testing levels done to see in this point of perimenopause, it's not typically recommended. It really isn't until menopause, that they would recommend doing testing of hormones to actually sort of prove the case that they have come to a level without a cycle, you're no longer ovulating. And some women actually haven't done the testing to make sure that they're actually not ovulating. From just like a sexual standpoint, they're just ensuring that they can't get pregnant any longer.
Scott Benner 1:17:19
Yeah. Oh, god help you imagine having a baby when you're 50. I'd be so tired.
Jennifer Smith, CDE 1:17:24
I personally i can't i
Scott Benner 1:17:27
i would be so tired. That's all I can think of.
Jennifer Smith, CDE 1:17:31
Yes, I mean, from an age No, I can't.
Scott Benner 1:17:35
So no, my God. Last night, Kelly was like, can you imagine if we had had three kids? And one of them was just a couple years younger than Arden. Wouldn't that be nice? And I was like, No, I don't think so. It's it's 930 and I want to go to bed. How would that be a good thing? That child would end up being feral? I'd be like, just try not to die. And I don't know if I'd have the energy to take care of it. I really don't. I don't know. I mean, good for you. If you do. I don't think I could. That it. We're
Jennifer Smith, CDE 1:18:01
good. I think that's it. We should be good.
Scott Benner 1:18:04
Alright, so thanks. On the whole that's everything. I'm
Jennifer Smith, CDE 1:18:09
probably not everything but you know, it's
Scott Benner 1:18:12
alright, cool. Awesome, Jenny. I really appreciate this. Thank you so much. Thank you. Yeah, you're very welcome. My friend Jenny Smith has had type one diabetes for over 33 years. Jenny holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian and certified diabetes educator and certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She is also all over this podcast so if you like her check out the finding diabetes es has gotten Jenny the rest of the Pro Tips and so much more. Jenny does this for a living by the way you can hire her at Integrated diabetes calm Okay, I promise you euphemisms for periods so let's do it
Okay, some of these are going to be in delicate so stop listening now if you don't want to hear them. Alright, what do we got here? Strawberry week. Red and Red Army. Red wave. Red Ant is visiting men's which is short for menstruation. Riding the red wave code red. The red plague Aunt Rose is visiting red Castle entering the Red Sea tomato juice ketchup week. Ketchup week. That's not good. I don't I don't like that one. That makes me upset. What else we got here? Oh my god, that one's horrible. This is from in French. Fare do boo dime. I mean I don't think Big French but cooking black pudding. The hell's wrong with you people? The small little elves Niagara Falls. I have my things. The marquee red see? I feel sick red light red balloon. I have a flood lady days that time of the month, painters in the stairway what else we have here? special situation. These are Chinese special situation. Apple bread. Bloody Mary. That thing that comes in Japanese a Girl's Day. Blood festival once a month. Arrival of Matthew Perry. I do not understand that one at all. The Spanish say indisposed girl stuff. The frosting the steak. The frosting the steak. That's terrible. Little Red Riding Hood. Your devils the red cousin the vampire. I'm not even gonna say that one. What do you think of that? There's one I won't say that one's that one's terrible red tide. I prefer lady time. That's my favorite one. I'm also a fan of my baby box is trying to kill me. Here is another list. I painting the garage door. Moon time cranberry woman the Curse Girl flu. Girl flu is funny. Checking into the red roof in lady business Bloody Mary. Oh, i Ooh. I'll say it. Ready? Hold on. 123 the blob on the rag. I find that to be vile Crimson Tide. It's nice. I like that movie. Alright, I mean, listen, there's more than one of these obviously, you probably have a favorite. I just told you my favorites are girl time. My baby box is trying to kill me. And I did find girl flu very, very entertaining for some reason. Okay, if you're still listening, I really appreciate it. Thanks so much. I'll be back soon with another episode of The Juicebox Podcast. Make sure you check out those pro tips from the beginning. Listen through it'll be well worth your time.
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#608 Diabetes Pro Tip: Honeymoon
Scott and Jenny Smith, CDE share insights on type 1 diabetes care
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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 0:00
Hello friends, and welcome to episode 608 of the Juicebox Podcast.
Today I bring you the 25th installment of the diabetes Pro Tip series. On this episode Jenny Smith and I will discuss honeymooning. I know that a honeymoon can be very difficult to navigate both during it. And as it ends. It's difficult for parents of children with type one as well as newly diagnosed adults. So today, Jenny and I are going to do a deep dive on it. I think it's going to help you. Please remember, while you're listening that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan are becoming bold with insulin. If you're looking for the rest of the Pro Tip series, it's available diabetes pro tip.com, juicebox podcast.com, where you can go right into your podcast app right now. Hit search and look for diabetes pro tip Juicebox Podcast, they should all pop right up. But there's great lists on the website.
If you're looking for community around type one diabetes, or diabetes in general, you should really check out the Facebook page for the Juicebox Podcast. It's called Juicebox Podcast, type one diabetes. All you have to do is search for it in your Facebook app, answer a couple of membership questions. And the next thing you know you'll be in there with like 20,000 people living with type one and type two diabetes. You can ask questions, make friends, use this space, any way that's best suited for you just lurk if you want. There's a lot to learn just by looking Juicebox Podcast, type one diabetes on Facebook. I know. I know what you're thinking Facebook, people are going to argue and complain it's going to be horrible. But this group really is special. There's not a lot of that going on in there. And I think you'll like it. Just give it a shot Juicebox Podcast, type one diabetes. Last thing before we get started. If you have type one diabetes, or you're the caregiver of someone who has type one diabetes, and you're a US resident, in less than 10 minutes, you can take a survey that will help people living with type one. It's AT T one D exchange.org. Forward slash juicebox. I've taken the survey myself, it really does just take a few minutes you can do it from your phone or your laptop or wherever is 100% HIPAA compliant and absolutely anonymous. It really does help people living with type one, give it a look. T one D exchange.org. Forward slash juicebox. Okay, so we're recording, I want to tell you that this lovely woman named Isabel has been helping me with the Facebook pitch. And she came to me recently and said, You need a pro tip for female hormones and you need a pro tip for the end of a honeymoon. She said these are things that people ask about constantly. And they must not feel like they're getting what they need out of the podcast on this. Now Jenny, you know, in my heart, the end of the honeymoon just means use more insulin. And when you get your period it means use more insulin but darn it, let's let's just dig into it and find out that the details Okay.
Jennifer Smith, CDE 3:47
Sure. Yes, they're both good. Good topics. Yeah,
Scott Benner 3:50
the details are apparently what is needed, and I am happy to deliver what is needed. And by that, I mean dig it out of your head and record it so people can hear it. Sure. Okay. Because my only experience with honeymooning that my only experience that I'm aware of personally with honeymooning because Arden had diabetes, you know, was diagnosed so long ago, and we had a little meter and some needles. I mean, I didn't really know what was happening in her. So the one thing that I can tell you is that I called my friend who was my children's pediatrician one day, and I I told you this before, but it fits in this this episode. So let's put it here. And I told him I preface my conversation by saying I know what I'm about to say is ridiculous. But is there any chance Arden doesn't have diabetes? And he said and he sounded sad. I think sad that I asked him and he's and he said why? And I said, Well, she hasn't needed insulin for about a day and a half now. Right? And that lasted maybe? I don't know. 72 hours. And then it was just going. Yeah, anyway, that's my entire personal experience with honeymooning but I know how difficult it can be for everybody. So,
Jennifer Smith, CDE 5:10
well, another good question. And that I mean, as you sort of began with, I just give more insulin right? Well, a good piece of honeymoon is or coming out of honeymoon, right? You're, you've kind of moved through that lack of insulin need or really, really, some people can get by on just Basal insulin. They might not need anything for their meals or their blood sugar's don't go high enough to correct or anything right. But did you notice also that after that, like, three ish days, that her insulin needs were higher than they were before that?
Scott Benner 5:48
Well, here's the here's the honest answer. I don't know. I didn't know. You don't remember. No, no, forget that. I don't remember. I didn't know what I was doing. Right. So like, I think that feeling maybe encapsulates more honeymooning and the and the leaving of honeymooning for people more than anything like, right. So somebody you or your child gets type one. It's a whirlwind. It's you know, and if you're honeymooning, insulin needs are changing kind of radically sometimes. So just when you maybe get the nerve to, I don't know, Bolus two units of a Basal, you know, and then the next day Your fight is 60, blood sugar all day that won't go up. And then the next day, you think, well, maybe I shouldn't use the two units of Basal and then you don't and then your body doesn't help that day and your blood sugar's 300. All day. That uncertainty, I think, is the main characteristic of honeymooning, don't you
Jennifer Smith, CDE 6:42
true and honeymoon is it is really different person to person, as well as the like, movement out of honeymooning is different person to person, like you didn't have art and didn't have a very long honeymoon at all. And that's not uncommon from the studies that have been done. It's not uncommon with kids under the age of five who are diagnosed, to have a much more rapid rapid onset of type one very quick, very aggressive, really high blood sugars, you know, unless they've been watching for it, or they know because of previous antibody testing that it could be coming, you know, DKA, all of those kinds of things. And what that results in is causing enough of the betas to be stressed enough and the body kind of decreasing them enough in, you know, in amount that now diabetes presents itself, okay? So but in older kids, and especially in adults, there is often a slower progression of type one, like, you know, here it is, yeah, and all those symptoms, and that often leaves more betas in the picture. Also, what's been found is that the sooner you get containment of blood sugars after diagnosis, you give some relief to those beta cells. And because now, you know, you're either injecting or you're pumping insulin. And so that's something that's helping to take care of the blood sugar levels. And your betas that do remain can actually help out and so honeymoon then often comes in, you know, where, usually somewhere between about one to four months post diagnosis is the typical like, honeymoon, time to expect that to come into the picture and how long it can last again as person to person, it could be a couple months, it could be three days, it could be a year or two that you continue to have this like lack of more typical insulin need.
Scott Benner 8:54
It's the consistency that you're that you're missing and, and yeah, that breaks people's hearts I think I'll tell you after interviewing so many people, I've heard, I believe every variation of time and distance about honeymooning from adults and children and crazy stories where blood sugars are suddenly super normal super out of whack. One lady I'll never forget told me like she thinks her honeymoon lasted years. And then I'm wondering like, is that? Is that honeymoon? Or is it a slow onset? Like is that like, and I guess it doesn't really matter, right? Like, what matters is that you're using insulin now. And in there's going to be this variability to how much until things I guess you could just say settle but obviously it's not settle. It's until your beta cells give up. Right right completely. Do do some people just not see a honeymoon at all. What does that mean? And they're not aware of it. In talking
Jennifer Smith, CDE 9:53
with so many people that I have, and you know, it's always something I asked about his diagnosis. If somebody wants to talk about it, you know, or if it's been very, very soon after I get to talk or, you know, before I get to talk to them, it's been very close to that time period. And it seems like, again, everybody is a little bit different. A little people again, very little people tend to be the ones that I hear the most, we didn't notice very much honeymoon, or, you know, parents are concerned, because they're like, I don't know, I feel like we never had a honeymoon, I feel like, we never needed just like a little bit of insulin, we just went from not using any really using insulin, you know.
Scott Benner 10:37
So functionally, how do people deal with it? So when, you know, let's say, I came to you and I said, Hey, here's my seven year old kid, yesterday, this Basal, and this meal ratio worked perfectly. Today, it's a hot mess. And I'm saving low blood sugars all over the place. I don't know what's gonna happen tomorrow. But as I look back, this is bouncing around. It's two days of this one day of that. But how do you find reasonable stability until things get normalized?
Jennifer Smith, CDE 11:12
Well, some of it again, in that early time period is it's a bit of estimation, you can base it on Well, yesterday was a really sensitive day, if it looks like we fought low blood sugars all night. And we're entering morning time again, today, with lower blood sugar's yet again, that's a good visual that maybe today needs to be covered similar to yesterday, or even less aggressively than yesterday, right. So some high insight can help. But then, you know, tomorrow morning, you wake up high. If you didn't do anything strange overnight, and you're all of a sudden, high, today might be one of those days that you're going to need more insulin. And so it, it's hard because it takes out of the picture, a lot of the things that we've done. In other we've discussed in other episodes, like testing, right, and doing things like Basal testing, in this time period, it's kind of hard, because you don't really know exactly day to day, how things are going to move overall, the general idea that kids before puberty, once remission, has kind of gone away, right? Once that honeymoon period, you're expecting it's over. Insulin needs usually are about point seven to one unit per kilogram per day of insulin.
Scott Benner 12:34
Say it again,
Jennifer Smith, CDE 12:36
point seven to one unit per kilogram per day of insulin. So and if you don't know, pound two kilogram conversion, just take your pound weight and divide it by 2.2. And you'll have your weight in kilograms. But that's a it's a, it's a baseline, you know, if you were really, really, really low to begin with, and now you're doing a really low carb diet as well. You may not really see that insulin dosing kind of go along with what we would expect in terms of overall insulin need, right? Usually, people are considered in remission, if they're at, you know, point five or less point five units per kilogram per day or less of insulin. And then, you know, once you get to puberty, gosh, I mean, you could use anywhere between a unit to two units of insulin a day during puberty, and that's completely normal. Absolutely, and completely normal. So if you're not so sensitive anymore, you definitely see these swings in blood sugar, you know, especially in that growth period overnight or in the aftermath of meals and is lasting and lasting and lasting. guarantee you're probably not in honeymoon anymore.
Scott Benner 13:50
Well, you know, you I've said it to you have said to everybody listening, you have to meet the need. And I don't know, it's clear enough about that. But if one day the need is greater than meet the greater need and if one day the the need is lesser than meet the lesser need and, and flexibilities just it's completely key. It's what you're saying. It's like you have to sort of I don't think that I don't think that during honeymoon you want to look real macro. Not all the time, right? You want to kind of just deal with diabetes and segments of it of half days or hours or something like that. Like here's what's happening right now. If it starts trending one way, then adjust with it if it starts trending the other way then adjust with it. But I don't think there's a lot of value unless you're matching an apples to apples day and going well last Thursday. You know she was really low so I don't want to be aggressive six days later. You don't I mean like today's got no no Yeah, yeah, there's no correlation between now six days ago when you're in this honeymoon fluctuation. And I know that people We're gonna think I'm flipping but I think you could just retitle this episode, diabetes pro tip ministration. And I don't know that we're gonna say too many different things when we get to it, which is why maybe for some people, they gloss over it when we talk about these basic ideas of like, it's not always going to be the same all the time, you can't always ask for a cut and dry answer. I mean, if you want to get through a honeymoon period, and it's, it's particularly, you know, Rocky, I think that just staying flexible, meeting the need, you know, taking a little bit of historical knowledge off of days that were similar to the one you're experiencing now. I think that's really the whole thing.
Jennifer Smith, CDE 15:45
I think that's the best that you can do oftentimes, especially in honeymoon, and then even, you know, coming out of honeymoon, there's, I know, some people use the word like it becomes more stable. Okay. Sure. More stable in the fact that you're not like giving only one unit and that whole talk takes care of your whole day. Yeah, yes, absolutely.
Scott Benner 16:12
But yeah, or that one day, the units necessary. And then the next day, it's not necessary. But there's,
Jennifer Smith, CDE 16:19
I think there's more consistency is, is it exactly and I mean, in honeymoon, again, there are ups their downs, yes, you can, you can choose to use insulin from some hindsight from, again, I know, on a really, really busy day like this, my child needs a lot less insulin, but is running high today. Okay. Again, it's the then meet the need in terms of where the blood sugar is right now. And thankfully, these days, I mean, you didn't have an I certainly didn't, as a kid have any visible to where my blood sugar was going at all. It was a one number, it could be rising in 10 minutes, it could be dropping in 10 minutes. And that's what
Scott Benner 17:03
it was. I wonder sometimes when I'm like, I'm speaking to this person, now, who's got a very small child who I think still their needs are, well, they're not honeymooning, they were just, they had too much Basal going. So it's, you know, by using too much Basal, they were getting drops, that didn't seem to make sense, right. And so it took a day or two to figure out that the Basal was too high, to bring it down a little bit. But in there, while we were trying to figure it out, this person was using pens. And so they were relegated to point five units at a time, right, and I just said you have syringes, and she did was like, just eyeball less than a half. Next time we go for this meal, and did that and fixed a lot of their problems. So while this kind of unseen force, obviously, I'm talking about Basal that we needed to fix though, but you know, let the unseen force be, you know, your pancreas working all of a sudden, was dropping or down? If the limiting factor was the was the measurement on this on the pen. And then you like, for some reason, your brain doesn't jump over that and go, Well, this might be too much. But your brain says this is all I'm able to do. Do you know, I mean, like, and so but the minute we dropped down to like these quarter of units, then suddenly, there was far fewer spikes in the meals, and then far fewer lows afterwards. And I'm just wondering, like, during the honeymoon period? If you are that scared of these crazy drops? Do you maybe just draw back your Basal a little bit? And then on days when that Basal is not enough, just increase your meal insulin a little? Or do you mean like, because also these these poor people are probably MDI in this moment?
Jennifer Smith, CDE 18:55
Correct. Most often, and like you said, unless they have, you know, half half unit dosed or marked syringes in which yes, if you've got to, to get good eyes, or you have a good magnifying glass, you can get kind of a quarter unit fish in there, whatever it might be. They've got a good friend that does just that, and she's done it for a long time, and it works great for her. But again, you have to kind of use those microscopic doses and on pens, it's a hard thing to definitely do because all you can get is a half a unit. I mean, I think on pumps, honestly in honeymoon and I know a lot of clinics often don't encourage people to start pumping until honeymoon is expected to be almost over. And I sometimes I agree with that. Sometimes I don't agree with that. I think it kind of is individual in need. You have to look at what people are able to do and kind of a knowledge base of where are you already but those doses they do, they do shift and change through honeymoon. And then, you know, going out of honeymoon, you can expect the doses to definitely increase your child, your TN, your, you know, adult that you're living with or your partner to or whatever you're going to expect that their doses are going to increase. And while kids are growing at the same time as coming out of honeymoon, there are a lot of factors there. Another piece in the mix that often shifts things to higher insulin, and we've talked about it before we talked about illness and management is that if a child is also sick, within honeymooning and is now requiring more insulin, then by the end of the illness, they may actually either leave honeymoon sooner, or they may just be still at a higher insulin need as during the illness, the pancreatic beta cells were trying to assist, and there aren't very many of them left. So they were getting stressed out and can all can leave less than Yeah. So
Scott Benner 21:07
that's interesting. Yeah, I think that. So I think that the next step here, I mean, besides telling people like, look, it's gonna happen, you know, if it's happening, it's flexibility is key, it's going to be a little more stressful, but only if you I guess, only if you're looking macro when you should be looking micro. And then vice versa. Like you just talked about a lot, a number of ideas where you do want to pull back and see the big picture, but not about the fluctuations day to day those you kind of got to get on like a bowl and ride them, you can't step back and have an existential conversation about whether or not you should be bull riding, you know, so. But but the other stuff, are there illnesses, is there growth, you know, activity, those things are, those are big picture items. So now, okay, so now you've figured out a way to ride through this honeymoon, the thing that I see from people over and over again, is that when it ends, you know, like when the honeymoons over, they can't believe it. They can't pull the trigger. They can't ramp up. Think about it any way you want to. But they get stuck in the game, and don't recognize that the game changed.
Jennifer Smith, CDE 22:23
Yeah, I think the big thing there is that, especially in honeymoon, the sensitivity to insulin makes people very wary of using more. Right, right, because you can get burned, right, by using more thinking you needed more, because yesterday, it clearly didn't work with this, you know, lunch that we provided we're giving the same lunch today. So I'm going to be more aggressive, you know, gave a quarter unit yesterday, today, I'm definitely giving a half a unit and then on the back end of the drop happens, right? The good thing to know is that in, you know, the coming out of honeymoon kind of moving out of that that phase is that you will have again, more consistency in more need for insulin, you won't have as much potential for those drops, where you learned they typically happened even if it wasn't every day, you probably got a good idea of where things needed to be lower in dose or, you know, that won't necessarily be the case. Once you're out of honeymoon,
Scott Benner 23:36
I feel like you I mean, when I tell people about it, I say you just kind of have to reset at that moment. That's when you go back to the setting Basal insulin pro tip, you start over again, you get the Basal straight, you reevaluate how long your Pre-Bolus time is, you reevaluate your meal insulin after you've re evaluated your Basal insulin. And you just kind of start over that. The truth is, is that I think that the transition from honeymoon to out of honeymoon is not actually much different sometimes than the transition from MDI, to pumping in that it's just the it's the same game different players, like I don't know how to like, how to think of it, it's like, you know, right church, wrong, pew. I don't know what the what the the thing is, like you're doing the same thing. But the pieces have all just sort of adjusted a little bit. And you have to just step back, take what you know about the thing you've been doing, and reapply it to the new situation.
Jennifer Smith, CDE 24:31
Right? Correct. And with pumping, you know that you've got a lot more precision that comes along with that. So if you've been doing things as precisely as possible with let's say, Just half units, right, and Basal that's given once or maybe twice a day. Now you can really address where insulin needs are heavier and are lighter through the course of a 24 hour days. Yeah, you can meet the need more precisely, thus, the benefit of doing some Basal testing again, even if you're just doing it overnight, and everybody wants to sleep. So if there's one time a day that you're going to do it, do it overnight,
Scott Benner 25:14
get that part done, get that part done. And you steal a bunch of a one C and some just good feelings. In general, if you're, if you're thinking all 24 hours are just a train wreck, like maybe you can at least get eight or nine of them straight, you know, and say, and it's a jumping off point, figure out the rest of the day. I think that when you were saying something a minute ago, this thought just jumped into my head, and I'm gonna put it here. And I think it fits. I think no matter the situation, maybe I'm talking about just diabetes or life in general. But do something is often the answer. People, there's a people freeze, wondering what the something should be. But if you're watching the same thing happen over and over and over again, if you just change the variables, the stressors on the situation, you might see something new, that helps you understand a bigger picture something different. And so, you know, if blood sugars are, I mean, I don't think it's a joke. But like online, sometimes somebody will throw up a graph and be like, I don't know what's wrong with this. And I'll literally just type more insulin. Because put in some more and watch what happens and then go Oh, cause and effect if they want to know where
Jennifer Smith, CDE 26:29
Right, yeah, not just more like, but where should I put that more insult
Scott Benner 26:35
thing, though, it's like do something right? Like, if you haven't been on vacation in 15 years, take $5 a week and put it in an envelope, you know, do something, try to change the situation a little bit. And I get that it's frightening. And I used to think, Jenny, I used to think that all these things that I saw around diabetes, were so specific to diabetes, but I've been having some personal things going on with my mom's health recently, which Jenny knows about? Probably not. Yeah, about right away. But but the point is, is that I recognize that the confusion, and the the lack of knowing when to jump and feeling like you're overwhelmed and feeling like you don't understand what to do next. It's life, not diabetes, right. And maybe it feels a little more dire in some situations than others. You know what I mean? Like standing in the store, trying to decide between two waxes for your car might not be as crazy as I wonder if I want to add three more Basal units to my kid or something like that. But the truth is, is that that inaction, that's what keeps you where you're at. So if you're sitting where you don't want to be, do something,
Jennifer Smith, CDE 27:47
right, and easier one to honestly do, let's say you are running high, you know, all day long, and you're higher after meals, but you're still just stuck high in that scenario, and a safer thing is just add a little bit more Basal add just a little bit more Basal, right. If instead, in time periods where you're not actually eating, it doesn't look too bad. And then you've got these big excursions after you eat just about, you know, anything, even a microscopic eight grams of carb, maybe and it goes rocketing up, well, then you may be okay with Basal and maybe the next place to add more. And again, not three units more, but maybe add a half a unit or adjust your insulin to carb ratio by one gram to get a little bit more insulin around the times that you see the change that you don't want to see happening.
Scott Benner 28:45
Yeah. Arden's been getting up in the morning going to school, and her blood sugar has been rising. This this school year, like 30 points in the morning. I tried to let the algorithm mess with it didn't work. I tried making just some simple Basal adjustments wasn't enough. And then finally I just said doors like when you leave the house from now on, we just Bolus three units, please. And she's like, what I was like, just throw in three units, get the car, go to school. I was like, because whatever's happening is happening enough. I believe it's happening. I trust that what I know is going to happen is going to happen. And she's using an algorithm. So if you make an uncovered Bolus, it removes her Basal immediately. So her Basal is like 1.2 in the morning. So I figured it was about a unit and a half or so to fix the number or to get ahead of the number. And we got to cover the Basal that's gone. So it's like just three. And then we adjusted off of that and did a little too much the next day we did a little less. The next day, we had a better outcome. The next day she forgot to do it, you know, on the third day and I was like see it happened again, like you know, like do this thing that made her trust the drive Do it and it becomes a little more important to her. I just think it's another example of do something. Right. You know, I, I've been saying online a lot to people lately. And you'll forgive me because I can't pronounce it in its in its origin language in Latin, but I've been telling people lately, Fortune favors the bold. Just try something, you know, they mean stand up thump your chest and go, I'm gonna take a swing here. Let's see what happens. And then you get back to this stuff you hear in the earlier pro tips, you know?
Jennifer Smith, CDE 30:35
Right. Well, and I think the bigger thing too, that you're, you're bringing in is try something, right? But then analyze what that trying did. Right? Don't just try it and be like, Wow, that clearly didn't work. Like, still focus on it? Well, it didn't work, your adjustment either left you to higher like, you know happened for you caused it to be a little bit too low in the algorithm couldn't really save you from that extra insulin well, but now, you know, so you use that for that information. And you move forward and you say, Okay, tomorrow, we're going to do it this way. I mean, that goes into, you know, a lot of things in terms of kind of the exiting of the honeymoon. It does it's try this, it looks like consistently in the past week, he's needed more insulin, right? Okay, great. You're trying to add more insulin? Is it enough? Is it getting to you to the place that you want to be? Insulin needs may actually continued to climb a little bit. It's not like a night and day like yesterday, we needed one unit and tomorrow, we're gonna need 10 units. That's not typically the exit of honeymoon. But over time, that lack of beta cells that is that was helping you write is going to show up very evidently, in that you don't return to that minimal amount of insulin,
Scott Benner 31:57
when you know what made me do this episode when Isabel told me that she thought it was necessary. It was that I had to get over that thing in my head that it's already in the podcast. Like I was like, No, it's in there already. You just have to listen to it. And then I thought, well, it's in there. But it's in a different way. Because what we just talked about, what about that? It really is the way when I'm when I was talking about God, I don't even know what episode it was not that I guess maybe that's a good point. It's hard to find them all. But But, but when I was talking about like sometimes you know, people's meal insulin right meal ratio, sometimes their insulin to carb ratio can be like spot on for a number of meals, but not work for a certain meal. And I always use that silly example, if you have meatloaf and mashed potatoes and green beans, and you count the carbs. And it says the carbs say Oh, this is five units, you make your Pre-Bolus. You spike, you end up correcting later with two units, which brings you down and you don't get low. Well, the next time you have the meatloaf in the mashed potato, seven units, you use you seven units, right? Like you see it happen. And then you take the leap, you stop looking back at the meal ration going no, that's not right, I counted the carbs, it's right, this is five units, very similarly to the idea of you're using a pen that only goes up to a half a unit and you keep using it and then watching a low blood sugar happen. I go, I'm powerless, but you're not powerless. Like you just need to go get a syringe and do it a different way. And you're not at the mercy of your carb ratio just because it works five days a week, but not on Sunday when you have meatloaf like right. So, right. It's all kind of the same idea. Like right, I know it sounds trite. But
Jennifer Smith, CDE 33:37
well, and that's I think it brings in a good a good piece too, in terms of, you know, multiple daily injections, then we move to pumping, and then we move to the fancy features of pumping. And then you might move to an algorithm driven pump, right? All of these things take. They take like evaluation. And a good example from somebody I worked with a while ago, who had started using one of the algorithm driven pumps, and she was fantastic. I love it. It's working so awesome. But it doesn't work on Friday night. I was like, Okay, well what were you doing on Friday night, that this doesn't work anymore for you. And she had this like, whole thing figured out for her dinner Friday nights that she would go out to with her husband. And on a conventional pump. She could use like, you know, a temporary Basal she could use an extended Bolus and she had it down, Pat, that was like just go to manual mode in your pump and use it that way overnight and Saturday morning. Turn your algorithm back on. She's like, why didn't I think of like, oh, I don't know either, but I hope that it helps and it it seemed to be much better than we did
Scott Benner 34:53
last night. Yeah. Because we went to a bar and art and got nachos with cheese steak on top of it and had French fries, and I crushed my first Bolus. I was like, I haven't been this excited about a Bolus and was like I was on top of it. And then I started seeing the fat rise, and we hit it again. And I was like I was over. And then I go upstairs to start working. And suddenly she jumps up her blood sugar jumps out, but I go downstairs to my lab and see what happened. I had some gummy bears, she told me and I was like, no, no, we can't put simple sugar on top of fat and protein. I was like, are you all out of your minds? Without like, significant I said, Aren't you were going to gummi bears in this situation, the Pre-Bolus would have needed to be causing a fall before you put the bear the bears in, you know. And then that would have been okay, but she just did the like my blood sugar's great thing, threw in some insulin, wait a little while and ate it. And it was not nearly enough. We needed to be more drastic with it. And so I was like, so my text, my text said this, I'll bleep it out. It said it said that it said, open the loop Bolus for you.
Jennifer Smith, CDE 36:06
And let and let the Basal run let's
Scott Benner 36:09
back to normal pumping for a minute and stop asking this algorithm do something that it doesn't know how to do. Because it's
Jennifer Smith, CDE 36:15
not it's not a learning algorithm. Unfortunately, it doesn't, you know, it doesn't react the way that we have the experience to say, I know this is what's going to happen. Please don't fiddle with the insulin that I put in purpose.
Scott Benner 36:32
Now's not the time to take the Basal away algorithm. Yes, gummy bears and cheese stick nachos happening right now. Anyway, Jenny, you know, there was in the past, there was a moment when I, I used to worry. And I think like, Well, we've already said these things. And people will find it. And now I realized that that's not how this is going to work that these continuing conversations are incredibly important. I think maybe the conversational part of this episode, and many episodes is more important even than the technical aspects of what was said inside of it. Right? You know, like, if you listen to the Pro Tip series, and you had your brain or my brain, or your experience, in my experience, you could derive from the Pro Tip series how to manage a honeymoon. But for people who are in that situation, I think they need the information here. Right, you know, in one spot. Yeah. And I just, I don't know if I was just like, super hopeful or lazy. I'm not sure. But I used to think like, just go listen to the pro tip episodes, it explains the whole thing, you know, and it really does. So I appreciate this, I think we're gonna have to, you know, like I said, I want to do one for you know, female hormones, menstruation, that kind of thing. Yeah, specific the next time we record. And then from there, I'm going to say this year, Jenny, because it will put us both on the hook. In 2022. Jenny and I are going to go back to certain pro tip episodes, were going to re listen to them on our time. And then incorporate questions that I'm collecting on Facebook, on how to supercharge those episodes. So they're going to kind of create some of them are going to get a part to kind of a situation. That's cool. That's what that's how we will you and I will spend our time seeing each other through the winter of 2022 sequels to certain episodes. I'm thinking of them as director's cuts for oh, there you go. Yeah, for older people who you remember the directors commentaries? Yes. Yeah. You know, where do you mean you'll flip the movie on and the audio goes away, and you just hear the guy go. In this shot. What I was thinking was that if the sun came in from the left,
Jennifer Smith, CDE 38:41
and we could could pan over here and listen to this music from this producer, you know, whatever. See
Scott Benner 38:47
how missoma Hykes eyes are glistening. i I told the DP like I don't know if you ever listened to them. They're pompous exchanges, Jenny and I will not do that. But we're gonna go back and listen to what we've said. Because I've done it a couple of times, like in Episode 500. I went back to Episode 11. That's bold with insulin. And I listened to it and like talked overtop of it like so people listening and episode. I think it's 100 Oh my god. 100 500. Sorry. In episode 100. I just basically did a director's cut of that, because I realized that when I said it, I was just saying it. Like there was and now I've lived all this time since then, and had these interactions with people that maybe there'd be more to add to that. And I think that exists for the Pro Tip series. Like and I'm excited. I'm sorry that you're gonna start getting emails from me that say please listen to this one before we talk again. But
Jennifer Smith, CDE 39:36
no, that's fine. You're busy and I can do it during my workouts. That's not usually I just That's my mental like, my moving like mental sort of like strategizing time is my exercise time. I am not like a sit in one space and like meditate. I'm a moving meditator But I can meditate on the episodes so we can make them better for everybody else. Excellent.
Scott Benner 40:04
I have a question, then I'll let you go. How do you make out listening to your own voice? Does it freak you out?
Jennifer Smith, CDE 40:12
It's I don't know, it's I guess it's kind of weird to me because I like I hear myself speak, you know, in your brain like, but when you hear yourself, it sounds different. I guess. I don't mind listening to myself. But yeah, I don't know. I don't think that I sound like what I sound like when I listen.
Scott Benner 40:35
No, no, no, I sound so right now we're recording, I can hear you and me and my headphones. I sound different in my headphones than I sound on the recording. And if I'm just speaking out into the world, I don't think I sound like the person on the podcast at all, but people think I do. But in my ear, it doesn't sound the same. Although And do you ever get on you ever? You ever say anything and hear yourself and go? Oh, Jenny, you should not have said it. You should have said it like this? Do you ever correct yourself?
Jennifer Smith, CDE 41:01
I do? Absolutely. And a lot of the ones that I've listened to don't like, oh, this would have been a better explanation. Or I could have put this in as an example. And that would have been better. So maybe we Yes, I think it's great to sort of rethink them. Because then we can add extra and
Scott Benner 41:15
I agree that there's there's just always going to be other stuff to say. And as we move forward into 2022, and beyond more people are going to be using algorithms. And there's going to be a whole new layer of understanding for diabetes, there's going to be things that you and I don't have an experience yet that, that through these experiences over and over again of using this technology, you're gonna come out I don't see an end to this podcast, I used to think it was finite. And now I think somebody is gonna need to, you know, make up a cure for this podcast not to be necessary.
Jennifer Smith, CDE 41:47
So Well, that's what I was gonna say I don't think until there's honestly a true like, you don't have to use any technology or anything. You just go in and get your bloodwork done and make sure your doctors like yep, you still look great. It's all perfect. I don't think you know the information that people need, especially with life changing and everything. I think it's purposeful. So
Scott Benner 42:10
I do too. I appreciate you doing this with me. It's the end of the year. So let me thank you for giving your time so greatly to the podcast.
A huge thanks to Jennifer Smith, my good friend for being on this episode of The Juicebox Podcast. Actually, Jenny does the podcast for fun, but she also does this stuff for a living. So if you'd like to hire her, you can at integrated diabetes.com After the music. I'll give you some agenda specifics. Don't forget the Facebook page for the podcast Juicebox Podcast, type one diabetes 20,000 people strong, just like you looking for advice, community and support from people who understand. Please take advantage of it. It's absolutely free, and really valuable.
My friend Jenny Smith has had type one diabetes for over 33 years. She holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She's a registered and licensed dietitian and certified diabetes educator and a certified trainer and most makes and models of insulin pumps and continuous glucose monitoring systems. She is also on every one of the diabetes pro tip and defining diabetes episodes. You can find those episodes in your podcast player. We're at Juicebox Podcast comm I actually think there's a list on the Facebook page to up in the Announcements section. Is that what they're calling it now that used to call it all a sudden? I'll find out for you. And then I'm going to tell you about the other stuff that you need to know. Yeah, so if you're on the private Facebook group, they call it featured now used to be announcements now it's featured. So if you go to the featured section, you'll find lists of the pro tips how to start listening to the podcast, defining diabetes, all kinds of stuff that you need. Actually, there's lists of ask Scott and Jenny episodes here. All kinds of good stuff. You should check it out. Look at there's so much to choose from special episodes after dark how we eat okay, I'm not going to bore you with this. But by the way, it's not boring. I'm just trying to fill you in. Are you arguing? am I arguing with nobody? Hold on a second. I want to tell you about the diabetes pro tips. So they began back on episode 210. With an episode called newly diagnosed or starting over, I'm going to try to list them for you pretty quickly. Episode 211 all about MDI episode 212 all about insulin episode 217 Pre-Bolus Episode 218 Temp Basal 219 Insulin pumping to 24 mastering a CGM to 25 Bumping nuts To 26 the perfect Bolus to 31 variables to 37 setting Basal insulin 256 exercise to 263 fat and protein 287 illness injury and surgery 301 glucagon and low V Gs 307 Emergency Room protocols 311 long term health 350 Bump and nudge part two 360 for pregnancy 371 explaining type one that's for other people like so you can share it with like a family member, a loved one who needs to understand type one 449 postpartum 470 weight loss and this episode 608 And there's going to be more in fact, there'll be another one next month on female hormones. Thank you so much for listening. If this is your first episode, please subscribe or follow in an audio app of your choosing. Apple podcasts, Spotify, Amazon music anywhere you get audio. I'll be back very soon with another episode of The Juicebox Podcast.
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