#105 All About A1c with Jenny Smith CDE

Jenny Smith CDE takes a deep dive into A1c with Scott...

#A1CyaLater

Jenny Smith CDE (from episode 37) is back to have a macro conversation about the A1c test and why it is so important to understand for people living with type 1 diabetes. 

Learn more about Jennifer and the services that she provides at Integrated Diabetes Services here.

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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
Nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making changes to your health care plan. Episode 105. The Juicebox Podcast is brought to you by Dexcom and Omni pod. You can learn more about the sponsors and help support the Juicebox Podcast if you go to my Omni pod.com forward slash juice box and dexcom.com forward slash juice box. Today Jennifer Smith, r d l d c d e LMNOP returns to the podcast Jennifer has been living with type one diabetes since she was a child. But but but but she's also been teaching people how to live better with it for quite some time. She's a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitors. And if it sounds like I just read that I did write from integrated diabetes.com Because that's where Jennifer works. And even though she's superduper busy, she found time to come back on the podcast today at my behest. I said Jennifer, please, I need you to come back on your Episode Episode 37 Jenny Smith diabetes Guru is a fan favorite. But I have more questions. And I want to speak specifically about a one C and I want to do it with you. So Jennifer was kind enough to come on and spend her time you can see this episode is extra long. It's an hour and a half. But trust me, it is full of things you want to know, I have to say that after 10 years of my daughter living with type one diabetes, I always feel like I understand what a one C is and why it's important and why I shouldn't judge myself too harshly about it and blah, blah, blah and all those other things. But I don't know, I just want to know the rest. So buckle up by the time this is over everything you ever want to know about a one C and probably a bunch of stuff you didn't want to know should be answered. You guys are in for a treat today.

Hello, how are you?

Jennifer Smith, CDE 2:09
I'm great. How are you?

Scott Benner 2:10
I'm excited that you're doing this actually.

Jennifer Smith, CDE 2:13
Yeah, I know. I was excited to like get an email from you.

Scott Benner 2:18
I just you know, obviously I'm recording already. So any of this may be used. But I since it's so since the podcast is began, which is now you know, it's been a while it's over 100 episodes, it's been since 2015. Awesome. It has been really way more than I could have expected. But it feels weird to say this, right? But the emails and the messages are more and more consistent every day. And they all have one of two, maybe three messages. You know, like I saw him I saw myself and someone you spoke to and it really helped me to find my way. My Awan say or my kids a one C has dropped one or two points since I started listening to the podcast. Oh, awesome, right? Or the other one is, it's always like, well, I'm still figuring it out. I'm trying but I feel really motivated. And I was like, This is amazing, you know. And so I recognize that a decade into my daughter's diagnosis. There are things I don't know. And I learned every day one one of them without a doubt is that I have at best a limited understanding of what anyone says. And so you know what I mean? Like I get it, and I can admit it, I'm gonna tell you what I feel like it is but but I just want to really do like a deep dive and spend the entire time because if you hear me go off center for if I if I see something shiny and I start heading down a different path to yell no, Scott, we're only talking about a onesie today. Okay, that's

Jennifer Smith, CDE 4:03
certainly Shiny, shiny dangling objects even along the path of a onesie. So

Scott Benner 4:09
try to follow them, I guess is say. So most of the time I say to the person, hey, you introduce yourself and then I'll ask you a question. But we're going to sort of do this backwards today. So I'm going to introduce myself, then I'm going to introduce you and then and then I'm going to ask you a question and then you're going to do a lot of talking so. So hi, I feel like I'm in an AAA meeting. My name is Scott. My My daughter has had type one diabetes for a decade. And my understanding of what a one C really is is pretty basic. So I have invited Jennifer Smith. You may recognize her name from a previous podcast episode that a lot of you email me and say is fantastic and you love to come on and school me about the the what A once he really isn't, we're going to try to look at it in a complete way so that by the time this is over, I, and anyone listening aren't just using it as like, Hey, I got my score today and it was good or bad. Like, like, you know, I don't want people to think of it that way. So, okay, so Jennifer, you can say hi, now.

Jennifer Smith, CDE 5:19
Hi, I'm Jennifer Smith, dietitian and diabetes educator. And thanks again for having a chat with me. I always love contributing and giving information. And I think it's interesting that you bring up that you feel like even a decade in that you're not quite school, the so to speak in a one C? And I, I would have to say that most people probably have the basic that a one C is it's an average, right. And they don't really get more into that. And they do they see it kind of like a scorecard even mean, I've had type one for almost 29 years now. And even still in the back of my clinical and personal life with diabetes educated mind. Even still a onesie is still like a report card to me. Even though I know more about it.

Scott Benner 6:18
I think it's difficult not to feel that way. I've told this story on here before that, you know, after years of just the slog of not being able to get my daughter's agency to move it moved, you know, like, I don't know, like point oh, three, it went like from eight, seven to eight, four, you know, and I broke down in tears and hugged my nurse practitioner in the office in front of about 30 Other people waiting to go in for their appointments. And, and at one point, she was like, she was just holding me. And she said, she's like, are you okay? And I'm like, I'm so happy. And I don't even know why I'm crying. And I think it was the relief of like, wow, I actually got it to move.

Jennifer Smith, CDE 6:54
Right. It's almost like that report card you get in school when you're really not quite sure what the end result of your hard class was going to be. Right? And you get it. You're like, Oh, my God, I passed it, right?

Scott Benner 7:07
No, it's funny. My son just retook the LSAT. A couple of weeks ago. Yes, taking it a couple of times. Right. But this time, he's been doing okay, but he's been trying to improve and, and, and this time he came out, I said, How was it? He goes, that was the hardest one I've taken so far. And he had taken like practice tests and, and the actual tests and everything. And now it's two weeks later, I mean, he kind of just out of nowhere, said to me the other day goes, I may have done okay on it. And I'm like, what? And he goes the he's like, you know, I the LSAT I took a couple weeks ago. He's like, I'm thinking, maybe I did, okay. And I thought, Wow, that's amazing. He took a course, he had a tutor for nine weeks, he'd already taken it previously, he's a very good student. And two weeks passed the test. He's still like, I don't know what happened in there. And that's sort of how I feel sometimes. There are times when I look at my you know, look, I'm notoriously bad I don't keep logs. I don't take notes. I don't write down I don't even count carbs, but

Jennifer Smith, CDE 8:09
but still all of that stuff very in depth on a day to day basis.

Scott Benner 8:12
Yeah, I just don't write it down. That's

Jennifer Smith, CDE 8:13
what I'm saying. not writing it down. You have pretty you got in depth analysis. It's just that you're consistently doing it.

Scott Benner 8:20
Well, yeah, you're very fine. But But my point is, is that three months, every three months goes by and Arden does see her her endocrinologist but we never see the endocrinologist we see a nurse practitioner. I don't even know if the endocrinologist wasn't alive anymore. I'm not 100% Sure, I would know that but But nevertheless, you know, there are times I go in and I think about like, it feels like the last three months. I'm like, Oh, wow, you know, there were a lot of highs overnight she grew she gained 10 pounds, she gained three pounds, she got an inch taller, I fought with blood sugar's a lot. This is going to be this is not going to be our one of our better agencies. And I go in and it didn't move or it went down. And I'm just like, Wait, how did I not even know I feel like my son come out of the SAP like, How did I not know what I did? You know,

Jennifer Smith, CDE 9:05
and I think that that is a really good kind of it opens up the box of why is a onesie not the end all be all of analysis and why it shouldn't actually be because what goes into that average is variable person to person. Right? And so when we look at a onesie, we know that it measures the you know amount of sugar that essentially stuck to the hemoglobin in our red blood cells, right. And that's averaged over the course of 120 days mainly because we our red blood cells are regenerated every 120 ish days.

Scott Benner 9:51
The Mayo Clinic defines a one C like this. They won t test is a common blood test used to diagnose type one and type two diabetes and then to gauge how While you're managing your diabetes, the A one C test goes by many other names including gleich sated. Wow, here we go glycated hemoglobin, glycemic oscillated hemoglobin that I definitely said wrong. Hemoglobin a one C and HB a one C, the A one C test result reflects your average blood sugar level for the past two to three months, specifically, the A one C test measures what percentage of your hemoglobin a protein and red blood cells that carry oxygen is coated with sugar lysate, the higher your agency level, the poor your blood sugar control, and the higher your risk of diabetes complications. See now this is why we had Jenny Come on, because I read that and I don't know what it's at.

Jennifer Smith, CDE 10:43
Okay, at least that's the thought there is other research that's thinking that perhaps some people have red blood cells that regenerate sooner or last even longer. So even in that, that could change up what you're able to see result ends up being right for question,

Scott Benner 11:01
I don't want to break your stride. But so if my red blood cells generate quicker than my A's, one C might just be lower. Because there's not as much data on the cell. Correct. And the other and the other way is if I happen to have red blood cells that don't regenerate in these in this 90 day period, I may look like my a one C is higher than it actually is.

Jennifer Smith, CDE 11:21
Because there's more data quote unquote, there. Right?

Scott Benner 11:24
Right. So more data, but in the same time periods not stretched out over more days. Correct. And

Jennifer Smith, CDE 11:29
that's kind of where, you know, agency is, again, one average number it gives you now that estimated average glucose, which is oftentimes how they'll report it on a lab report, they'll tell you your agency, they'll tell you what your estimated average glucose is that corresponds with that. But again, as a one, so looks like one number, unfortunately, that is all military bases that every individual can

Scott Benner 12:00
try to let you get through that. But you broke up so much, I'm gonna have to ask you to go back I'm sorry,

Jennifer Smith, CDE 12:04
oh, that's okay. I would just be the a one C is like one, one number, right, and it goes along with an estimated average glucose value. But if we only look at that as a one pinpoint number and say, well, it looks like my a one C is, you know, such and such, it's five. So that means that my estimated average glucose is 97 or 5.4, for those who might be doing millimoles. But the variants that cause that can be different person to person, you may have what I call roller coaster, blood sugars. And you might be getting an A one C of 6%. But that's a variance between really low and really high. That doesn't mean that you're a one C of six, it looks beautiful, and your endo is gonna say, Oh, that's awesome. That's fantastic. Let's just keep doing what you're doing. But unless they look at the data points of actual fingertips, or thankfully, now we have even more than that a CGM with even more information about trends. Unless they look at that. And unless we look at that, as people who live with diabetes, we will say great, I'm doing awesome. My agency is right where it's supposed to be. But then you might look at somebody who has an A onesie of six and their variants looks kind of like slow, gentle rolling hills.

Scott Benner 13:33
And so in that specific situation, that health, the overall health of the person who's not on that roller coaster, even though they're a onesies are the same is likely better.

Jennifer Smith, CDE 13:46
Correct? Okay. Absolutely. Because, you know, there is research that shows too, and I'm sure you've probably read it, but the more the more the roller coastering, the more the variance between the highs and the lows and the ups and the downs, that causes complications to develop as well. Even again, if you're overall a one C It looks like it's been beautiful. Down the road, because of that variance up and down. Complications can develop because there's not as much tight control.

Scott Benner 14:17
So let me dumb this down for me to make sure to make sure I understand before I move on, if my life consisted of me sitting on a sofa, and that was my whole life. And then there was another person whose life was better than like, more more relaxed than that. They were laying on the floor comatose 28 hours, 2423 hours a day. But in the in the other hour of the day. A prize fight Boxer was beating them in the face. Then even though that they're 23 hours were spent comatose and calm and happy and I spent all 24 hours just sort of sitting on the sofa watching television. They're not as relaxed as I am because there was some time in their life. This is a horrible analogy, but there's time in their life where they're being beaten. And even though the even though the calm time is calmer than my calm time. And so the when you average it out, you're still getting punched in the face every day.

Jennifer Smith, CDE 15:09
Correct. There is still like, quote unquote, damage that's happening. Yeah.

Scott Benner 15:13
Okay, so Okay, so here's my, here's my thought, like, based on my decade with this is that and I've never had anybody tell me this is true or false, but it's always been my guess that a one C is just sort of the best medicine has to offer as an insight into generally speaking how you're handling your diabetes? Is that even close? Like that's how I always feel I always feel like, look, here's the test we have. It's not great, but it's not bad. And it's all we have. So shoot for a lower number, because that generally means better. And is that yeah,

Jennifer Smith, CDE 15:50
I think in a general sense, yes, we have many, many, many years, I think a one C, one C first started to be used in the 80s. And so since then, you know, we have kind of use that as an important tool for looking at what somebody's average has been. But again, as I as I said, that average, unfortunately, when the medical community is just using an A one C, and I really have to think my my maternal fetal medicine team, I just had a baby. So gratulations I, yeah, he's nine weeks old. So yes, I will get a four year old too. But as both I use the same team for both. And I have to say that they really didn't want only in a one C. And so I bring this up in the context, because they knew that a one C as a one value number didn't show the variance that I might be having on a day to day basis. And so in the medical community as testing an agency, great, it says it's a good starting point. But I think for somebody who does have an agency that looks like it's good, I think even more information needs to be gathered within an appointment with, you know, someone like that, because we should be looking at at least fingerstick data. And what is that in to this a one C? Is there a lot of variance despite this a one C number looking good. And I hate the terms are good and bad. But that's kind of what we do. Right?

Scott Benner 17:45
Here's what I've learned about talking about diabetes, if we spent the time to parse out every word into a sentence that didn't make anybody upset, the conversation, the conversation would never get had listened. If I say a bad number, I'm not judging you. If I say a good number, I'm not judging you. I'm just trying to get through the thought. Right. And so, you know, so it's funny. So it took me a number of years, like because in the beginning, you know, first of all, my daughter was two, I didn't know what I was doing. And you know, somebody just said, you know, I remember you see, it's on the wall in the office, right? It's a I don't most offices probably have this chart that looks like a thermometer, and where your a one sees, quote unquote, bad, it's all red, and where it's good, it's green, and I'm like, I'm in the red. And like, it's, you know, I'm always in the red boiling, dying, it's what it all felt like, right? Like, I always felt like I was killing her, like, Oh, I'm killing my daughter, um, this is great. And so, you know, in so when it's put into those terms, and I do, I don't want to go down this road, but what people I think really do need to understand what you're talking about what I'm talking about kind of taking kind of taking charge of understanding it better, because you really only have a few minutes with your doctor every three months. And if we're being honest, it's hard not to think of it as your time and everything but that doctor is seeing people over and over and over again every 15 minutes all day long. You're not getting you're not getting great care, let's be honest, like get anything like you're getting, it's better than third world care. But it's not as good as having a private physician come to your house and sit with you for two hours over tea and explain your health to you. So you're like so it's always going to sort of be what it's going to be and you have to expand on it and there was that day where I thought I don't understand this well enough and and so I forget who said it out loud first but I want to say it might have been Mike Hoskins diabetes mine I might have read something that he wrote that made me realize just maybe think about it differently. I was like, Oh my God, this thing is an average. So if so if my daughter's blood sugar is, I don't know. 50 overnight for eight hours and then 300 While she's awake. Her a one C may look not bad. But right but that's not healthy for her and it It's like it's almost like cheating on the test. Right? Like you. Right? Right.

Jennifer Smith, CDE 20:04
That's a great way. That's a great way to say it. And and she's unfortunately not by your own choice to cheat. Oh, exactly. It is what it is it is kind of cheating. Yes, because it averages out to look like Well, I'm not doing so terrible because my number looks this one pinpoint number tells me that it's averaged perfectly. But I think it brings up a good point of, you know, we've got that short time with our clinician, whether it's an endo or an educator or you know, a nurse in the office, etc, I think we can, we can improve our outcome of what we get back feedback wise, by actually bringing in more data than just expecting them to go by in a one seat. So anytime you can bring in even a written or printed out from your glucometer or your pump download or more beneficial, actually, AES a CGM. If your office doesn't download your CGM, print it out, bring it in, bring a couple of days worth bring the average or the overlays. Because really, you can then prove to them and say, My agency looks nice, but I'm worried because I'm having these issues. And one of the one of the major things that a one see, again, doesn't help to bring into the visual field of a clinician talking to somebody is, where are the episodes of low blood sugar in that? Where are they happening? What we know low blood sugar is dangerous, right? I mean, it can be especially The overnight lows. Like you said, if your daughter was hovering at 50 all night, and you didn't have a CGM and you're only going on a onesie you're missing a very dangerous piece of her management.

Scott Benner 21:59
Okay, let's take a quick break and talk about Dexcom. As most of you may know, my daughter Arden uses the Dexcom G five mobile continuous glucose monitoring system that tracks her glucose levels throughout the day and night, you know, the Dexcom G five, notifying her of highs and lows so that she can take action. There's a beat from it right now. But that's not all it does. Dexcom also has a share feature so Arden can have up to five loved ones like her mom and I you can just hear now in the background that I'm watching Arden's blood sugar through her Dexcom. Anyway, her mom and I and up to five other people can track her numbers in real time, no matter where Arden is or what she's doing. She always has backup. Now if that's the kind of peace of mind that seems like something that you'd like to know more about, I think you should go to www.dexcom.com forward slash juice box or click on the link in your show notes. To find out more. Keep in mind, CGM based treatment requires finger sticks for calibration may result in hyperglycemia. If calibration not performed or symptoms or expectations do not match CGM readings. And you can always contact Dexcom toll free at 877-339-2664 for detailed indications for use and safety information. In the end, if you go to dexcom.com forward slash juicebox fill in a tiny bit of information you will be starting the process of talking to Dexcom by getting your very own continuous glucose monitor and having really I'm hoping the same experience that are done I have with it. Alright, let's get back to Jenny Smith. diabetes guru, as we talked about a one see a one See you later. That was corny. Come on.

Now, there's so much that can be hidden. And I'll repeat something I've said here before but prior to Arden getting a Dexcom CGM. I used to set her blood sugar up before she went to bed and like around 160. And she'd wake up at 90. And I was like, I thought, Jennifer, I thought I was a genius. You know what I mean? Like I really did, I thought I had it down. And then we put a Dexcom on her. And what I found out was she was at 160, she'd fall to 55 sit there for four hours, her liver would probably be like, Hey, let's try not to die tonight. And then her blood sugar would then creep back up to 90 when she woke up. And all that happened in the eight or nine hours she was sleeping. And all I saw was when she went to bed and when she woke up and I thought I was doing great, you know? And so so much is is missed. But so I want to sort of go back for a second to what I said about cheating on the test because because it's the concept of if you get the grade, not the right way, then it's a meaningless grade like you know what I mean? Like I got an A on my test and math but I don't understand the math and that's gonna catch up to you at some point. So my blood sugars are all over the place or they're really high during the day and really no at night or something like that. And they're averaging out well. My seven a one C is fantastic. but it's not, you'd much rather have an eight a one C and understand what's what's going on and and be able to work on it still. So what I ended up doing was, I took that simple concept of, if I have a lower a one C because of protracted lows, I'm cheating. And I thought, Okay, now how do I take that from a bad connotation to a good one? How do I cheat on purpose to really get my daughter's health in line, like, it's going to end up being a lower a one C, and even when I talked about it on here, it's the easy way to say it. I say it all the time, I want people to understand the things I'm talking about law have led to my daughter's a one C being between five, seven and six to for three and a half consistent ears, which is awesome. It's amazing, but I can't explain it every time I say it in in 20 minutes. Like that's why I wanted to do this episode like I because I felt bad about just saying it without more context.

Jennifer Smith, CDE 25:57
But so into that management, yes.

Scott Benner 26:00
Right. Because every Listen, every episode, we talked about what goes into the management, but every episode can't be a preamble of 20 minutes of me explaining a one C so I was like, you know, I gotta I have to really want to do this with you. But anyway, I took the cheating at concept, the quote unquote, cheating concept. And I said to myself, Okay, overnight, there's no food. There's nothing easier than managing overnight and now people are listening to this now who are who are fighting overnights and they're like, fu buddy, right? Right. Right, right, once, but overnight, they're just like you suck is what I'm hearing. But But, but what I'm saying is, is that once you can, once you teach yourself how to keep your blood sugar steady, where you're not scared that it's going to skyrocket up or plummet down. Once you get to that spot. You want to put your at your blood sugar at overnight, because if you can let it sit at 80, while you're sleeping for nine hours, you're way ahead of the 24 hour average on your agency.

Jennifer Smith, CDE 27:00
And that's, that's a great a great point. And it's something I try to explain to all the people that I get to work with is if the overnight can be managed, if we split up our 24 hour a day, that's three eight hour time periods right now I think about it. And if our a one C is waited over three months, and we look at a third of the weight of a one C being from overnight management, you can make an immense impact on a onesie even if the rest of the day is up and down roller coaster and you haven't figured it out yet. A third of the weight being from overnight if you can get that nice and even and like you said at 80 or 90 overnight. That's huge.

Scott Benner 27:45
So so understand this that when I'm sitting up the other night watching a baseball game, which I was doing, and I was I was up very late watching it. You know what, it's funny the nights when I am not messing with Arden's blood sugar and I'm like, Oh, I could go to sleep on it. But nobody else I could like live like a real person and watch this baseball game. And so and so instead of getting some sleep, I'm sitting there watching this game and Arden's blood sugar on her CGM is 78. And it's just sitting there. And I am as happy as a person can imagine being about her blood sugar. Meanwhile, as the game goes into a commercial and I flip over onto social media a little bit, I see this frantic mom saying to somebody, my daughter's a blood sugar's 95. I just gave her a juice box. And I'm like, 95, I'd be like, I wonder if I could get that down a little farther. Right. And it's just it's a difference. By the way, it's a difference in concept, maybe, but it's more more likely a difference in where she is, in her time with diabetes versus where I am. And maybe she doesn't have a glucose monitor and all these other things, right? It could

Jennifer Smith, CDE 28:47
certainly be and or, you know, taken out of context, again, if there wasn't a photo of it or whatnot. She's at 95, maybe, maybe she was looking at it. And there was like a trend down on the three hour screen. And she had actually been at 180. And now she's at 95. And it's still going down, right. And having

Scott Benner 29:04
said that, even in that specific situation, I would have just cut basil for like a half an hour and tried to stop it right. But but it's just it's so like I said earlier, when we were talking when I hear back from people that they've listened to the podcast, and then they kind of pick up these ideas, and they're utilizing them and the results that they're getting from them like that's, that's the person I want to talk to like I want her to hear. Maybe I could have taken 10 more minutes and just not you know, thrown food at this because you know, you know when I log back on the next day, she's still talking about it. The kids blood sugar went to 250 You know, like a roller coaster right? And that's what we're talking then she's then she's low. She's high you have to you have to first figure out how to stay steady. And by the way, you can pick any number to learn how to do it at you know, and then

Jennifer Smith, CDE 29:53
comfortable being at 150 Instead of being at 110 Then be comfortable but be steady at one 50

Scott Benner 30:00
and understand this once you're steady at 150 and comfortable with that, there's genuinely no difference between that and being steady at 80.

Jennifer Smith, CDE 30:08
No, that's right, absolutely. It's just then figuring out the insulin to bring it down and keep it down

Scott Benner 30:15
further. And I want to say this without getting too far off the agency path, which I know I was going to do at some point, but

Jennifer Smith, CDE 30:21
the dangling pretty glittery thing, right?

Scott Benner 30:25
I'm just gonna start talking about anything in a second. But the difference I've said this a million times, but it's very worth repeating in this episode, the difference between steady at 150 and steady at at the only difference between those two things is your fear. That's it, and ad you're afraid you're gonna get low and at 150. You think, oh, if it goes down, I have time to stop. But you have time to stop it at 82 If you're steady,

Jennifer Smith, CDE 30:46
so you have the tools to know what to do. Yeah, yes. Yeah, you

Scott Benner 30:50
gotta you have to, you know, look, you know, if my daughter's blood sugar at 80 started falling in my neighbor was here alone with her, she'd be dead. You know, because I knew my neighbor would be like, I don't know what to do. Goodbye, kid, you know? You know? Yeah, it's always listen, everything I say is parsed with once you understand and you know, I will at any point in any conversation, say, of course, all this is made incredibly easier if you have a glucose monitor. So

Jennifer Smith, CDE 31:17
absolutely a CGM. I think, you know, there's even I read a study gosh, it was last last fall. And it was about the Europe the European equivalent, essentially of the FDA, and the fact that they are looking at utilizing an evaluation of an evaluation of a person's life of, of red blood cells as well as CGM data to see the accuracy of a one C. And I don't I don't think that you know, here in in the States, I think a good thing that we could at least look at doing would be some type of even a closed CGM in order to actually get an idea of what is the variance that's going into this a one zero result for this particular person? Right? Because I, I believe that that it's a major place that we're missing information. And like you said, coming into this, I know very little about a one C Tell me more? Well, again, most people know the basic of a one C. And the more that you understand that a one C is really just that one value. And we have to know over let's say three months, what went into making that value as just an average. And a CGM is a huge tool in that

Scott Benner 32:56
it's such a, it's always difficult,

Jennifer Smith, CDE 32:59
better than a pump. Uh, you know, if I, when I'm working with somebody, and they're doing injections, and they're thinking about technology, I'm like, get a CGM. I don't care that you're not in a pump, get a CGM, you'll want a pump three

Scott Benner 33:13
seconds afterwards. But it's a good first step. And it's it, it gives you more information. And that information is always actionable. I was, as you were talking about, about that just now all I thought was, you know, in the moment, in any part in history, you're, of course, at the most advanced part of society, right? Like we are at the most advanced part right now of computing, blah, blah, blah, all these things, but you never take a step back to think of it as that it's in its infancy still. You know, like when you stop and think that the internet's only really existed for what, like 25 years. It's in its infancy, right, you know, CGM has been around for you know what I mean, I'm sure they they launched it a while ago, but I've only known about it for the last six years. And I'm pretty much on the cutting edge of this stuff. And so it's in its infancy. You know, I always say I imagine there'll be a day you'll go to a hospital, be diagnosed with type one diabetes, and there'll be like, you'll then say, Hey, what are you doing? The guy will say, I'm putting your Dexcom on you now. Because why in the heck would I let you out of here without knowing what your blood sugar is? You know, like, why would why would I? You know, if you imagine if you had a heart attack, and the doctor said, Look, you need to be on a heart monitor. Because moment to moment, you need to know what your hearts doing. Except, you know, we're not going to give you one so goodbye and

Jennifer Smith, CDE 34:28
right. This is very, very good point because quite honestly, even just finger sticks as I'm sure that you know they're chart after chart in the research that's kind of been done. Why as CGM shows so much more. It shows you the finger sticks right in a day. And it says, okay, this person if we were only going by finger stick, it looks like it everything is in Target once you load in the CGM trendline that happened within in between those fingers. are sick, you see the immense amount of variation that can be happening?

Scott Benner 35:05
Yeah, and one of the ways I figured my way through that before glucose monitoring was I would test the origin at the most bizarre times. So then when the when the Endo, when the nurse practitioner would look at my, my meter, and she said, wow, why did you test 45 minutes after she ate? And I would say, because I wanted to know what happened 45 minutes after she ate. And she's like, but she's 300. And I'm like, yeah, oh, isn't it good. I know that, you know, like, and so at that time, I was still just collecting data and collecting data and just trying to figure out what to do. But But I just kept thinking, like, what's the I saw someone online recently posted their, their fingerstick tests they for the day, and each one of them was spectacular, right? And it was really cool. And at the same time, I thought, I randomly could have tested that person at eight other different times of the day. And they'd look like that day was a complete and utter failure for their blood sugar. Because they because they don't know what was happening in between those finger sticks, you know?

Jennifer Smith, CDE 36:04
Right? Absolutely. And that's it is it's like you said about the heart monitor, we're going to start you on one and send you out the door with it. I, I truly believe while we do, you know, having worked a clinical position in a hospital many times as a diabetes educator, and working some inpatient as well as outpatient, we really did try to set somebody up with a glucometer to go home with we tried to give them as much in depth education as possible to go out the door. But honestly, in that setting, there's so much else going on that it's also not a beneficial education, time. And, you know, a glucometer unless you stay, let's try to do testing, you know, 10 times a day, when most insurance companies don't cover. Unless you have like, that extra letter of medical necessity, you know, has very interior blah, blah, blah, whatever to get that many tests. I mean, before I started using a CGM in 2006, I was testing a lot. I mean, my endo was very happy to write my prescription for however many tests I wanted to do, but he was like, Are you sure your fingers are okay. And I was like, but I need to know what's going on. You know, I, like I need to know, do you understand? I don't want to just know, four times a day before meals. That's not telling me enough. That's

Scott Benner 37:27
what I call keeping you alive. Advice. Right? Yeah. This is the don't die advice. Not to make not to be healthy advice. This is the this is the don't die advice. Right. And so and so. Okay, so we have this to get back on track. We have

Jennifer Smith, CDE 37:45
all relevant to a one

Scott Benner 37:46
person is we're staying in the ballpark. So when someone says to me, oh, gosh, what's that phrase? I hear all the time. That makes me sad. Like, because I feel like I don't understand it correctly. What's your there's something about variability? There's maybe I'm thinking of it wrong. Geez. But tied to a one. See, there's there's see, when you're talking about it, the reason I keep dumbing it down is because when you're talking about it, you're talking about it correctly. You're using clinical words. And and it's your I know, you're I know, you're fantastic. And I know what you're saying is 100% on but at the same time, I'm like, Wait, what is like those words seem like words, I don't say all the time. And so you know, I just want people to understand even when you start talking about averages, I don't want to lose somebody there. You know what I mean? Like, I want to talk about it in such simple, simple concepts, that that they understand, first of all, you know, that the number might not be as important as they think, at the end, not not nearly as important as the as the idea of stability. And so,

Jennifer Smith, CDE 38:54
stability is a great word that should be included. Absolutely. Because a one c does not indicate by any means stable, right? Yeah, it does.

Scott Benner 39:07
Yeah, it's the exact same idea. If I cheat on all my tests, my GPA is not an indication of my intelligence, or my understanding of the of the, of the stuff that I'm trying to learn. It's right, that number is meaningless if you're, if you're skewing the data, especially in that roller coaster situation. And by the way, let's talk for a minute let let us get off the path for a second. Let's talk for a minute about the, you know, a couple of different ideas like where are you being when your blood sugar is at a range? Where is the most damage to your body happening? Like let's talk about low first. So you don't want to get too low because an absence of sugar in your in your blood. I hope that people understand that on a very basic level. Your brain is a machine that runs off of the gasoline that is sugar. And so if you don't have enough sugar in your blood, your brain just shuts off And that's when you're

Jennifer Smith, CDE 40:02
Yeah. And just as an explanation there for those who are doing more of like the low carb high fat? That's correct. If you're in a carb, specific, fueling body, then yes, your brain lives off of carbohydrate. Yes.

Scott Benner 40:19
100%. And so when I'm when I'm a person who's saying, Hey, I like it when my daughter's blood sugar 70 What is the where's the line where I don't want her to be? Do I not want her to be 65? Do I not you know, and by the way, I don't think there's anything wrong. I think that a person who doesn't have diabetes, I've seen people where glucose monitors and they'll show their blood sugar will follow 65 for an hour sometimes. But of course, they don't have manmade insulin, who it's it's dumb and doesn't know to stop. So you know, so, but but if your blood sugar hit 65 for 15 minutes and comes back up again, you know, to 80 this is not the worst thing that's ever happened. Right? But if you're sitting stable at where's the number, you would tell somebody? I don't want you sitting stable that low.

Jennifer Smith, CDE 41:03
Yeah. And that's, it also kind of then goes into what are you doing in the setting? Right? Because if she was writing, she was sleeping, her blood sugar was 78. You're like, awesome. That's fantastic. I'm just gonna let her ride there. She's sleeping. Now, if she was going to go out for a bike ride, and she was 78, you wouldn't have been happy? I would have been you would have said what do we need to do to accommodate to prevent it from dropping further, right. So again, setting of the value also makes a very big difference. So I think, you know, safety wise, we always consider lows as less than 70. So you want, you know, less than 5% of your time to be less than 70. But I also think that it kind of taking it a step farther is where has the average been? Consistently, because she's likely not going to have symptoms, like somebody who was averaging, let's say, 170. And now is sitting at 80. Those she's not your daughter's not gonna have symptoms, because she's used to being at 80. Whereas somebody who's used to being much higher glucose wise is going to have symptoms much sooner, even at what looks like a normal blood sugar value,

Scott Benner 42:24
how long does it take for the body to adjust to that, you know, if you're a person, because you hear people say that all the time, I'm more comfortable 200 Because they've basically trained their body to feel good at 200. But once you've made that decision, like I recognize, I need to be more like 90, how long does it take for your body to go, oh, 90 feels right, is it is there an average of time,

Jennifer Smith, CDE 42:45
I don't know unnecessarily an average of time, from clients that I've worked with that we've kind of worked things down and they're now happy feeling normal again, at you know, more in Target blood sugar ranges, it seems to take at least a couple of weeks, I'd say three to four. And again, that's with a consistent bringing it down, sometimes it takes a little bit longer for somebody to get comfortable from being consistently over 200. And now they're consistently at 150. And that might take six months, or somebody's comfort level or you know, psychological comfort level to power things down enough. Whereas other people might be more comfortable doing it, I have to get these numbers down. Let's do it quick.

Scott Benner 43:26
So I'm gonna, I'm gonna take a detour here, because I saw something the other day that upset me. And, and you just said something about psychological comfort. So I saw something that I want to be very vague because the person who did this is a grant as a great, great part of the community doing a really great thing. But they did something. And then didn't give it full context, I thought which I thought made it dangerous for the for people who might be coming in from the outside, they gave a voice to people who keep their blood sugar higher out of fear, which I think is is completely understandable happens to a lot of people, and it should definitely be spoken about. But what my fear is that when you just let somebody say, Hey, I keep my blood sugar 200 Because I'm scared, I'm gonna die. And then and then don't give any more context. And person new to diabetes comes in and hears that and they go, Oh, I have to keep my blood sugar 200 Or I might die. And so if you let somebody give the voice to that, and then explain to them, ways that they don't need to be at 200 where they're not going to you know, die, then I think you've done a real service. But I think that once you just let people run around going, listen, the reason I have five gallon buckets of dehydrated food in my basement is because when the zombies come, I want to be able to eat. That sentence should be followed with, I completely understand there's no such thing as zombies and if I'm eating rehydrated mush with my own urine I probably want to be dead anyway. And so like there should do the rest of the context of the conversation. Right. And so while I thought it was amazing to give a voice to those people, and I thought it was amazing for other people to see that, that that they're not alone in that feeling, I felt that it fell short because it didn't then show them a path to not being in that situation. Right. Right. And so and that's just me, and I'm sure, I hope I was vague enough that no one even knows what I'm talking about. But it brings up it brings up a really valid point, I think.

Jennifer Smith, CDE 45:30
Yeah, absolutely. I mean, any there are even I think the psychological even on the opposite end of that. Is, is not as scary. I mean, for people who are consistently running just really low blood sugars, because they truly psychologically fear complications, can also run the same, not the same risk, but a similar consequence, right, of the possibility of just being too low and not being able to revive themselves. If something happens, right. I've

Scott Benner 46:07
seen people who come off as lunatics about their blood sugar, you know, like, my blood sugar went to 83. So I had to quit my job and stay home, you know, like, you can like, get by that kind of thing. Yeah, I guess it happens on either side of the spectrum, right. Like you can you can you can your fear can drive you one way or the other, I guess.

Jennifer Smith, CDE 46:26
Yeah. And that I think, even as a reference, you know, back to a onesie. Absolutely. I think when people are, are driven to seeing that, well, great. I have an A onesie, that's 8%. And I've been keeping my blood sugar, you know, here that must mean it's not so quote unquote, bad, right? Whereas if we looked at the variance, again, within that, to be able to actually see where is that going? The agency of 8% actually could reflect kind of that average blood sugar anywhere from the mid one hundreds, to a little bit above 200. That's a huge variance, right. But we're not necessarily seeing it again. So running things higher from that psychological standpoint, I think we're also doing a disservice by only saying a one, see, oh, this is what you're averaging? Well, great, you're averaging, that means that there are lower and higher values to get to that middle number.

Scott Benner 47:34
So I want to share something personal here about about my daughter's blood sugar, because I because I'm always sharing, you know, every one see to make the point that I think the podcast is is a value. So I want to be 100% clear to people. If you think that my daughter's a one C being between five, seven and six, two for three and a half years means that her blood sugar is always sitting at 90, you're out of your mind. I want to thank our sponsor, Omni pod for supporting the podcast. And take a moment to let you know more about how you can become an omni pod user just like ours. Honestly, it's pretty easy. Here's the deal, you go to my Omni pod.com Ford slash juice box there, you fill in a tiny bit of contact information. And on the pod is thrilled to send you out an absolutely free nonfunctioning demo pod. This gives you a real opportunity to take the pod and put it on yourself somewhere and say, Hey, I think I would wear it here. I wonder what that would be like, if you're an existing pump user, you can see what it would be like to be able to deliver insulin without tubing. If you're a person using pens, you can stop and really kind of imagined you know what if I was in a restaurant, I needed to give myself a couple of units or something. I'd pull the personal diabetes mantra out of my pocketbook or my pocket and push a couple of buttons. And wirelessly it sends a signal to the pod and the insulin goes in no tubing, no connection needed. No thing to be tethered to. could not be simpler to get a demo pod. It really couldn't. You know I talked about in all the other episodes about why you walk on. But let's assume now you're kind of excited about getting one and you just need to remember how simple it could be my Omni pod.com forward slash demo tiny bit of information, they send you out a demo pod. you contact them back and say hey, this is for me. And you are well on your way to a life untethered. Such a nice idea. Such a nice idea not to be connected to something all day long. Not the feel that tubing on your leg, going up your shirt, and still being able to make these fine adjustments to your Bazelon boluses. When you're done listening to Jenny today, take all that enthusiasm that she has given you. Get yourself a demo pod. Be the next person to send me a message that says I am so happy that I did this my omnipod.com forward slash juice box. Now back to Jenny Smith diabetes guru. I gave her that name by the way she doesn't call herself that I'm Looking at her six hour graph right now, and I'm and the reason I'm looking at six hour graph is we basically had, like, you know, when you have the technology catastrophe where everything stops working in the same hour, your Dexcom gives up and your pump, like, you know, site goes bad 12 hours before you thought it was going to it, it all happens at one time. So that happened to Arden last night, her her pump needed to be changed, you know, hours before I imagined it was going to and what that meant was it just suddenly stopped, you know, the site just suddenly stopped helping her. And her Dexcom was time to be switched. And we switched it. And it just, I don't know what happened. But I had to take it off and put another one on something that happens never to us. And I want to be really clear about that. Not just because they're sponsoring the show, but because that never happens. But I'll be darned it happened last night. And so and so

Jennifer Smith, CDE 50:48
I, like you said everything happens at once. Yeah, it was

Scott Benner 50:51
really like there was that feeling like someone was going to come out of a shadow in the corner and just hit me with a bat. Because why not? This would be the time for that to happen. You know, like, did you know snakes live under your house. Now you're going to find out about that, you know, like, everything was going at once. But nevertheless. So it took me it took me a number of hours to get her blood sugar back where I wanted it to plus to have eyes on it and everything. She got low because I lost my eyes on it. About 430 in the morning, she dropped from a fingerstick tests where I was comfortable to like 56. And I got her back up, and she got around 80 and everything's good. So for the last six hours, from 5am till 10am. Basically, in those five hours, her blood sugar has been exactly the way you would kind of imagine it's been around 100 between 80 and 100. And it's been fine. And all of a sudden, she I know she we she had something for breakfast she doesn't usually have and I didn't quite Bolus it correctly. And we had what for us is, is it's not a panic situation, but it is definitely outside of what we want. And and it was something that we have been steadfastly addressing over the last hour and a half with, with this in mind that as you and I are talking right now I'm going to text with Arden to Pre-Bolus her lunch. So her blood sugar went to 200. And that for us is you know, you can use any word you want. It's unacceptable for me, I'm not I don't want that, right. But at the same time, she's at school, and I couldn't just crush it, you know with a sledgehammer because as it was coming down, I need to Bolus Pre-Bolus for her meal. So so I was sort of light handed about it with the idea that I was hoping I could get it to trend down at her Pre-Bolus. So we're going to Pre-Bolus Any minute now as a matter of fact, can you hear me click around I'm gonna open up my I'm going to text message right from my computer. So Arden's blood sugar was 220 minutes ago. And now it's 181 Diagonal down. And that's based on a Bolus that went in 40 minutes ago. Now I if she was home, I would have been more heavy handed and I would have her back down to like 110 right now and we'd probably be looking at a couple of carbs to stop a fall and to get it right back again. But again, because of the situation I've been a little lighter with it. I use the increased Temp Basal with a smaller than normal Bolus to create a a slower drop than I could have made right. And so now so now excuse me Arden's 181. And she still has a lunch that includes cantaloupe yogurt, to Oreo cookies, to Easter ones with a yellow filling. a grab bag of Doritos, a banana, a half a bagel with butter, and an iced tea that doesn't have sugar in it. That's what her lunches. I have no carb lunch, she's going to she eats like a horse. And so I don't know, if I'm being honest, how many carbs are in that meal? What I can, what I can tell you is this is that in four hours, she's got to work out for the softball team for the school. So I don't I don't want her low at that time of the day or falling. I also don't want her to Hi, I want to avoid a spike and I need to address the other 80 points of this blood sugar. So so I'm in a second going to tell Arden I'm even going to start typing it. Now we're going to do a Temp Basal increase of randomly I'm gonna save 50% for an hour and extended Bolus. I'm guessing based on what I

Jennifer Smith, CDE 54:41
thought going into the extended Bolus.

Scott Benner 54:44
She is She is falling now. I would bet right? And so she's falling now and she's not going to start eating for 15 minutes. Yep. So I needed to get enough of the Pre-Bolus working so that when the food goes in her blood sugar's around 100 The Pre-Bolus is working but it's not crushing her because that will give the food enough time to start that the tug of war where I want it to happen around 90 and not lower or higher. Because if I give her too much of her Bolus right now, then she's going to go into lunch 15 minutes from now falling towards 60. And the fault the food's not going to have a chance to counterbalance that. Right, right. So, right. So yesterday, I gave her 8.7 for this similar meal. And it wasn't quite enough. So I'm going to do extended Bolus nine units. And let's do she's one ad diagonal down. That Bolus was 45 minutes ago. Let's do 50% Now and the rest over half hour. She just said pre lunch. I pushed enter. It's almost like I set this up. But if you're listening I didn't. It's just dumb luck. How are dumb bad luck, I guess actually. Okay, so Temp Basal increase 50% for an hour and an extended Bolus of nine units 50% now and the rest over a half an hour. And I'm gonna guess that around you Around noon, which is 40 minutes from now, her blood sugar is going to be around 90, and she's going to be done eating.

Jennifer Smith, CDE 56:21
And do you and her her? Softball is what time.

Scott Benner 56:26
Okay, so the softball school ends at 245. They won't get outside till about 310. And so all this insulin should be good done, especially because we use a Piedra and I find it I find it's action time to be much shorter, shorter. Yeah, right. So I'm going to be pretty comfortable. If that's happening, she's going to be excited. It's only the second day of practice. So there'll be a little bit of you know, Zippy there a little excitement to help hold her blood sugar up, she's gonna go out, she's going to feel a little competitive with the older girls. And she and but at the same time, it's also a softball workout at the beginning, there's not going to be a ton of running, she's gonna feel some balls, she's gonna throw some balls, she's gonna swing a bat a little bit. You know, it's not soccer, it's not like she's gonna run 20 miles or something like that. So, and then what she'll have when they're going out on the field, but besides her Dexcom that I can see on my phone, she's gonna have nothing more than a juice box, whether and a pack of like, like candy, in case, you know, in case something's up, that the coach does have. It's weird. The coach has juice boxes in a medical kit. Okay. And the glucagon thing, which the nurse put in actually, she called me yesterday, she's like, I'm gonna give the coach glucagon. And I was like, Okay. And she's like, Well, can you bring another one to the school? And I said, Yeah, sure. And I handed it to her. And I said, you know, we've never used this right? In a decade, I've never used the glucagon. And she's like, really? And I said, Yeah, never. I'm like, you can welcome to it. As a matter of fact, take three of them, they just sit in my Georgia they expire. No, I

Jennifer Smith, CDE 58:03
don't even know how many over the years I've thrown away, right?

Scott Benner 58:07
I give them to the school because then the proxies practice with them. You know, and so, you know, okay, so I don't think that was off of our agency beaten path. Because this because you're a one C is tied to your variability. Your variability is tied to this one very simple concept. And then you and I have not spoken since I have come to this revelation. Okay. Managing type one diabetes is almost completely about understanding how manmade insulin works in your body. Can you agree with that? Say it again.

Jennifer Smith, CDE 58:44
In your body? Yes.

Scott Benner 58:45
Yes.

Jennifer Smith, CDE 58:46
How are a very individual thing,

Scott Benner 58:49
right? Yes. Until you figure that out, the rest of it is just going to be it's just gonna be you trying to stop a dam with your hands, like broken down with your hands, like, like, there's too much happening. And there's, there's this data coming back to I watch so many people try to make sense of what's happening to them out of context. And I just ended up telling them like, please stop wondering why it happened and just address it. You know, like, you can figure it out. Why later. Don't don't sit around for two hours while your blood sugar's 250. Tapping yourself on the forehead going, why did this happen? Because it doesn't matter in the moment it happened. Now get your blood sugar back down. Right,

Jennifer Smith, CDE 59:32
right. So go back to your notes or go back to the setting and say, you know, what happened? But yeah, it is. Yep.

Scott Benner 59:40
What I what I've come to sort of understand is that none of none of what happens to me in the management of Ardens. diabetes is ever a success or a failure. It's just data. It's it's data back data back and I need to make sense of that data. I did and it's a very simple formula. If you think About a mathematical formula, it's filled with letters that you have to fill in later, the formula is I did a, b happened next time I want C to happen. Yep, that's it, you know, so I did a Bolus of five units and the blood sugar ended up at 303 more units product down to 100. Next time that Bolus should probably be eight units. Or maybe I've missed timed my Pre-Bolus. This I just, you know,

Jennifer Smith, CDE 1:00:32
for Miss analyze the components of the meal and perhaps needed, you know, to use something like an extended Bolus or right, right, it's, it's analyzing and looking in your right understanding? How does the insulin work in your body? And I think that, you know, even in the context of our a one C kind of discussion here, I think that that is really important. Because when you're looking at data, and you're analyzing a B, I want to be to see, right, I want it to end up this way. But it happened this way, what do I need to adjust? It also then speaks to, how am I getting? To my average, I like to wear this number looks like it is for my clinician. And I think much more. So we really need to look at how much time are we spending in range? And what range do we want that to be, you know, for, for you, you know, your range might be very tight and on the lower end, versus somebody who has started higher and now is working to get it lower? What time in range Do you want to end up at? I mean, we always aim to have 75 80% of time in range, when we're working with our clients, we aim to have less than 5%, low, less than three episodes of significant low where you know, you need assistance or some type of major, you know, correct treatment during the course of a week. But all in all, we kind of want to look at the end range. And when you look at in range, and a onesie doesn't show you that

Scott Benner 1:02:16
well. And I want to say something about it range too. Don't cheap and count in range while you're climbing or in range while you're falling in range study and range. Because, right? Because if you say if you tell me your ranges, you know, and you know, when people are diagnosed, doctors will tell them like, hey, try to keep your blood sugar between 90 and 200. Well, right. So if I'm at 180 the whole time, I guess, technically I'm in range, you know, but and also, if I spend my whole day climbing from 90 to 200, and dropping back down to 90 and climbing to 200. Again, sure it's in range, but it's not valuable to your health.

Jennifer Smith, CDE 1:02:52
That's where variances that right.

Scott Benner 1:02:54
Word I don't understand.

Jennifer Smith, CDE 1:02:57
The variances are I'm sure you've heard or you know, if you send you're using Dexcom. You know, when you look at your if you're looking at your clarity report, you would see something called standard deviation. Right, their standard indicates how much you're going from low to high, to LOW to HIGH write variance of up and down swings, a better thing to look at variance would be a rollercoaster, where you're at the bottom of the hill, you go to the top of the hill, you come to the bottom of the hill, you go to the top of the hill, that's a lot of variance from low to high,

Scott Benner 1:03:35
right, it's your standard deviation of what's in what's the number that's attached to standard deviation that indicates success.

Jennifer Smith, CDE 1:03:45
I think it's different for every person, but really our aim is standard deviation of 25 or less. Again, if you're somebody who's starting out as standard deviation of 62, getting down to 50 is going to be a huge improvement, right? So you have to kind of start where you are and make incremental changes to get that in a tighter range.

Scott Benner 1:04:18
And it's a slow process it mean it genuinely I mean to say it's a slow process is almost it's it's the understatement of all time. You know, like it just genuinely is so in because Arden's last 24 hours have been crazy with the with all the Change Overs and stuff like that with the gear. Like I just looked at her her app and her standard deviation over the last 12 hours been like 40 So that's not It's not great, but it indicates it is an indication of what happened. Right right right there was there was a nice steady blood sugar that all the sudden became high and stayed high for six eight hours and and you know, like in blah blah blah. So, yeah, so

Jennifer Smith, CDE 1:05:00
gradual basis if you look day to day, and you can then say, okay, great. Some of these days, I had a standard deviation that was here, that's exactly what I want it to look like. Or you look at even the trendline. And it looks like nice little gentle rolling hills up and down. That's what you want to aim for going back to the day itself and saying, This is what went into that day. And of course, everyday isn't going to be the same, like you're sitting on the couch example, right? It's not, but if we can learn what went into that less, that lower amount of variance, it can make a difference than into the future days to kind of try to mimic, right?

Scott Benner 1:05:43
So so here's where I want to, I want to say this to people who are listening like I have, there's a very standard line that you hear people give advice to other people and somebody's having a bad day. Someone always wants to come into their, their, their conversation and make them feel better, which by the way is fantastic. But they'll make this very simple statement that, you know, this is what diabetes is. And, and it's a true enough statement. But it's not what diabetes is every three hours. It's it happens sometimes, like I've just explained to you like yesterday last night was, you know, it was a was a was a perfect storm of diabetes issues for my daughter, her blood sugar went to 270. It eventually got the 200 You know, like it was a it was a mess for six or eight hours. And it was overnight. So it felt worse. And I could describe what happened last night by saying that happens. Sometimes it's just diabetes. But a person who's sitting at home having that experience every 90 minutes. That's not what that statement means. Right. And so a lot of times, I always it makes me a little sad when I see people struggling that that in itself is sad, because you know, there's a there's a space they can get to eventually where this won't exist in their life anymore if they get the right, the right information, right. But what makes me sadder is to think that someone has come along and indicated to them that this is just what normal is you are accomplishing. Normal, don't try for better, because this is what it is and you can't fight it. And that I wholeheartedly disagree with. Right? It just it just I always think that I'm a fantastic example, because for years and years and years, I was really bad at this. Like, like really bad at this, you know, like a one C nine? Hey, I gotta to 8.5 Hey, I got an eight point to Hey, I got the 7.8 sat there for two years, I didn't know what I was like 7.8. Like, is it gonna get better than this? You know, and and. And then finally, these lessons over and over again, just kind of beating you in the head over and over till finally you go Oh, I get it. You know what I mean? Because I don't have the kind of mind if you listen to the show, you hear it like I don't know how many carbs are in Ardens meal, I am a more fluid manager of diabetes. If my daughter's blood sugar is too high, my assumption is I have Miss timed her insulin or I have not given her enough of it or a combination of those two ideas. And if her blood sugar's too low, I assume I've Miss timed or insulin given her too much of it or a combination of those ideas.

Jennifer Smith, CDE 1:08:24
And I mean, right now like a sugar surfing,

Scott Benner 1:08:27
we try to keep, keep manipulating it and keep manipulating, like it's better when it's when you don't have to serve when the when the water sit nice and still on your float and on your board is much better. Right? But But yes, it goes up, I push it back, it tries to go down, I push it up. And I do that by manipulating carbs, insulin, you know, whatever I have to do.

Jennifer Smith, CDE 1:08:48
Interesting talking about just even the carb counting component of that. There, I can't remember where I read it exactly. But there is the thought that carb counting should really be for those people using carb counting should really be more of a range, where you would say, let's say one unit of insulin covers a range of 15 to 20 grams of carb. Because some the study that I read that talked about it showed that there's even variation, of course, then in digestion, you're talking about the variation in insulin use individual to individual and how it works for you, right? Well, the same thing could then be whole be held true for digestion, if we're really going to get into all of the small little grains of effect on diabetes. That we have to say, Okay, I counted this to 23 grams of carb today and this is what happened and why didn't it happen tomorrow? Well, there are other factors that go into that.

Scott Benner 1:09:55
You're never I'm almost beating my hands on this. I'm so excited that you brought this up right like so because So many factors by the way, that your body the amazing machine that is if you have a working parent Korea's can adjust to on the fly. But but even if you knew what they were as a human being, you couldn't adjust for all of them. And I'll give you the example of the craziest one that has proven out. Thank God ordain doesn't listen to this. But if Arden's constipated or has not gone to the bathroom as regular she should, her blood sugar is harder to bring down and stays higher. Yeah. And if she disappears into the bathroom has a big success and comes out. You wait an hour, you don't give her insulin, you wait an hour, because I bet your blood sugar is going to start coming down again. Now listen, I'm sure there's a medical explanation for that. I don't have the time or inclination to find out what it is or how to manage it in my life. I just know that that exists. And in that situation, my daughter gets more insulin. You don't I mean, like I don't sit around wondering about it. Arden's blood sugar is stuck at 170. Let's do an increased Basal for for two hours and see what happens when we go to the mall. And we're shopping, which I don't do much anymore. I think the mall is something that doesn't exist in many people's lives. But if I'm wandering around and situation, all of a sudden people are like, hey, it's lunchtime, let's get this incredibly bad for you Chinese food. I don't sit and wonder how much of it is how much you know, carbs, I look and I go, the last time we were in this situation and went to this Chinese restaurant, it took 10 units of insulin for art and to make it through the food without a spike. So I'll be darned. Here we go. Here's 10 units of insulin,

Jennifer Smith, CDE 1:11:34
right. And that's what our experience has led you to be able to do that. And experience being remembering the experience. I think from even basics of entry learned the basics of carb counting, you probably started out doing that to a degree and now you've moved into more of the this looks like it was about 10 units, because that's what we've done before. Yes. And the carb count is still in there to a degree even though you're not putting a number to

Scott Benner 1:12:05
it. Absolutely. It's just bastardized at this point. Like instead of looking at it seriously, instead of looking at a half of a bagel and going, I believe that's 28 carbs, I look at it and I go, I know that's four units of insulin, right. And so I have a friend who

Jennifer Smith, CDE 1:12:21
does exactly that she doesn't cheat, she actually doesn't even use a pump, she uses injections. And she says, For my apple and peanut butter, I know that I need three units.

Scott Benner 1:12:31
And so and you know, and as much as that example, I think is amazing. I think that in real world, when people listen to that they go Oh, that's wonderful, but we don't eat an apple and peanut butter every day. And that's why I'm happy to tell you, I'm talking about this around Chinese food, pizza, bread rice, like that sort of stuff. And if I if I'm wrong, you know, if we sit down at dinner we had the other night I took I took some shrimp and some some steak and some chicken and I put it in a pan with some garlic, peppers, mushrooms and a little oil and butter and I fried it up and threw it over a bed of rice. And I was like here. Now if you think I counted any of that you're flatly out of your mind. Okay, and so I said to Arden I was like I gave her scoop mound of rice like God knows how many actual carbs are in that rice. And I said here let's you know Temp Basal increase all the way up like flip it double your basil for an hour and a half, put this Bolus in you know Pre-Bolus They got her moving in the right direction I think she was like 110 Diagonal down when she started eating good enough started eating and maybe about two hours later, she was sitting at 113 and then it just I saw that the band and I'm so grateful for the podcast that I did with the people who made their own artificial pancreas because something because something was said in that interview that I refer back to all the time and if you look at the three hour line on the Dexcom you can actually see the last three dots on the right side when they start to bend in one direction or the other. It is a fantastic indication of something that's coming and so she was 113 and it started bending up and I said to her I was like hey Bolus a unit and just do it because because because a half units probably not enough and you know and these numbers obviously are different for every person but a half might have stopped there but I bet you a half was gonna get into one at I'd rather give her one and end up at at before bed and go and she's probably gonna need a few carbs before She brushes her teeth. Then to be at 150 and think I'm going to spend the next couple of hours kind of nickel and diming these 50 Points off this blood sugar or worse I pass out on the sofa because I'm old and I don't exercise and and in her blood sugar sticks at 150 for until I wake up at two o'clock in the morning. Yeah you raining. So

Jennifer Smith, CDE 1:15:00
yeah, well in that bend is really, really important. I mean, even you probably you probably use it along with the Pre-Bolus, right? You say, Okay, I'm gonna Pre-Bolus blood sugar is here to begin with, we add the Pre-Bolus, we look for the bend, when it starts to drop, that's a great start time to eat. Right. Another good concept is, and I think it's discussed in sugar surfing, talks about that bend or the rise, fall going into a meal. And what that really means if you're starting a meal at a great blood sugar, it's 90, but the bend is heading off, and the Engel arrow is heading up. That actually means that if you didn't eat and Bolus right now, that up trend is going to change your blood sugar, you know, about one to two milligrams per deciliter permitted over the next 30 minutes, you could be anywhere between 30 to 60 points higher

Scott Benner 1:15:57
by the time the insulin you even gave yourself right then at 90 starts to work,

Jennifer Smith, CDE 1:16:01
right. So if your Bolus thing based on a blood sugar of 90, but in 30 minutes from now, you would actually be at a blood sugar of 120 to 140, or whatever it is. That means that you're actually missing out on a chunk of insulin. And you're going to rise despite your best effort at carb counting and Pre-Bolus thing, et cetera,

Scott Benner 1:16:24
because you have to Bolus not just for the meal you're about to eat. But for that 100 points that's coming that you don't see. You don't see. Right. And that's why See, when I talk to people, I like you have a job. We should tell people what you do. But, but but I have, but you know, listen, I am the sort of guy on a Friday afternoon if I'm just cleaning the house, somebody's like, I want to call and talk about my blood sugar. I'm like, oh, that's fine. And so you know, we will chat. And I always say the same thing on the phone calls. And it's funny because they listen to podcasts I go, Hey, real quick, before we start talking, Jenny, nothing you hear on this phone call is advice, medical or otherwise. And I usually in a personal situation, I don't do it on the podcast, I go. If anything I say here kills that kid, I did not want to hear back from you. And so like you're just like, seriously, like, it's not advice. You know what I mean? Like, I'm just here's what works for me. But try to listen through it because you might Co Op some of it for yourself. And

Jennifer Smith, CDE 1:17:20
by listening, I learned things from people that I work with every single day.

Scott Benner 1:17:24
Yeah, no, absolutely. I can tell you, I let me tell you this. And I'm gonna repeat it a number of times in the next number of episodes, probably because I'm so grateful for it. The process of recording this podcast has made me much better at taking care of my daughter. So when people send the email, and they're like, Wow, this is really helping them. I usually email them back and go, You have no idea how much it's helping me. Yeah, because giving yourself the the time to sit quietly and thoughtfully discussed. diabetes is not something that happens in your regular day.

Jennifer Smith, CDE 1:17:57
So usually, I usually say that people, diabetes management is very, it's very silent, especially that for the person or for the caregiver living it and doing it. They don't understand. Most people don't understand why you might be looking like you're looking off into lala land at a dinner meal. And really, you're contemplating everything that goes into what you're going to do about the meals, right. Everybody else is socializing. And internally, your brain is thinking okay, I've got these carbs, I've got this type of food. I've got the components here. I'm going to probably go for an hour walk on the pier after this. It's like this consistent dialogue in your brain that nobody else here Yeah,

Scott Benner 1:18:45
no, no I in sometimes at home, I'll you know when I'm here by myself. And I'm doing like gardens Pre-Bolus For lunch while she's in school. I almost talk it out loud to myself sometimes sometimes. But sometimes I'll do it when people are around and not understand and I hear my wife go oh, he's mumbling to himself. And and I'm just doing the like, you know, yesterday at this time about or, you know, a big concept for me is and we don't talk about it enough. I had Jeff you know, Jeff from from the JDRF. He was on tons of episodes ago. He said something that's always stuck with me. We never talk about the technology and you don't think of this as being technology but the technology that goes into making cannulas is not great. And cannulas get blocked. Doesn't matter which pump you're using or anything like that the delivery of insulin is not a steady at the you know at the second hour that you have your pump on or the 40th hour that you have your pump on and is it may be at the 20th hour that you have your pump on and that is not something people think about but I do on on the third day of an infusion set. I use more insulin. If that's if it's if it's seeming. And if it's seeming like it's fighting with me then then I fight back

Jennifer Smith, CDE 1:20:01
thing that I noticed and it again, that's it's great that when you notice that kind of a thing, and you either accommodate or you change it out earlier, right? Funny thing that I noticed is that anytime there is less than 30 units remaining in my pump, I noticed resistance. And I don't know I don't go into is it relative to the cannula is it relative to the site just now being finally oversaturated enough? And it's time to change it out anyway? Is it that the insulin is bad? Is it blah, blah, blah? I'm like, No, I just don't let my pump for less than 30 Unit

Scott Benner 1:20:38
exam. And that goes back to what I said a half an hour ago. Don't sit around wondering why just do

Jennifer Smith, CDE 1:20:43
it? Do it. Wonder why this

Scott Benner 1:20:47
is happening? Who cares? Why it's happening? Like you wouldn't? If you saw a car about to crash into you and you had time to get out of the way? Would you stand there and wonder why it was about to hit you? Or would you dive you know, so just oh, there's my ice machine. I usually turn that off during the podcast but I love a nice statue of ice in my in my drinks. And my iron is not low for anyone who's gonna it's gonna say the chewing ice is a isn't is an indication of low iron, which it is. I don't know if you know that or not. But if you if you get some weird satisfaction out of chewing ice, your iron might be low.

Jennifer Smith, CDE 1:21:21
Oh, I did not. Interestingly, I did not know that being dietitian I am I did not know.

Scott Benner 1:21:28
I am 100%. Sure That's true. I just happen to love the two eyes while I'm drinking it. So it's a way for me to force more water into my body than I would normally want to take. And I think so. But But nevertheless, that's way off the path of valency. Jenny, are you worried on time? Because we've now talked for an hour and 15 minutes?

Jennifer Smith, CDE 1:21:46
Yeah, I'm doing actually fine. I think my my next call isn't for about a half hour.

Scott Benner 1:21:53
So let me let me do this for you. Tell people where you work and what you guys do.

Jennifer Smith, CDE 1:21:59
Yeah, so I work with Gary shiner Integrated diabetes services. And we are a very, I guess. We deal mostly with people with intensely manage diabetes or type one diabetes. And we take it, we take education to the level of really working with people, wherever you're coming to us at whatever level of management, and we work with people all over the globe. So the nice thing is that while our office is based in Philadelphia, we do a good majority of our visits via phone via Skype via FaceTime, and very indepth education as far as helping people to either start a pump, learn how to use their pump, use all the ins and outs of record, you know, analysis, and we help people to get their management keyed in

Scott Benner 1:23:00
that that is really cool. How do you How would somebody contact you if they wanted to? And it's not a it's not something your insurance would cover? Right? This would be something you'd pay out of pocket for? Is that right?

Jennifer Smith, CDE 1:23:07
Correct. It's a pay for service, I can say that as far as the insurance coverage, there are a good a good number of our clients who actually they pay and then essentially submit the billing forms that we always have a diagnostic code on. They submit them to insurance and many people who have no restrictions as far as network provider, they do get some type of compensation or reimbursement Some people also use their flex spending benefits to pay for

Scott Benner 1:23:36
it. What's What's the website address?

Jennifer Smith, CDE 1:23:38
Yeah, it's integrated diabetes.com

Scott Benner 1:23:41
And you said Gary's name and most people in the diabetes world who know they'll hear angels singing when Gary's name is spoken out.

Jennifer Smith, CDE 1:23:49
Yeah. Either that or they'll know him by his think like a pancreas book. Right?

Scott Benner 1:23:53
Yeah. Oh, that book Think like a pancreas? Gary, I know that. Yeah. So yeah, there's definitely he, it's how he was introduced to me years and years ago, and it's how I think of him every time. So it's so it's funny, because, you know, what you're doing is, it's just, it's, it's the next level, like, it's, it's the, it's beyond the just the idea of, you know, it's beyond the idea of, hey, this is just gonna keep you alive. And this is how can I be healthy and not afraid and, and live my life completely fully, it's the rest of it. It's the stuff that doctors don't because of insurance or time or however the world works or maybe just their their flat misunderstanding of it. If what some people I've spoken to have said is even close to true, or a lot of people who talk to clinicians who don't really know what they're talking about, and so you guys take that into it's a more deep dive and but in a way that's manageable in your life. And,

Jennifer Smith, CDE 1:24:55
and I think the big thing in what we do too, is we really teach people the concept To apply themselves and we a lot of what we end up doing. The later or the more that we work with somebody is really teach their own self analysis and self adjustment. So many people are afraid to make their own adjustments. They go to their doctor every three or four months and wait to be able to look at enough information for the doctor to say, we'll adjust this here, this looks like this is happening. And I mean, that's three to four months of management that you could have done something along the way yourself. It's constant and knowing what you were doing. It's

Scott Benner 1:25:36
a huge part of it. And I do people reach out to me all the time to say when you adjust it, because I'll say on the podcast, like Oh, aren't just gained like six pounds, and she's growing, you know, so I changed her Basal rates. Well, how did you know how much to change them by I'm like, I don't know. Like, you know, like that if you want to know the how much to change them by and why you talk to Jenny, if you want to write right if you want to know the if you want to know that, hey, that kid got bigger needs more insulin. So I gave her more insulin. You listen to the Juicebox Podcast, because I because that is just sort of it. I looked at her blood sugar. And I said, look, it's been sticking. It's trending through everything that I can conceive, food activity, cannula. All those like outside forces that we think of no matter what I've done to adjust it. Her blood sugar's higher than I want it to be. I'm looking at her. I threw her on the scale, she's gained some weight, she looks a little taller, it's time to move it up. How much should I move it up? I don't know. Like, I mean, I could tell you I did 30%. But what does that mean to you, your kids different different height, it doesn't mean anything. What I can tell you is, is I gave her more. Right. And if it was enough, I stopped. And if it wasn't enough, I gave her more.

Jennifer Smith, CDE 1:26:41
You're basing it on previous experience from having watched it so much over a decade. Again, you got experience going into this, this isn't like your one month in trying to figure things out. This is experience on top of experience. And putting all of that together. I think the biggest thing when you're the biggest thing when you're the caregiver to a child, or a TN is then making sure that they're gathering in their teen brain. Absorption is there for them. Right? That it's like sort of osmosis sizing into their brain. So eventually, they take over, or hopefully there's something that takes over for them. And we don't have to use our brain anymore. I

Scott Benner 1:27:27
keep imagining that I am slowly passing it off to Arden, which I do believe I see evidence that that's happening. But I keep imagining that there's going to be this day, maybe she's going to go to college. And that 10 in a row episodes of this podcast are just going to be me explaining Arden's diabetes to Arden. Yeah, you know, you know what I mean? Like and so?

Jennifer Smith, CDE 1:27:48
And there's, yeah, absolutely, yeah,

Scott Benner 1:27:50
there's also a part of me that sort of like romantically believes that she'll be able to listen back to this one day and figure it out for herself like this, you know, II mean, and at the same time, it's funny, sometimes I don't ever want her to hear this, because I never want her to think of that her that she was in any way a burden to me or her mother. Because she's not, and I would, but I would never want her to feel that way. Because there are times on here I'm speaking honestly about, you know, not sleeping for days at a time. And, you know, considering jumping off of a roof, parents

Jennifer Smith, CDE 1:28:21
do talk about whether their kids even know it or not. Most parents in the online forums and chats and whatever are another sleepless night, or I was up all night, or I was up at two and four, and you know, six and whatever. So,

Scott Benner 1:28:37
yeah, and while you're talking about yourself, that's fine. What you don't realize maybe is that scene from the other perspective of your child, that's you going, Hey, I made this baby and it's killing me. You know, and so that's not something

Jennifer Smith, CDE 1:28:50
you never want them to feel that,

Scott Benner 1:28:51
because you don't feel that way. And right. Yeah, Jenny, it's all right. And you've got these two kids, now you've got a whole lifetime of terror coming your way. Um, trust me, let me ask you a quick question. You're gonna re enroll your kids and TrialNet?

Jennifer Smith, CDE 1:29:09
You know, that's a better question and something that I have brought up with my husband in the four years since our first son was born. And I actually add a D, in not a D sorry, at the Scientific Sessions this past June in New Orleans. I actually stopped at the trial, that table to talk with them because I wanted, I wanted more information about it. And so I believe that we will do that. In the past, I've thought, you know, if it's going to happen, it's going to happen and I it doesn't necessarily help me mentally to know that there's a piece there that says that, at some point in the future, your child could have type one but I already know that right? I mean, I, I have a genetic piece to it, I guess. And they're my children.

Scott Benner 1:30:08
So they're more predisposed in some way,

Jennifer Smith, CDE 1:30:11
or predisposed. You know, the, the risk for them is interesting. If a woman with type one diabetes has children under the age of 25, the risk of her children developing diabetes is more than if she has children after the age of 25. Why I have no idea, I don't know what the research that goes into that is, I had children after I was 25. So technically, my children should have less risk. I'm also not a man. Being a man with type one, your children have a higher risk of developing type one than a woman who has type one and has children. So they are also at lower risk that way, but the risk is still there. And there is a lot of autoimmune disorder in my family. I'm technically the only one with type one. But there's a lot of thyroid disorder. My brother doesn't have type one, but he does have some other autoimmune conditions. So you know, with that being said, that piece is there for them. So I already know that. Yeah. But I don't I don't yet quite know if I want to know if the markers are there. Right.

Scott Benner 1:31:25
Essentially, it really is, you know, it's and

Jennifer Smith, CDE 1:31:29
I've got friends who've done it. And, you know, I think the smart thing to do would be to to get it done. Yeah, it's

Scott Benner 1:31:36
an emotional decision, though. And it's hard to know. It's just hard. It's hard to because once you know, you know, and you know, you can't not not know, you know, and so do you want to have that in your formation in your head forever, because it is genuinely like someone saying to you, hey, on, on April 15 2046, you're gonna get hit by a car, you know, and you can't do anything to stop it. And so do you want to know the future? It's, I just was interested because of your background, what you thought there at the end? Okay, so let me thank you for doing this because you were a gem, by the way, and I want to tell people this, I didn't just have Jenny on because because of where she works. I didn't, wasn't she didn't contact me like, hey, I need to plug Integrated diabetes. I just in 102 episodes. I hear back from people who will people always say that hearing people's stories is a great way to mine information. But when when they speak of specific episodes that move their idea of management forward, yours is one of them. Really, yeah. And so and so you're gonna get dragged back on this podcast a lot, as long as it's going on. And you have no choice when I email you, Jennifer, you have to say yes. So always say yeah, I appreciate that very much. But I do want to give you some time to, you know, be by yourself before your next client comes in. So just thank you very, very much, and I generally appreciate you coming on.

Jennifer Smith, CDE 1:33:05
Absolutely. Thanks for inviting as always, I'm always willing, you'll always get a Yeah, I appreciate

Scott Benner 1:33:09
that. And congratulations on the baby too. That's fantastic. Did we say the baby's name or do we not do that? It's another

Jennifer Smith, CDE 1:33:14
boy. And so I have an author who is four and then our new little boy is Conan,

Scott Benner 1:33:20
Oscar and Conan? Yep. Excellent. Those are good names. And I like I like a different name. I really I had somebody say to me yesterday they were like, what's your daughter's name? And I said Arden and she goes Oh, that's so different. And I was like, that was the goal. So

Jennifer Smith, CDE 1:33:39
the loose Nino nephew you know the Lisa or the Sarah or that right? You know if

Scott Benner 1:33:45
your name is Lisa Sarah please send your hate mail directly to Jenny adults.

Jennifer Smith, CDE 1:33:50
Well, I'm a Jenny. I went to high school and graduated with six other Jenny you go by Jennifer though, right, Jennifer or anymore, Jennifer? A lot of my clients do call me Jenny. I don't answer when people call me Jen.

Scott Benner 1:34:04
I go right to my brain jumps from Jenny to that it's 6793 Yeah, that song I have a very I might have ADHD actually is what I'm saying. All right. Well, thank you very much. I appreciate you doing this.

Jennifer Smith, CDE 1:34:16
Absolutely. Have a great day.

Scott Benner 1:34:23
Thanks so much to Jennifer for coming on. If you want to learn more, you can always go to integrated diabetes.com. I'll put a link in the show notes. If you're enjoying the podcast, please tell a friend. Don't just tell them grab their cell phone go over to them. Most people have iPhones grab their iPhone, open it up. There's an app on it called podcast, open up the app and then just search Juicebox Podcast and then hit Subscribe on their phones. Take away their personal choice. Subscribe to the Juicebox Podcast today. Listen if you want to take complete strangers phones and subscribe to the podcast. I'm okay with that. Also, what else that's it, I think yeah, if you're enjoying the podcast, please leave a rating or review on iTunes. tunes, please follow me on Instagram or Facebook, it is really a great way to find out what's coming up on the podcast it's Arden's day or Juicebox Podcast in those places. And last thing is, I feel sort of awkward about but enough people have asked me about it. Now I have pushed myself past that awkward feeling. A number of you have asked if you can give money to help the podcast keep going. I'm not a charity. So it's not a donation, but it's the only word that really works. But nevertheless, if you go to juicebox podcast.com, and scroll down a little bit, there is a place where you could make a gift to help the podcast get produced. I am genuinely grateful for those people who have said they would like to do that. I don't particularly understand you wanting to pay for something that is already free. But I appreciate it. And I would like to help you. I want you to feel good about your desires. Seriously hope that this has been an episode that you'll love and come back to and refer to back over and over again. I thought it was fantastic. I will talk to you very soon with another episode of The Juicebox Podcast.

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Arden's Day and The Juicebox Podcast are not charitable organizations. Your gift (which is very much appreciated) will be used to help run the podcast and is not tax deductible. - Best, Scott

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