#1021 Diabetes Pro Tip: Postpartum

September 24, 2023Scott Benner

Scott is joined by Jennifer Smith, a registered dietitian and certified diabetes educator, who shares her insights on Postpartum and type 1 diabetes.

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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 0:04
Hello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CD and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisit double. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. While you're listening 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 healthcare plan or becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have an amazing offer for you. Right now at my link only contour next one.com forward slash juicebox free meter you can get an absolutely free contour next gen starter kit that's contour next.com forward slash juice box free meter. while supplies last US residents only the remaster diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one, see all of the good work they're doing for people living with type one diabetes at touched by type one.org. And on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries G voc hypo Penn Find out more at G voc glucagon.com. Forward slash juicebox. At the end of this episode, which by the way, if you're a person who's like, Oh, I'm never gonna have a baby or I'm a boy, or whatever it is, you're thinking right now postpartum doesn't apply to me. These diabetes pro tip episodes are, I think terrific. And I think they all go together. There's a lot to learn from listening to this episode, because at its essence, it's dealing with huge variables, which is what you'll find after you've had a baby. So it doesn't apply. But it does. You'll see, at the end of this episode, I'll tell you where you can find Jenny, I'll tell you where the rest of the pro tip episodes are and what the topics are. And anyway, I think you should listen to this one, whether you're going to have a baby or not. Alright, well, that took three minutes, which is probably two minutes longer than it took mostly to get pregnant. So here's Jenny, but a bump. As time passes, I'm becoming more and more aware of a lot of pregnant women or women who want to get pregnant who have type one diabetes who are listening to the show, and who are enjoying like there's a series back in the show with Samantha where I interviewed her every three months, like during her pregnancy. Yeah, I remember you mentioned her and that apparently, is making the rounds on the on the internet and the way people listen to things. And I just get a number of emails and I'm sure you do as well that are either that start off with like, I can't, I'm never going to be able to get pregnant because I can't get myself together. And then they go I can't believe I did it or I'm doing it you know, like that kind of a thing. But then there's that. The rest of it that I guess we stopped thinking about because the baby's out. And I don't know that's that's weird. So a person in my mind, being a person who's never been pregnant and doesn't have type one. That journey seems painfully taxing to me from going from not thinking you'll be ever, ever be able to have a baby to figuring it out to then doing it having these insanely great a onesies while you're pregnant. And I don't know it just feels like it would be super simple to just not abandon it but lose sight of it after you have the baby because of all the things that happen after that.

Jennifer Smith, CDE 4:46
And I don't think it's that. I don't think it's that the good majority of women really think that they're just going to just give it all like all the work that I've put in over the past, you know nine to maybe 12 Once if they really did a lot of really good preconception management to kind of get there, and managed, it could have been a long haul of, you know, nine to 18 months, let's call it of trying to really strategically nail things down. But I don't think that if you've done that, or even if you've come into pregnancy, maybe not where you wanted, but you really did an awesome job of mastering things and getting things taken care of through the pregnancy. By the end of pregnancy, most women aren't like, Oh, I'm just gonna, like throw it all in the basket, everything I learned how to do. But there is a big piece postpartum that, especially as a first time Mother, is completely 100%. New. Yeah, it's I mean, it is it's like being thrown into like, a new job. In a country where you don't speak the language, they're like, here you go, it's all yours to like, figure it out.

Scott Benner 5:54
And by the way, that job will die. If you drop it or leave it,

Jennifer Smith, CDE 5:58
you're gonna kill a million people, if you don't do it exactly the right way.

Scott Benner 6:01
That's how it feels, isn't it?

Jennifer Smith, CDE 6:03
That's kind of what it is postpartum. I think a lot of the a lot of the up, down comes in, because you're trying to manage something 100% new, or the hormones that shift and change after you deliver can be a roller coaster of effect. And for me, I usually say in a general sense, the first three months post delivery, is going to be kind of a rollercoaster up and down. Mainly because especially if you're nursing or pumping to feed your child, the shift in hormones, and the shift in how much your nursing how much you're pumping, can drive things, the opposite way that you would think that they might, which makes it very difficult to establish, I would have usually like over Bolus for this, or I would have usually been really aggressive to nail down this now climbing blood sugar, but oh, I'm going to nurse in the next 15 minutes. So I really can't do this strategy, because otherwise I'm going to tank. So there's a lot that changes postpartum.

Scott Benner 7:23
Okay, so not only. So there are some people who enter a pregnancy and already have that a onesie that they need. But But despite that, whether you're a person who had to get there, or you were there already, once you're pregnant, your insulin needs, they drastically changed. I know it's not like trimester to trimester Exactly. Right. But there are times when you don't need as much as you think and times and you need so much more that it's hard to imagine how much more you need. Right? Right. So now you have that in your head, you've been pregnant, you're having breakfast that prior to pregnancy, took three units during pregnancy took 12 units, and now you've you're holding the baby, you're thinking is this 12 units? Is it three units? Why does the weight of the world feel like it's on my shoulders? Like, you know, am I nursing? All this stuff comes together? And how do you do that? So you started by saying the hormones, and I only want to spend a second on this, but you know, I'm older. And growing up, it doesn't happen much anymore, like society has really shifted, you know, in the way people are towards each other. And that might be harder for like somebody in their mid 20s to believe but when 30 years ago, you know, stuff that you think of as a joke now is actually how people would think about women sometimes like, oh, you know, she gets upset, or you know what time of the month it is, or that kind of thing, not giving any, like, credence to the idea that when your hormones are jumping around is really difficult to deal with. And you're right, and that women are in a particularly vulnerable situation because of that. So how you feel from a hormonal shift could be physically, it also could mean your your clarity. And I think what you said is just really important to remember, especially for first time mothers, when you have a baby and they give it to you, it does genuinely feel like someone just told you that the fate of the world rests in your hands, and you don't understand what to do. But if you mess it up for certain the universe won't exist anymore. It really feels like that.

Jennifer Smith, CDE 9:33
And some people have really awesome babies that are like the easiest. They just they sleep when you'd expect that they nursed beautifully. They sleep again, like they don't have any like major poop problems. You know, you just have this like, what you would call like, I have no trouble with my perfect baby. And then there are women who just don't like some kids are just one that type of an infant as a newborn, and I think when you have diabetes to then it brings in management again of something that's completely new. I don't know, should I do this? Should I try this is the doctor right? You know, am I going to do this wrong to my child, bla bla bla. And then there's diabetes in the picture, and the timing of insulin, and the timing of adjusting and remembering to change your pump site or to actually take your Basal insulin injection. I mean, there's a world of scheduling difference that comes into the picture postpartum.

Scott Benner 10:35
And I would imagine to and this is just me imagining but if you live for nine months with an A one C, and like, the low fives, there's got to be a part of you as a type one is just like, wow, I want this for the rest of my life to write. And now you feel like if it's going away, now, it's another failure on top of, I don't understand why this baby throws up all the time. Or, you know, like, I I'm sure people are like, oh, yeah, like I've everyone's heard the joke about like, the baby peed on me one time. Yeah, that's fine. My son couldn't hold down food for months, until we figured out what to give him. And, and the combination of it was, quite honestly, Kelly holding him at her grandfather's funeral. When basically it felt like somebody took a half a gallon of spoiled milk and dumped it on Kelly, because it just came out of him like that at a funeral. And she had only been a mom for a little time. And it's hard. And so it's fun to talk about like, oh, the baby peed on me. Right throws up all the time. But sometimes it throws up at a funeral and your hormonal and your grandfather's bed.

Jennifer Smith, CDE 11:41
Your CGM is going off because your blood sugar is skyrocketing. Because you're stressed out about said incident.

Scott Benner 11:47
Yep. And so I was gonna say my wife didn't have type one diabetes. So then all that other stuff that goes on top of it. So what do you so is it similar? Like, could you sit down and make a flowchart? Is it similar for people at at least at some core level? Or is it going to be different for every woman?

Jennifer Smith, CDE 12:06
There are similarities as you know, we talk about in our in my pregnancy book that I co wrote, it's, there's enough similarity, just like in pregnancy, I mean, everybody's going to have some shifts and changes that are a little bit different, very specific to just like diabetes is very specific person to person, but postpartum Yes, I mean, the transition typically, as soon as you have delivered and the placenta has been delivered, as well. It's, it's like the placenta, which is the major like functional hormonal unit. Once that's gone, and baby is out, the hormone shift. It's like a drop off a cliff. It's like, it's gone fast, which is the reason that we usually say, based on where you were, at this point in pregnancy, just before delivery in terms of insulin use, if you didn't know where you were pre pregnancy, so you could see how much things shifted up by the end of pregnancy, than we usually recommend adjusting Basal rates down by about 50%. Wow, okay, that's the that's expected, it could be a little less, it could be a little bit more person to person, again, may differ. But that's a baseline adjustment. So if you've never been told what to do, and nobody's directing very well expect that postpartum you should cut your bezels by 50%. Another really good idea is to most women know when their due date is. If you're using an insulin pump, especially set up a profile that's called postpartum, because as soon as you deliver, all you have to enable do is enable that.

Speaker 1 13:40
Wow, that's that was gonna be my question. Like you're saying, like, placenta comes out, you take a deep breath and go, I need my pump right now. And that's it. 50% Less 50% Less. Yeah, so that placenta is

Scott Benner 13:54
please forgive me if this is ham fisted, but it's the it's the equivalent of a giant sausage cheese pizza sitting in your stomach that somebody just reaches in and takes out all the sudden and now you don't have that impact anymore. Correct. Wow. Okay. Yeah, I don't know if anybody's ever seen a placenta but it is very close to a cheese pizza. When you look at it.

Jennifer Smith, CDE 14:13
They're very interesting. organs. I mean, they're and the cool thing is that your body creates it for one purpose. And then it's gone. It's not like your heart which is like you know, it's always there for your whole entire life. It's like your body makes this thing just like it makes the baby and then it's all done it's only got this like nine month life

Speaker 1 14:37
I was just thinking this i It's funny you said that because I was just thinking the same thing like why can't we just tell our body to make another heart? Yeah, like I mean if it can do that, it could at least you know, vacuum or something, you know,

Jennifer Smith, CDE 14:48
at least also make another pancreas man if

Scott Benner 14:52
I mean, why not? I'm not a doctor, but somebody should get on that.

Jennifer Smith, CDE 14:57
I entirely agree.

Scott Benner 15:01
Imagine if you just had a panel on your back and you flip the switch and that nine months later your body just spit out an organ. Had a little slot on your side. I don't know why this is impossible, probably because of science but never. Okay, so baby comes out. We're all like, who went and on taking those weird bloody pictures that people take in the beginning and everything and then I changed my Basal rate. What am I going to see next my budget does the body begin making milk at birth or does it even start prior to that? That remastered diabetes Pro Tip series is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have a unique offer just for listeners of the Juicebox Podcast. If you're new to contour, you can get a free contour next gen starter kit by visiting this special link contour next one.com forward slash juice box free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juice box free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen, it fits well on your hand, and features Second Chance sampling, which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash juice box free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips, you can use my link and save time and money buying your contour next products from the convenience of your home, it's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now, through your insurance. Contour next one.com forward slash juicebox free meter go get yourself a free starter kit. while supplies last US residents only touched by type one has a wide array of resources and programs for people living with type one diabetes. When you visit touched by type one.org. Go up to the top of the page where it says programs there you're going to see all of the terrific things that touched by type one is doing and I mean, it's a lot type one, it's school, the D box program golfing for diabetes dancing for diabetes, which is a terrific program, you just click on that to check that out. Both for cause their awareness campaigns and the annual conference that I've spoken at a number of years in a row. It's just amazing, just like touched by type one touched by type one.org or find them on Facebook and Instagram. links in the show notes links at juicebox podcast.com. To touch by type one and the other great sponsors that are supporting the remastering of the diabetes Pro Tip series touched by type one.org. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. G Bo Capo pen is a ready to use glucagon option that can treat very low blood sugar in adults and kids with diabetes ages two and above. Find out more go to G voc glucagon.com forward slash juicebox G voc shouldn't be used in patients with pheochromocytoma or insulinoma visit G voc glucagon.com/risk.

Jennifer Smith, CDE 18:50
The way that it should happen again, everybody's a little different in what happens. But what should happen is a first milk is created it's called colostrum. And essentially that's very short lived in production before milk comes in. It could be a short lived, you know, few days, it could be 24 hours before your milk comes in. But that milk is a very like it's very simple form of nutrition for the baby. It's kind of what the baby is in need of right here and now. And there's not much of it. So it's not like if you were to pump it you're gonna get like six ounces of it. That's just not what you would get right. So, but in that simple form and with the loss of the pregnancy hormones. Now you have this sensitized system that was resistant, leading up to this point. And so there and also why some mental shift the shift of you know, nearing the end of pregnancy coming you know, pre Bolus is in 15 minutes, it's sometimes 45 minutes by the end of pregnancy, in order to have good flat after meal blood sugar as well. Now you have to completely flip that switch, and it's back to maybe I need 10 minutes, maybe I need no Pre-Bolus in the early couple of weeks post delivery. So not only is it that your Basal shifts, but it's also that your ratios shift your insulin to carb, your correction factor your Pre-Bolus time. So there's, there's a major transition,

Scott Benner 20:32
right? You just become a completely different person with type one diabetes, just like that. And, and so is it similar to, but more drastic to have getting your period like being that, like, there's that, you know what I mean, I don't know if it works for everybody. But Arden's three sometime now that she's on birth control, she's more like two different people during the month. But and, and it can be it's drastic for us, you know, she can go from a unit an hour to two units an hour, basil, depending on what time of the month it is, and that he doesn't flip like a switch. It's not like, but I can see it happen, happens over hours and maybe a day, but it doesn't happen. It's not like at three o'clock. She's like, I just got my period and everything changes immediately. What is it that just blown up? Much more? Because I mean, what are you really talking about? So for people who don't know, like, I go into pregnancy, I just said, I go into print, let's just say I'm pregnant. Alright, I'm pregnant. I

Jennifer Smith, CDE 21:35
have type one diabetes, you're a lady with long curly hair. I'm

Scott Benner 21:38
a lady. I have type one diabetes, I get pregnant, my Basal rate is 1.5 an hour in the first trimester, is it? How much does it go up? A lot in the

Jennifer Smith, CDE 21:50
early weeks. Typically, we a good round estimate is if you know the percent of increase you've had in the days before your cycle starts. If you've taken enough notice, and you have a rise and you offset it by a percent of Temp Basal or an extra Basal dose or whatnot, you can expect those early weeks of pregnancy, typically up to about 678 weeks that you're going to have an increase in insulin need. That's pretty similar. It might be more dramatic than that it may be less, but you're going to have a ramp as your body is increasing. Its production of now pregnancy hormones to sustain the pregnancy in furthering along.

Scott Benner 22:32
Okay, so I should have said my my Bolus was ones that we could keep track, right? It say I'm one usually when I get my period, I'm too. So then we're gonna say in the first six to eight weeks of pregnancy, I'm probably going to be more like two more like I have my period, correct exam there. Right. And then from there it goes, it goes up again.

Jennifer Smith, CDE 22:52
So end of first trimester, most women notice either a plateau, okay? Or they notice a bit of a dip off in their insulin needs. For just that end of the first trimester, usually, we say on average, it's about it starts at about eight weeks, goes through about 12, maybe even 1414 weeks, which is that fertile, very early second trimester start time period of sensitivity, you may have needed to back off of your Pre-Bolus time again a little bit, you may have gone down slightly in your baseline basil needs just more sensitivity around meal boluses. And kind of almost feeling like things have sort of stabilized like you have a little bit more wiggle room like I can eat three chips in between and not actually Bolus for it because it doesn't seem to do anything to me, or right. And then second trimester again, a little bit of a nudge up potentially an early second trimester. But a little bit more stability up until about 18 weeks 18 to 20 weeks. We kind of refer to it as the the slow roller coaster climb. So if you imagine you're at the bottom of the roller coaster to begin with, and now around 18 to 20 weeks, you start that slow like click click click up the roller coaster Hill. And that kind of progresses you increase in resistance along the way all the way up until about 3536

Scott Benner 24:20
ish weeks the steady climb.

Jennifer Smith, CDE 24:23
It's a steady climb. And initially in the second trimester, it's on average expect to make some tweaks to things about every two weeks give or take in basil as well as insulin to carb ratio as well as the Pre-Bolus time continues to lengthen. Your correction factor may need to get more aggressive. But usually by the beginning of the third trimester, that's the most resistant time okay, and often through like 34 to 36 weeks

Scott Benner 24:52
as you're talking I'm literally I have a piece of paper in front of me and I'm just kind of moving a pen. As you're talking I tried to make a graph of what to understand Especially now it's gonna grow up every two weeks. So I know this isn't mathematical. And I'm not telling anybody that if you started with one unit the day before you got pregnant, but where can somebody end up who started at one unit an hour, where could they end up at 35 weeks.

Jennifer Smith, CDE 25:14
So insulin needs, on average, double or triple from pre pregnancy to the end of pregnancy, or what we would consider just pre delivery time, which is about by 36 weeks, by 36 weeks, we reach again, this sort of like plateau place, where again, some sensitivity can start to come back, some women's Basal needs start to dip off just slightly shouldn't be aggressive or heavy. In fact, it's a time period that if you are having aggressive changes in your insulin in terms of like drops in need, it's a time to check in with your provider. Some of it can be relevant to placental failure. And so it's a time again, if things change drastically that you would check in. But otherwise, it's expected a little bit of a nudge down a little bit of increase in sensitivity kind of creep back in before you actually deliver. But on average, you know, how much to adjust. Like I said, most women either double or triple their needs from pre to about that 36 week point. And so

Scott Benner 26:19
I now you have the baby. And you could be going from this mindset on three units an hour. Back to why Yeah, back to one all the sudden, exactly. And on top of that, all the sensitivity around meals has changed. And and you're telling me nursing is going to drop the blood sugar

Jennifer Smith, CDE 26:38
nursing for most women who have good milk supply, and are able to, you know, pump or nurse completely without you know, most women experience especially in the early weeks, usually about the first eight to 12 ish weeks posted delivery, notice some shifts down in glucose. After nursing, during or after, if your child nurses for a lengthy period of time, you could notice it during the nursing session itself. Some women notice it only at certain times of day, versus the whole day, you know, having to consistently pay attention every nursing session, they're eating, you know, like to glucose tablets, or having half a juice box or something like that. I mean, our recommendations are once you once you're a few weeks out from delivery, kind of baby by that point has some typical sleep wake poop kind of patterns, you're probably still nursing about every three ish hours, maybe a little lengthier overnight, as long as your baby's nursing Well, during the day, are feeding well during the day. But you know, most often if you're going to nurse in the aftermath of a meal, a good recommendation is to take the Bolus dose down or count carbs, but underdose by you know 25%.

Scott Benner 28:01
So it's dramatic enough that if I eat, I keep saying I if the lady eats before nursing, that meal won't need as much insulin because you're gonna need some of that meal. So that means if you're not planning on eating, and you're going to nurse, you need to eat something going into the nursing,

Jennifer Smith, CDE 28:17
typically going into nursing or during the nursing session to prevent a low. Yes, and it could be anywhere, it could be simple, it could be five grams of carb, it could be as much as 15 grams of carbs. It just depends. And that's where, you know, looking at things like insulin on board, yeah, you might not be bolusing in nursing directly after but if it's still like within two or three hours after you bolused You still have some active insulin from that Bolus,

Scott Benner 28:44
and we tell people I at least I say and I know I feel like you agree with having active insulin while you're exercising is a pretty sure way to make yourself low. But so I'd want to avoid active insulin during nursing as well or plan for it. And the other thing is there too. If you can go negative insulin and get through exercise without dropping you can't do that with nursing this a nursing is more taxing on your body than some forms of exercise. Is that fair? Like is there a correlation to think about it in there are no

Jennifer Smith, CDE 29:21
I guess there's some relation to think about it. I think like I was thinking of overnight, right? Where for the most part. Mom, moms dads, they're tired at night with a newborn many people are and if that's the case, you're likely going to bed at like nine o'clock like you nurse your child and you're like, Okay, go into sleep because I'm going to be up again at like midnight, one o'clock to do this all over again. You may have eaten dinner at like seven o'clock. You're going to bed well you're well into Basal insulin by let's call it 11pm Right. So any time you're going to nurse after that And you're only on basil. And I experienced this myself for both my kids, Basil overnight, if I even if I had it at all. And my basil is, while I was nursing kids overnight in those early months, it was like near nothing. My basil was like, point 2.25 overnight, it was already down to almost nothing. And if I nursed and didn't still have something minimal, like I actually made these, what are called like lactation cookies. They're made with like oats and flax and peanut butter and stuff that helps with lactation, blah, blah, blah, but I made them so they were each about five grams of carb. But they were nice, because I could eat it, it had some stability to it, it wasn't just pure glucose. So it had some stability. And so I've usually eat it as soon as I started nursing, or something like trail mix some nuts and seeds with a little bit of like dried fruit in it, something that was no more than about five or 10 grams of carb. And that helped with the stability component with rather than

Scott Benner 31:00
the backhoe was die well, and so this is another time you know, where the food choices you make are going to make things easier for you to get you care. And, you know, so there's gonna, you're gonna have a different scenario going into nursing, if you're like, Hey, I know what to do. I'll have a handful of this and a little bit of that, and that's gonna work out perfectly. But on Thursday, when you're like, you know what I'm gonna do, I'm gonna have ice cream before I nursed there's going to be all everything about ice cream still exist there and your diabetes. Okay, in fact,

Jennifer Smith, CDE 31:29
those kinds of things, you know, as we know, ice cream, typically should cause a bit of a rise possibly later fat, depending on how much have you ate, you know, to spoonfuls probably not, but like the whole kind of it, probably,

Scott Benner 31:43
you're telling me that there's a way that I can get I can have ice cream far enough out in the future ahead of my nursing where I could balance that fat rise against the nursing. You know, there are some lunatics that listen to this podcast are gonna try that I saw somebody online this morning, who's trying to stay 100% in range till they get to their endosome appointment and they're doing it. That's awesome. Oh, my God.

Unknown Speaker 32:06
A lot of

Scott Benner 32:08
Yeah, I don't know. I don't do that. So I for Arden, I think they just got a little like, I just wanted to see if that's what I want to tell people to I know it sounds difficult in the beginning to have a baby. But if you want to know how good you will get at it at some point. Here's a great example. About two minutes ago, there was a bang in Jenny's house that was so loud. I thought the world was coming to an end. She didn't flinch. She didn't stop talking. It was that's what happens. Eventually, you just become a steely eyed missile man. She just did not move. She's just because there

Jennifer Smith, CDE 32:48
are beings all day in my house. I mean, when you work, you know from your own home office, and you have children in your home. I'm sure there will be more beings. I don't know what they're doing upstairs. But they are having fun.

Scott Benner 32:58
It was so it was just a great example of how you do become really great at parenting after you've had kids for I swear to you, you resilience. I don't think it's almost like you didn't hear it.

Jennifer Smith, CDE 33:10
Don't pay attention. Sometimes. Oh, yep. Sometimes, like, felt like I have a big sign that my husband made for me. It's outside my office door. And one side says quiet zone mommy is working. And the other side is Mommy is done. You may enter and be loud is what it says. Well, you know, when I'm working, it's still always in the quiet zone. Well, you know, with an eight and a four year old. They know what the sign says. But that doesn't always still click into place. So yeah,

Scott Benner 33:43
it does not overwhelm what they want in their hearts at that moment. That's for sure. Now, listen, artists funny artists going to be 17 in a couple of months. Wow. Isn't that crazy? And I saw her go into where my wife was working the other day. She looked at me like she was six like Hey, watch this. slides into Kelly's chair sits on top of ringers. Mom, can you wrap my head? Kelly's like, you know, reaching around for the keyboard and everything. So we will it will you won't always feel overwhelmed. How many people do you? I don't I'm not gonna say how many people but I mean,

Speaker 1 34:16
do you see women generally able to stick to their diabetes goals after pregnancy? Or should they expect it's gonna get out of whack? And they're gonna have to do some work to get it back like how does that usually go?

Jennifer Smith, CDE 34:32
i I see that. You should expect that there's going to be fluctuation that you will have to learn to adjust to. I myself, I had to learn to adjust because, you know as much as I know clinically and professionally, the experience itself speaks volumes about what you need to transition through. And so I think every woman postpartum should expect that things are going to be a little bit wonky here for a bit of time. I mean, some things that I think, helped me transition where I prepped some meals and froze them prior to baby coming, you know, and whether we have diabetes or not, that can be really, really helpful. You know, some of those kinds of things I also had snacks planned I had. Meanwhile, you end up sometimes nursing your child wherever is comfortable, you know, planned places, you know, in the baby's room in your bedroom and a comfy chair in the living room, just some things that were like easily reachable, that I didn't have to like, Call to somebody to bring me and I just had glucose tablets, and some juice boxes, some like trail mix, and that kind of stuff sort of set multiple places around. So I mean, there's some planning that you can do ahead of time. But the diabetes management piece of it, it kind of learned as you go, I mean, I'd say that about the women that I worked with, through pregnancy, if I had to estimate, I'd say about 50% of them end up sort of sticking with me a little bit longer postpartum, just because especially than the new moms, you know, ones that already have one or two kids. They're like, Yeah, I think I got this, you know?

Scott Benner 36:23
So does being pregnant with type one, give you an advanced. So what do I want to say here? There are so many times when I'm making this podcast, that it occurs to me that success with diabetes hinges, a good deal on your desire to be successful, and your ability to feed that desire with effort. Does that make sense? Yeah, absolutely. And so you, you get pregnant. And then it becomes like this thing we were talking about in the beginning like this, this feeling that you are in charge of the universe all of a sudden, and I will tell you too, and I mentioned it sometimes, when I talked to adults who didn't have particularly well managed, like teen years or whatever, a lot of them have a through line, they started to care more about themselves, where they started caring more about another person, like they want it. And then they wanted to be healthier, because they wanted to be in this relationship or because they wanted to go to do something or, and the baby falls in that category to me, like I want to, I'm going to do this so that the baby can be healthy. And that the number of women that I've talked to who were living really unmanaged lives with type one diabetes, and then are all the sudden 4.8 A one sees, you know what I mean, an eating like a lot because they're growing a baby, it happens. I just see it a lot. And so I always kind of think personally, as a person who's never going to have a baby and hopefully never have type one diabetes. There's something about that motivation in there. That I guess the fight in postpartum is to not, I don't know if it's something you can stop, but for all these things that are going to happen to you postpartum to try to still wiggle out a little bit of your energy or effort to devote to your blood sugar.

Jennifer Smith, CDE 38:19
Absolutely. And I think a good reason there too, in terms of diabetes postpartum is glucose management still translates into that time period for the sake of the child even though they're no longer growing in you. And your blood sugars aren't as direct of an impact postpartum, if you are nursing and you are not managing your glucose as optimally as you know would be helpful. Those higher glucose levels are going to impair your ability to make enough milk okay, if left high, your ability will be decreased. You will also be more dehydrated as you nurse it takes fluid out of you if you're not putting it back and glucose levels are also trending high that in and of itself is also going to make your glucose management more difficult

Scott Benner 39:17
does it change the milk itself?

Jennifer Smith, CDE 39:19
To a degree I mean years ago we don't we don't talk about this really much anymore. Although I have heard some women who've asked me should I just you know pump when I'm really really high and then dump it because I've been told that that I sugar milk is really bad for my baby. I mean, overall increment of right now my blood sugar is high because I ate something and didn't really have the right carb count and I'm knocking it down Should I not feed my hungry child right now? Absolutely not. Go ahead and feed your child nurse your child pump, whatever. Don't get rid of the milk. Your body works really hard to make that milk don't get rid of. But the goal is To have more sustained levels that are still in target to so you're able to continue to make milk and that the amount of milk sugar that's in that, that breast milk is stable, right? That it's stable and at the level that it's supposed to be protein fact, carb content of milk changes as the milk as the baby's kind of needs change through the growth cycle. So you want that amount of natural carbon there to be appropriate. If you're sustaining blood sugars, you know, well above 180, you can guarantee that your milk is richer in carb, not by like loads and gallons. But overall, you're supplying your child with bits more carb, and in a tiny growing body, a little bit can be a

Scott Benner 40:49
lot, okay, that's it just occurred to me, like we talked about undiagnosed people can, their urine can smell sweet, or their breath can smell sweet. I was like, I wonder if it could happen to the milk too. That makes sense. So much like most of this about diabetes, sustaining low variability is always just very important. No bouncing around, you know, that kind of thing. But if you just threw, like, say you were a person who had the baby, just like, boom, I'm going back to my nine a one see that milk would be tainted in some way? Not Yes. Yeah. It's not perfect as what we're saying.

Jennifer Smith, CDE 41:25
Not perfect. Right. I mean, you know, is enabled perfect. I don't know. But I mean, if you're sustained if you're sustaining these really elevated glucose levels, that's not a benefit. And you're going to I mean, for the most part, you're going to have difficulty maintaining

Scott Benner 41:42
milk production. You are, it made me wonder when you were talking about long term? What about people who I know sometimes you see people like nursing a two year old? So it for people who do that? Should they expect that? That hit like your body never gets used to that, right? Like, you're gonna get that? Yeah, that blood sugar head is gonna come forever, if you? No, not really,

Jennifer Smith, CDE 42:01
no, actually, no. In fact, after about three to four months postpartum, there's a stable enough nature to the milk supply, and to what your body or your baby is demanding. And that for the most part, things stabilize a lot easier after about three to four months. In fact, I nursed my kids while after they were a year old. And in fact, I think they were both almost two. I mean, it wasn't all day, it was like for bedtime, and for naptime by the end. So it wasn't really that they were probably even getting very much, but usually post a year, you're typically not going to see that hit. And the big reason, especially after about six months to a year is because now your baby is starting to eat. While milk supply is still considered the main nutrient up to a year of age. Some kids start eating really, really well, after 678 months. And so you may see a decrease in the amount of nursing that goes on as the baby becomes more interested in food and takes in less, especially the overnight many women, you know, might have a really great child who just sleeps all night. And so they might only nurse once or twice maybe, or eat, you know, some women nurse on need during the day. But those, those sessions are not typically going to cause the drop in blood sugar that the early three months will cause

Scott Benner 43:29
I want to make sure I didn't misunderstand something. So there is it a balance between you might not be using as much and your body's becoming very good at making it or is the like at first I thought you were saying like the same lady's body that can make an Oregon knows that can figure out how to make milk without it being like a tax on the system. Like is there some of that and some of the not being?

Jennifer Smith, CDE 43:51
I think it's Yeah, honestly, because for the most part, like I said about that three to four month mark, I would say the women that I get to work with well past the immediate postpartum time period, they find a lot more stability in their glucose even though they continue to nurse beyond that point, then the lactation or the nursing sessions don't have the hit that they do initially.

Scott Benner 44:16
Okay, thank you. It's a quick little parable, why are Vali asked you to think of there's anything that we haven't talked about. Let me tell you that I was interviewing somebody recently who said that they were listening to I interview this person I was talking to them doesn't matter. I was conversing with the person who said that they're pregnant now. They're listening to episodes of the podcast about pregnancy with you in them while reading the book that you wrote, and did not connect that you were the person from the podcast. They didn't realize the person that wrote in the book was the person talking on the podcast and all of a sudden it hit them one day. And she was like, Oh my gosh, it's the same Jenny. That's awesome. It was really cute. I want to tell you about that, I almost just texted me and I'm like, I'm going to tell her that while we're recording the postpartum episodes, that, that's awesome. That was really cool. Anything we didn't say that we should have, oh, I'm

Jennifer Smith, CDE 45:10
trying to think, um, you know, the only other thing that we didn't really touch on, while it should be considered is, depending on how you're feeling postpartum. I mean, most women have like this, I give you restrictions up until about six weeks post delivery, when you're going to have your check in with your OB and blah, blah, blah, and make sure everything's healing well, and you're okay. And then they kind of like, check you off. And you can drive again, or, you know, if you've had a C section, or you can get out and start running again, or whatever. And I think that's a piece to consider in the mix with diabetes, because, you know, we know what exercise. So now you not only have exercise coming into the mix, but you've also got nursing coming into the mix, and all these insulin changes that you're trying to make. So one of the big things that sort of fits here is if you have maternity time, not all women do. But if you do have maternity time, use your maternity time to try to establish sort of a route, like a routine or a schedule. And some of that's going to be dictated by the baby, obviously. But even regular for you trying to get your nutrition in timely through the course of the day. You know, once nursing is a little bit more regular, the baby's waking nursing times are more you can fit it in or around the meals and exercise is a big one of that. If you're going to start exercising, try it at a similar time of the day to kind of get a feel for how does this work? You know, what can I get away with? What's too much? What's too little? Because I think that just brings in the whole, like, I feel good enough to go and you know, take a three mile run. But what's this going to do? Oh, no, let's try.

Scott Benner 46:57
I hear you. So it's not dissimilar to it is interesting, as you're talking about it, it really feels like postpartum is a lot like just being diagnosed but having way more information about diabetes, right? Like Like, what if, what if somehow magically, I knew the things I knew, but never had to put it into practice. And then all of a sudden, there was a newly diagnosed person here, I'd be able to roll with the variables much better because I have better tools. And so you're going to go from having diabetes, maybe not doing it as well, learning how to do it really well, or already knowing how to do it well, and then it's going to feel like you're diagnosed again, and you're taking care of a baby at the same time. And all your variables changed again, I'll tell you, I'll tell you this is giving me a different feeling for first episode of season seven 2021 was with a woman named Jill, who was diagnosed as she got pregnant. So she was pregnant for the first time and had type one diabetes the first time and I am now talking to you thinking I had a lot of empathy for I might not have had enough like, like hearing about all this.

Jennifer Smith, CDE 48:11
That's a whirlwind of change. Not only is she pregnant, but now she's pregnant with something she has no background to managing. And she's got to learn how to manage it through the variables of pregnancy as they shift and change. I would imagine that postpartum was probably a lot more difficult for her than pregnancy was.

Scott Benner 48:31
I wonder? She's She's active on the Facebook page. She looks like she's doing terrific. She actually also was misdiagnosed type two diagnosed type one. It's a fascinating story. If you have to go listen to it. If you haven't heard it. Let me know which episode is it. I'm actually going to look right now because I don't know. I've I think I'm at the point now where this I've done so many of these.

Jennifer Smith, CDE 48:56
I know you're like I don't know what else.

Scott Benner 48:59
Let me look real quick. It is called Wait a minute. That was January 2021. I'm looking Why do I not see it? It'd be helpful if I knew what year it was. Now that I know what year it is. I'm getting down. It's called wine beans, babies and cue. It's episode to come up with these names. It's episode 425. Well, she was misdiagnosed as type two. So you know, she still went on a wind vacation with their friends. Beans, I forget babies because she was pregnant. Because she was told she could go she could she was told she could get pregnant by a person who told her she had type two diabetes. And then she got pregnant as she found out she had type one diabetes and a doctor with the last initial of Q set her straight. That's where all that comes from. And you just I can't remember what the beans were Damn it is a good episode. She's really lovely. Yeah, but I know her because she reached out right in that moment. Like she found the podcast and she's like, I don't know what to do. I just found out I'm pregnant. I have a baby coming in. I have type one. So I was like, well, after you figure this all out and have that baby, you got to come on the podcast. Yes. Tell the story. Anyway, she's terrific. And, and so are you. We've covered this pretty well. I like this a lot. We did a little like personal chatting at the beginning. So we didn't get to do one of the things I wanted to do, but I'll just put that on my list. Okay. I thank you very much. I somehow find it delightful that your kids were much noisier than normal. While we were talking about having

Jennifer Smith, CDE 50:41
this was one child. Oh, really? That was just just the four year old the other ones at school?

Scott Benner 50:47
Oh,

Jennifer Smith, CDE 50:49
I can imagine he is. So my mom came my mom came this past weekend to visit for my birthday. And she bought them a ring toss game, which has, like it's like a wooden base. And then it's got you know, the things to like, throw the rings over. And I'm expecting that either the whole thing was lifted up and dropped on the floor, or the ring toss was being thrown from a larger distance and maybe all the rings at one time were being thrown? How much

Scott Benner 51:18
of this do you think is the part of the country you live in as your mother prepping them for beer pong later is Do you think that what this could be I swear to you, it felt like two adults lifted up your dining room table and dropped it from about eight inches.

Jennifer Smith, CDE 51:32
And the funny thing is, it was like, like you said I didn't flinch. Because it was like a background like I don't it's just a background noise.

Scott Benner 51:41
I thought off the bleep myself out because here was the thought in my head. I thought did she not hear that? Cuz you didn't blink. It was fascinating. Anyway, ladies, have a baby get through all this and one day you'll either be as good at this as Jenny or is not Miss Jenny as I'm not sure how to put it. Yes. I want to thank assenza diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free contour next gen starter kit at contour next one.com forward slash juicebox free meter while supplies last US residents only. If you're enjoying the remastered episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org A huge thank you to one of today's sponsors. Je Vogue glucagon, find out more about Chivo Capo pen at G Vogue glucagon.com forward slash juicebox you spell that GVOKEGLUC AG g o n.com. Forward slash juice box. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bumping nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low Beegees in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two in Episode 1008 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025 We talk about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny Presented everything, even the scary stuff that reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning that Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active, took me already from a decent 6.5 A one C down to a 5.6. In the past eight months, I've never met Scott. But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast show Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link.