#1107 Grand Rounds: Insulin and Safety

January 18, 2024Scott Benner

The third Grand Rounds discussion focuses on insulin safety.

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

Scott Benner 0:00
Hello friends and welcome to episode 1107 of the Juicebox Podcast

Hello everyone, welcome back to the third installment of the Grand Rounds series. In the first episode, which was episode 1097. We did hospitals urgent care and initial contact the second episode, Episode 1102 Grand Rounds, diagnosing diabetes, and today we're going to do insulin and safety. My grand rounds series has two objectives, one to let doctors know what you need and deserve and to to let you know what to ask for. Nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your health care plan. If you're looking for community around type one diabetes, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, but everybody is welcome type one type two gestational loved ones. It doesn't matter to me. If you're impacted by diabetes, and you're looking for support, comfort or community check out Juicebox Podcast type one diabetes on Facebook

if you're not already subscribed or following in your favorite audio app, please take the time now to do that. It really helps the show and get those automatic downloads set up so you never miss an episode. This episode of The Juicebox Podcast is sponsored by cozy Earth cozy earth.com use the offer code juicebox at checkout to save 40% off of the clothing, towels sheets off of everything they have at cozy earth.com. This episode of The Juicebox Podcast is sponsored by ag one drink ag one.com/juice box. head there now to learn more about ag one. It's vegan friendly, gluten free, dairy free, non GMO, no sugar added no artificial sweeteners. And when you make your first order with my link, you're going to get a G one and a welcome kit that includes a shaker scoop and canister. You're also going to get five free travel packs in a year supply of vitamin D with that first order at drink a G one.com/juice. Box. Jennifer, we are back for the Grand Rounds series. Yay. Yes. Today we're going to talk about insulin and safety. Kind of these two things are gonna kind of go hand in hand in this conversation. They do. Yeah. So if you present Yeah, so far, we've talked about hospitals and diagnosis today, insulin and safety. And we're just going to start with what people sent us and then let the conversation unfold. Fantastic. The first bit of information that came back from a listener just said, we were terrified of stacking insulin. I think this goes to show that immediately on day one, you get told counting carbs, but in your insulin, you know, at the next meal, let's keep it maybe three hours from now. Do it again, right. And then inevitably, what happens is you either didn't Bolus well for the meal miscounted your carbs, maybe that ratio wasn't right, you get a high blood sugar. And that first thought comes into your head. Do I want to put more insulin in here? Right? But I can't because the doctor told me not to not to because it would be stalking. Yeah. So what that really points out to me, like if this was a management conversation, we would talk about, you know, when to Bolus again, or different impacts of foods. But in the context of this series, what it points out is you've sent people home with a misunderstanding of how insulin works on day one.

Jennifer Smith, CDE 3:59
Correct? Yeah, in fact, I've, you know, nobody reads the little insert in the insulin box, like Out goes the box or out goes that little insert that falls out all the time and nobody looks at what the profile of and we're talking right now rapid acting insulin right, the stuff that goes in out within a couple of hours. And it's got to finish to its action time. And I think it's a piece that's missing in initial education is the profile of your rapid acting insulin looks like this. I mean, if you're already teaching somebody how to inject a medication that will impact their blood sugar significantly, if they don't get it. Couldn't you also talk about that action profile? Because it would take away a fear factor? Yeah, it would give them something to visually be able to consider and so that you can explain stacking or the concept of stacking a little further right. I mean, in no way would be at advocate for well Bolus and if your fingerstick or your CGM looks like it's doing this within 30 minutes. Probably not a great Gordonsville. And Right, right. But there is there is that window of explanation that I think should be done up front. Because you're sending somebody home with something that this is 100% brand new to them. And

Scott Benner 5:25
here, this next statement, you know, if you're a physician, and you're listening, this person leads by saying, I wish my doctor would have told me to not be absolutely afraid to eat. This is a person who says that I've already lost a ton of weight because of my diagnosis. So they're in decay, they're losing weight, right, they're wasting away, they get lucky, and somebody tells them, they have type one. So they prior to diagnosis, they've already lost weight. Now, she says, I couldn't get enough calories or carbs, because I was afraid to eat. I was afraid that my blood sugar would rock it and cause blindness, the need for an amputation, a heart attack, or my demise. Wow. So that's what they went home with. So they got afraid to eat. So they saw one blood sugar jump up after what they were told, they don't know how to use insulin. And so you see this a lot. This is what drives people to like, like Uber low carb diets at some point to a lot of the time, right. And

Jennifer Smith, CDE 6:21
I think there's something to be said about, you know, we're talking from the perspective of newly diagnosed, right, from a clinician standpoint of explanation to that person. We're not talking about somebody who has had diabetes, and been using insulin for an extended period of time, there's a difference in explanation. And so I think initially, there is going to be a little bit of caution to dosing strategy. In fact, that's something that it's kind of like a marathon, you learn, and you learn, and you experiment and you learn along the way. But again, along with that should be a caretaker or caregiver, that actually is also getting good information and feedback from a clinician. And so from a starting point, decreasing that fear piece, when you're talking about insulin, having them understand some of the very basic concepts so that they don't fear eating, or they don't fear taking insulin at all. And they don't also fear correcting a high blood sugar, right? You know, if your blood sugar is sitting elevated, and they've not given you any, any information as to how and what to do about that other than just a set dose. That's your job to give that to them to begin with.

Scott Benner 7:45
So this never ending cycle that happens. And I obviously I record other stuff. While you know, sure. I've already recorded another episode today. So I have a lot of different conversations happening in my head right now. And I'm also making a series that I think I'm going to call whistleblower, which Jenny doesn't know about but it's clinicians, like doctors, nurses, pharmacists, people in health care, we're going to come on and speak anonymously, I'm actually even gonna change their voice so that they can talk about Jenny's like, Yeah, let's do it. So I had a conversation this morning with a pharmacist who works in an urban hospital, like an 800 bed hospital, pretty big hospital. Right. Yeah. And, you know, through that conversation, I almost got to the point where I said to myself, Okay, well, doctor, see a lot of mismanaged people with diabetes, yes, this becomes their expectation for what it is. And so that when someone comes into the hospital for an emergent reason, and has diabetes, they slot them almost automatically automatically into that space, right? Oh, you have diabetes, you must be unwell. You must not understand your blood sugar's probably high all the time, like all that, yes. But you just said something. Now, that brought this whole thought full circle to me, okay, which is, and it goes along with the statement that this other person wrote. So let me walk through it a little bit. She says, I wish no one would have said anything about a three hour rule or stalking or anything like that. I wish they would have just what Jenny just said, taught me how to use insulin. Right. And the note I made under that was that scaring somebody from stalking, which I understand why you would want to do that I would understand why you wouldn't want them to use, you know, uncovered insulin, sure, but it leads to their mismanagement. And it just hit me as this all comes together, I get diagnosed, and a doctor out of an abundance of concern scares me into not using my insulin correctly. And 20 years later, I end up in a hospital with high blood sugar's high one see I don't know how to manage my stuff and the doctor says up that's how people with diabetes are. But no, not if on day one. You want to help them understand and so maybe they never become that person and maybe that's how the system fixes itself. Right. Like right from from step one, not from you know what I mean? Like what I

Jennifer Smith, CDE 10:00
do. Yeah, I also think it's really important to, if you are a clinician, I think it's important to see the person and where they are. And expect that this might be your first interaction. And if they're in with a history of diabetes, as you're alluding to somebody coming in mismanaged for many years are not given proper information. This is your opportunity to start educating them. Every interaction with somebody who has diabetes, whether newly diagnosed or meeting have that information is your first point of ability to say, Hey, how can I help you understand this better?

Scott Benner 10:43
Yeah. And I think that based on this other conversation I just had today, the expectation is going to be that that's not going to happen, and that the doctor is going to have a reason in their head, why it's not okay. Why it's not their job, or they don't have time, and they probably they're probably right. But that's where I think, sure, we need to have a thing that you hand to somebody, and you go, hey, you know what it seems to me, you might not know how to use your insulin. And that's the core of this whole thing, just two sentences. Go listen to this, go read this, go see your doctor and tell them I said, XYZ, right. I think we can get you on a better path and keep you from being in this situation in the future. But that's, I think the problem is, is that we all are just waiting for the system to fix itself. And it's not that easy. It's not just a doctor, not wanting to do a good job. I think they all want to do a good job.

Jennifer Smith, CDE 11:39
Correct. Or they wouldn't have gone. Yeah, absolutely. If you're going into healthcare, I think 99% of healthcare employees are there in it to help.

Scott Benner 11:49
Right. All right. Yeah. I do think that based on some things that have been said to me recently, that maybe a certain personality drifts towards emergency medicine. Yeah. And that maybe a certain personality drift towards specialty, and that you might be getting a little more comfort and compassionate specialty than you are, you know, in the ER, absolutely,

Jennifer Smith, CDE 12:09
there is a certain personality that works the best in the emergency room. It's somebody who can compartmentalize a situation and then move on. And there's another new situation completely different, and they have to attack it. And they have to look at many different pieces that brought that situation in, and then they have to move on yet again.

Scott Benner 12:29
Right, right. So so it might be unfair to say I hope an ER nurse sees that my one C is nine and fixes it for me, that's not going to happen, right? Like no, top down there. They're trying to stop the thing is trying to kill you. Most importantly, you know, they also don't tell you to take vitamin D if you don't take it like they're not they're not there for your generalized. No. But when you get into a into a hospital setting, the expectation is, oh, this person must know a lot about this. But in the end, I don't think that's mostly ever true. You know, and if you don't know anything about your diabetes, and they don't know anything about it, then nobody's gonna do anything about it.

Jennifer Smith, CDE 13:06
Yeah, right. Absolutely. And acute care to, you know, in, in a hospital setting, not necessarily emergent. But in hospital is also it can be a tip of starting some information to bring to somebody but that person, you know, if you are the prescribing doctor or you're the doctor who's following the case or whatnot, it's not an educational environment. I worked in patient education for a long enough to learn one that that's not where I wanted to be. And to that you can only really give a little bit. And those little tidbits should be enough to send somebody out safely with some new information. But you have to be the one to set up the follow up. Yeah, you have to be the one to be able to provide them with the next step. I gave you this I taught you the basics of safely using insulin. Your next step is this person has been set up for an outpatient Yeah.

Scott Benner 14:10
This episode of The Juicebox Podcast is sponsored by cozy Earth and right now I'm looking at cozy earth.com to see what's going on. I got oh look at this bamboo pajama set for ladies. That jogger pants for ladies looks like plush lounge socks. That's one of Oprah's Favorite Things. There's the bath collection. We love the waffle towels but there's also premium plush bath towels. Everything that you see here can be had for 40% off with the offer code juice box at checkout. Even the sheets now we use the bamboo sheets, you may choose different linens I don't know what you're going to love when you get to cozy earth.com But we sleep on bamboo sheets from cozy Earth. They are incredibly comfortable, and I bought them myself with my own money using my own offer code, juice box at checkout 40% off is what I saved, you can as well at cozy earth.com. I partnered with ag one because I needed a daily foundational nutritional supplement that supported my whole body health. I continue to drink as you want every day because it works for me. Ag one is my foundational nutritional supplement. It gives me comprehensive nutrition, and it supports my whole body health, drink, ag one.com/juice box, when you use my link to place your first order, here's what you're gonna get a free welcome kit that includes a shaker scoop and canister, five free travel packs, a free year supply of vitamin D, and of course, your ag one. So if you want to take ownership of your health, it starts with ag one, try ag one and get a free one year supply of vitamin D and five free ag one travel packs with your first purchase. Go to drink, ag one.com/juice box that's drink ag one.com/juice box, check it out. Right, I'm not a Pollyanna person, I don't think that everybody who's doing poorly is doing poorly because someone just didn't tell them what to do. I know there are plenty of people who correct or a myriad of reasons don't take good care of themselves in a lot of different ways, what they eat, how they exercise, what they take in their body other than food. Like I understand all that. But when you initially set like, let's just say, you know, you see, I don't know, 500 new patients a year with diabetes, which is probably an astonishing low number, I would imagine. Yeah. And you don't give any of them a good direction, well, then they're left on their own to maybe find it or maybe not. But if you give them good direction, and a third of them take it, that's a win, you know, like, that's better than not anybody Correct? You know, this person says, Look, if you would have just told me that fat protein and adrenaline, for example, would have changed my insulin needs, it would have saved about three years of me banging my head against the law. Like, that's a long part of your life, to every day, every meal be going like I don't understand what's happening here. You know, and then you get that fear. Explaining why you're suggesting these changes would be great. This person says, also listen, when I tell you that they don't work and why I think they won't work, you know, so it's not enough to just say something blanket to them. Because your blanket idea may not be the answer. I'm just gonna go out and say that I've been doing this a very, very long time, speaking to people about diabetes, and seeing what leads them to success, right? And the answer, I think the only answer is information that they can access at their leisure. I think that's very important. Because you can't force somebody to care about it, just because it's day one, or because it's been a year, because you're a once they hit a certain number, they have to be able to intersect this information, when it's comfortable for them when they're ready to take it in. And I think that's what gives them the best chance at success and moving forward. Right,

Jennifer Smith, CDE 18:14
I think what you're talking about is kind of stepping stones, right? You give them a baseline, again, from a safety standpoint, this is safe, this will lead you to blood sugars that are more optimized, but then we're going to move on from here. And you have to look at it again, like a long duration of little pieces of inflammation information that collectively at some point, they'll start to fit together like a puzzle, they'll start to make a lot more sense. And it's, it's also from the person with diabetes standpoint, it's a lived experience, you know, if somebody tells them their diabetes educator, or their endocrinology doctor or whatever, says, why don't we start here and do this, and then you come back as the person with diabetes as the next visit. And the doctor should say, Well, hey, we talked about this last time, did you try this, you know, and did it work. And I think that that's the piece that often kind of gets missed, it gets missed in the jumble of there's lab work to look at and what they think they need to check off in terms of discussion, but what it needs to be is almost like a review, it's like, go back to what was talked about, did it work, and that's the person with diabetes that needs to bring in when you told me to do this. I tried it for a couple of days. And it didn't really seem to work. Right. Okay, then let's take another look. And let's see what else we can make a change to Yeah,

Scott Benner 19:42
and reasons why most likely doesn't work when it doesn't work. It's just settings, right? You know, if you don't have their Basal, right if you don't have their insulin to carb ratio, right, their correction factor, right. Like it doesn't even if you tell them the correct thing to do. doing the correct thing with the wrong amount of insulin is not getting you anywhere, right. And it points to this feedback here. A person that says that if the doctor would have just admitted to me that they were just starting me off that this wasn't the end all be all conversation, that would have been great. But at some point it felt to them, like, ego. Oh, almost like the doctor didn't want to admit, like the thing I told you in the beginning wasn't all of it, or they didn't know one or the other. But I'm telling you, if you're listening, if Basal should be a unit, and it's point eight, you're already screwed, right? It's that easy. You know, if you know your insulin to carb ratio is one to eight, but you've got it set at one to 10, you're going to lose, right? And that stuff, snowballs on top of people, and leads to the statements and leads to long term health. And you can't just say, well, that's diabetes, they're gonna have to figure it out on their own, right? Because, Jenny, I don't know, maybe that is true, on some level, that you are going to have to figure it out on your own. But you don't need to start me 10 miles deep in a hole, and then tell me to figure it out on my own. You don't I mean,

Jennifer Smith, CDE 21:03
right. And on your own, it implies that you don't have follow up or someone to check in with, right, what you're kind of seeing in a roundabout way to is that at that initial diagnosis time, or an initial re education time, but especially at initial diagnosis, it's the understanding that when you're talking about insulin use, and the safety of it, I think a safe piece to tell people is that we're starting here at a new diagnosis, this will change. And these are some of the reasons that as your child grows, or as you change your lifestyle as an adult, or as we see how things are moving and changing. This will get adjusted this 110 20 unit of insulin that we're taking now, it's going to change. So don't expect it to be this way for the next 20. I think if you're just told that right now, you are less likely to feel irritated when it does change. And you know,

Scott Benner 22:05
to look for it. Right? So my daughter was diagnosed at two, I mean, 15 years ago, and we struggled for years. I'll never, ever forget the time that I realized her correction factor was like one to one unit moved to 350 points or something like that. But that's because she was diagnosed when she was two, right? Yeah. And so like, now she's four. And I'm like, I don't know, why is there anyone seeing the eights? Like I can't figure this out? I'm trying to move her blood sugar with not nearly enough insulin. Right. And she went to a good children's hospital. They never change that. Yeah, even they weren't thinking about it, like so. I mean, I don't want to say like, it's, it's not, it's not, it's not hopeless. Okay. But, but I think it is important to remember if you're the person listening who has diabetes, that it could go this way. And if you're a doctor, and you're hearing it, I hope what you're hearing is that with tiny little adjustments, that what I say to these people, and how I say it to them, we could avoid a lot of these issues, I get a ton of them. And Jenny brought up such a good example, that she just kind of cruised over I think, but at the end of your notes, it should say, this is what we talked about. So that the next time you open it up, yes. Next time, we're together, you start with Okay, the last time we were together, we discussed this. And let's move from that point, instead of like you said, Oh, we're going to check your agency today. Let me check your sites. Don't put it here anymore. Move it over here. Great, thanks. How are you feeling? How school how school, shut up. told me how to make my blood sugar to be lower and stable. It's not asking me how math is for God's sakes, like like, you assessing my psychological well being, I tell you what, it would be better for me once he wasn't nine. What do you think of that?

Jennifer Smith, CDE 23:54
I could actually think when I was doing my test,

Scott Benner 23:56
I'd be doing great in math. If my head wasn't foggy all the time. And I wasn't constantly low and jam and a bunch of food in my mouth I didn't want while my mom's crying on the phone. Like I bet you all that would make it better

Jennifer Smith, CDE 24:08
or being pulled out a class because I mean, for kids, especially kids are consistently being pulled out of class because their blood sugar is too high for something or it's too low for something and they don't have enough, you know, authorized ability to treat it in the classrooms. They have to get pulled out and they go three hallways down to the nurse and they sit there for 20 minutes. Well that's 20 minutes of math class or 20 minutes of learning where to put the commas in your sentence. And

Scott Benner 24:30
while you're sitting here listening is a physician thinking that's not my fault. Yes, it is. I've told this story on the podcast before my daughter leaving second grade going into third grade. We thought she was like, stupid, but I'm not even gonna like idea. Like we were like, that kid can't do math, you know? But luckily for her, her second grade teacher did that leap thing with her class to the whole. She had the same teacher next year. And the woman just had an epiphany. And she said, oh my god Arden's struggles with math. If Arden goes to the nurse every day while I'm explaining the math section, and that's why it took her a whole year to get back on course with it by the way Arden's very good at math now, yeah, but why was that happening? It was happening because in Arden's insulin to carb ratio was wrong. So she had to go to the nurse because we were afraid of how high your blood sugar was going to be. And we were setting up the certain times of day to try to check them, no lie. If art in settings were better, she wouldn't have struggled in math. And that is a direct correlation. And you should be aware of that if you're a doctor. Because

Jennifer Smith, CDE 25:34
that's, that's where as a physician, again, you know, I understand time constraints and everything I really, truly do. But as I said before, that's a, you have to also have an idea, especially when you're working with kids and teens. Their schedules are crazy, honestly, and you have to have an idea of what is their life, like, if you're going to try to navigate, helping them manage with their insulin doses, and strategizing, adjust this way, one day and adjust this day, because this is the recess B and it comes right after lunchtime. You have to know that type of thing about your patient,

Scott Benner 26:12
you have to have that conversation with them. Right and ask them what are the struggles you're having? Like, where are you having these problems? Not just like what happened here at two o'clock? By the way people hate that question. Because it was three months ago at two o'clock. I don't know what happened. I have a low blood sugar, right? I don't know. And by the way, in case you're wondering, I know that you have to ask about the lows for insurance reasons or whatever. Like I get it like I know what's happening. But the people don't understand that they think this is like your high level, like deducing like you're trying to figure things out. Not that you're just trying to get them to say something that looks good on the form. Because I see what's happening when I'm in there. This this one person says, if you just would have explained Pre-Bolus thing to me, that one concept, oh my gosh, what things would have changed. I tell people all the time, if you're not Pre-Bolus thing, you might knock a point off, you're a one c by Pre-Bolus. And and that's not even like purposeful direction. It's just something that I've noticed. So Right.

Jennifer Smith, CDE 27:10
Yeah, absolutely. And I think it it boils down to, there's an there's an also an age appropriate component to that Pre-Bolus. Right, especially with a new diagnosis where you're not quite sure where, where the doses are gonna go in the next week or two, as the body sort of responds to getting insulin and having more normalized blood sugars and insulin, you know, maybe honeymooning comes into the picture. And so all of this as an explanation of this time period, it's going to look a little bit up and down, we're going to have real close conversation. Here's our office number. And many pediatric practices actually do that they provide enough hand holding. But if you're not doing that, that's really important. And it's even important for what I think is like the Forgotten crowd of people with type one diagnosis, which is adults. Honestly, if there's an under education that

Speaker 1 28:01
no one's followed up with adults, nobody fought like they're given.

Jennifer Smith, CDE 28:05
If anything, this baseline of this is how to do an injection, take this amount of insulin, and make sure you take it with your food, no reference to Pre-Bolus. And if they're at their insulin needs, and the type of food that they're probably eating and the load that they're probably eating. Most adults even at early diagnosis, need some kind of a Pre-Bolus They're not three years old, where you're questioning whether they're going to eat the 10 grams on their plate or better for

Scott Benner 28:33
my brothers that type two. And his last day once he just came back five, five down from seven, eight. Awesome in that crazy? Do you know who led him to the information that got his a one c into the mid fives? It was me. Yeah. A guy with a podcast pointing out you know, nobody can see that is Doctor Who, by the way had been doctoring him for three years to a mid seven a one C and tell him you're doing great. So yeah, but

Jennifer Smith, CDE 29:01
without also and I don't know whether he was using a CGM, but a mid seven could have been with a very considerable variance. So it may not have you even if seven was, quote unquote, healthy and where they felt like it should be fine at if his variance was excessive. Yeah. Well, that's not

Scott Benner 29:20
healthy. He was sick a lot. He was tired a lot. Like he just couldn't like get anything done. And finally listened. This has happened to me. And it's interesting because the people in my life, it's harder for me to tell a person in my life, I think you should do this than it is for me to tell a stranger on the podcast, which is interesting. We had this situation last night in the Facebook group. It's not really a situation like I sort of got irritated about something and I made a post and somebody was talking crap about me on the internet somewhere and I just kind of It's okay, don't worry, it happens sometimes.

Jennifer Smith, CDE 29:50
It's never kind of do I don't care who you are very nice. It comes with.

Scott Benner 29:54
I don't feel right saying this, but it comes with popularity. The more popular the podcast is the more people kind of take shots and stuff like that, so it's fine. So I put this post up that I guess led everybody to think that I was in a bad way. And to help me what they did was they came in and they told their stories about what the podcast has done for them. And if I spent the next two hours on this recording, I could probably record everything that was said. But suffice it to say, the podcast helps people. They say that that's me helping them, which okay, it is, but all I did was told them how insulin works, right? That's all I did. I know that everybody like, it's nice. And I appreciate the credit and all the good wishes. But all I did was teach you how insulin works. If doctors would do the thing I was asking them to do, I put myself out of business. And, and by the way, I'm getting older. So let's go. You know what I mean? Like, like, let's get to it. Now, I can't do this forever. You know, I wish my doctor would have told me about the balancing act of insulin to carbs and how insulin actually works. Over and over. These are different responses from different people all telling you the same thing. Now that I've had it for a while, now that I found the podcast. Now that my agency is low and stable, and I understand diabetes, I wish you would have told me how insulin works. It's what everyone is saying in here. Just everybody.

Jennifer Smith, CDE 31:18
And there is you know, as this is insulin and safety. There's a safety component to explaining that from the get go. Yeah, I mean, it's like it's like thyroid, for example. Right? That's a medication that is for everybody I've ever worked with who takes meds, Synthroid, for example, or the other, you know, options. They're given that information from their doctor or from the pharmacist who they get the medication from, about timing it away from food away from certain supplements away from other things. And this is a simplified example, in comparison to insulin, but they're told why y with insulin can cause such extremes in blood sugar,

Scott Benner 32:03
don't take Synthroid with this vitamin, don't take it on a full stomach don't like here are a couple of things to do. We'd like you to take it in the morning be consistent every 24 hours, actual direction about how to take the pill. Now, if you don't do it that way, then it's your problem. Like but at least,

Jennifer Smith, CDE 32:18
you're also not going to end up with a blood sugar. That's 42. Yes, right.

Scott Benner 32:23
Right. And so they do the thing of, instead of telling you what to really do, we'll just err on the side of caution, which is a way of making it sound like you're doing them a favor, but you're not doing them a favor, you're turning them into a person that 20 years from now in an ER is going to be treated like a scumbag for not understanding their diabetes, but your initial meeting with them put them 20 years later in that position, and maybe not 20 years, maybe much sooner. 510.

Jennifer Smith, CDE 32:49
Right, almost a blame for maybe they are coming in with some complications or something in the picture already. And I think it's an an unfortunate thing that happens, because your expectation about what you know about somebody just based on now seeing their diagnosis. Yeah. You don't know what's gone into their life up to that point. Yeah, or

Scott Benner 33:15
what their initial meeting with health care is put, listen, here's a here's an example that I think is pretty dead on. If an 18 year old kids caught with three joints in 1970, and thrown in jail for 20 years, and then murders two people in jail 15 years later, you say, Oh, look, we were lucky. We got him off the street, he was a murderer, I say, maybe if you would have just taken the weed from them and been like, hey, go home, you wouldn't have sent them on this path. Right. And that's what this I swear that it's going to sound harsh to a doctor. But that's what this is, when you intersect people early with diabetes and don't do the right things for them. And I'm telling you the right things are explaining how insulin works. Like when you don't do that. every bad thing that happens to them afterwards is likely avoidable. Or you'll never know. Maybe Maybe the guy was gonna murder somebody in 15 years, but you're never going to know because you didn't give them the right chance. In the beginning. I

Jennifer Smith, CDE 34:13
meant that could have encouraged the behavior for what happened 15 years later. Yeah. Versus like you said, Oh, slap on the hand, send them home, hey, probably don't sell those or give those are yours.

Scott Benner 34:26
We're not going to for you to for 20 years, which by the way, 20 years later, society generally accepts that that was the wrong thing to do. I mean, this, like, if you live your whole life as a physician doing this, and you go retire somewhere, and then you're just sitting around enjoying your life. And you see that health care has jumped forward and proves out that the thing you were doing now wasn't the right way to go. It's going to eat at your gut. So just like listen now like because Jenny mentioned thyroid a little while ago, we're talking about diabetes, but all of these disease states that require the user, the patient to understand it and to help manage themselves. We always say it right. I guarantee every doctor listening has said this, you know more about your diabetes than I do. First of all, why? Like, it's not that hard to figure out. And secondly, okay, well, if they know more, why aren't you listening to them? And why does it happen? A generation again, like, Okay, well, we figured out doctors don't know, but the users know the patients now, let's go ask them what they know. And we'll make that the standard of care. It's all I'm saying right now. That's all I'm saying. No, yeah,

Jennifer Smith, CDE 35:38
I think I think I mean, thyroid was my example. But I can think of another one that I was, as a dietitian, gave education on was the Coumadin diet, people get more education about using Coumadin, which is a blood thinner, essentially, and a specific, right, Vitamin K kind of type of diet, and what do you have to they get more education, you think that medication using insulin? So there you go.

Scott Benner 36:08
So what is really happening is, I'm left to look back on this and say to myself, you either don't know what you're talking about, or you are willfully not explaining it to people, those are the only two options and neither option is okay. So either educate yourself about it, I have a, I have a series of episodes you could listen to while you were driving, and a week and a half from now, you'd go Oh, I understand how insulin works. Now, that would be that easy. Or just admit you don't know. Right? But stop being punitive to these people and sending them down a path that leads to things you can't even imagine poor health psychologically and physically. relationship problems, you know, like because they can't write their blood sugar's are bouncing around, they can't even communicate with people well, and we hold the

Jennifer Smith, CDE 36:57
job well enough for absolutely, yeah, chronic

Scott Benner 37:01
pain comes and then they start doing things where they're like, oh, all start managing this. But this next thing, you know, they're taking 16 different meds, and they're smoking weed and stuff to try to get through their day. And I know that all sounds like that's not our fault. But yes, it is. In this specific scenario, every person you let leave who doesn't understand. This is what your basil is for. This is what your insulin to carb ratio is. This is what your correction factor is. Here's how these foods impact versus these foods. Don't just say glycemic index and glycemic load to them. And if they don't listen, it's their fault. Like because that's like Chinese. Yeah, I don't understand. I've said on this podcast a million times. Somebody said to me one day, hey, glycemic index, glycemic load, it's really important. And my kid had just been diagnosed with diabetes. I was like, what? And then I never thought about it again. I started making this podcast and I said to Jenny, one day, I'm like, Oh, my God, the biggest problem is people don't understand the impacts of their foods.

Speaker 2 37:55
So did someone try to tell me years before? I don't know, not really. They pulled me into an office, they set a thing. They checked a box, and they kicked me out again. That's what they did. Seriously. That's what they did to me.

Jennifer Smith, CDE 38:09
I'm sorry, you got to boot. They were able to say, hey, we

Scott Benner 38:13
told him, Hey, that kid drops that it's not our fault. Like that. That can't be the way you do this. No, it just Yeah. You know,

Jennifer Smith, CDE 38:21
can't I think I think it also brings up from a component of this conversation being safety. There's an elephant in the room that honestly needs to be brought up. And it's, if you prescribe insulin, Scott, what else should you prescribe?

Scott Benner 38:39
Oh, glucagon, yes. Because you're right, it is dangerous. And they might pass out and freaking try to die. And it would be cool if they had a thing where they could just jam it in them and stop that from happening. So Correct. And how do you get in that position? You don't tell them how it works. And then they start sniffing around it, and they kind of figure it out. But they don't have a lot of directions, they start doing these like crazy. Like, I'm just gonna give myself a bunch of insulin and see what happens ideas. And sometimes that doesn't go well. So it's not just use more insulin, or it's understand how to thoughtfully use things. How does the insulin work? How do I thoughtfully apply what I know about the insulin to my specific situation, diet, etc. Yeah. And by the way, poor women who are already told so many times, like, that'll go away after you have a baby, or I hear that happens to a lot of you like like that, like that's your level of care you get sometimes. How about no one tells you that you might be three different kinds of people with diabetes every 30 days. Right? You might be the nice stable one. Maybe during your period, you might be the one that has troubled prior to your period after. Yes, I know. It seems like Oh, they'll figure it out. A lot of people never put two and two together. As

Jennifer Smith, CDE 39:57
far as the person with diabetes. You You may not put it together, because it's never been defined to you as a difference from female hormones impacting a certain way. And impacting a certain way, depending on where you are in your life cycle of those hormones, creating a different type of impact compared to male hormones, which absolutely are very different than female hormones. And we, I feel like, you know, I work with a lot of women and women's health has become much more important to me to provide the right type of information for the females I work with. Because they've been left in the dark, they may have been given information about insulin reaction, and what to do and what their Basal and their Bolus do, they may have been given that but you ask the majority of women about whether they were told what to watch for once they start having a monthly cycle, or early like the preteen not even having a cycle yet, but the potential that there's a pattern that's starting to emerge, and you feel like a crazy parent that brings something up, and they're like, Well, I don't know, it's just, you know, we'll just adjust this way. And then the next time they come in, it's a different time of the month and the poor kid is like, well, let's adjust down this way. Instead, give them the reason that this is happening, right? And how to fix it. Yeah.

Scott Benner 41:22
Listen, I sometimes I even get frustrated because people give they bring you these very specific situations. What's happening right here? And I always answer the same way, you're not using your insulin correctly, right? There are different variables, there are things that are happening to you. Maybe they're hormonal, maybe they're food related, maybe they're exercise related, hydration related, there are a couple of like big ones, right? That it could possibly be. And, you know, setting setting settings settings have to be right, you need to know when to use the insulin. And I say all the time, like if I had five seconds to make this podcast, I would tell you that it's using the right amount of insulin at the right time. It's timing and amount, dependent on variables. So when someone comes to you and says, I don't understand, you know, I'm good at this except when I'm swimming. Okay, well, then swimming is the variable, right? And we'll figure out like, where do we put the insulin? How much of it and where, you know, so when do we put this so that you can swim without a low blood sugar? It's infinitely doable, right? It really is. And yes, your doctor's probably not going to explain that to you, the day you're diagnosed, or even in the first couple of years of you going into that office. But if you knew its timing and amount, it settings, it's understanding the impacts of food, the impacts of hormones, the impacts of those sorts of things. Hydration, if you're not well hydrated, your insulin doesn't move around. Well, it doesn't work the same way. This person here says, hey, it might have been nice to tell me that my insulin sensitivity would act differently if my blood sugar was higher, because you gave me settings and directions that drove my blood sugar up. And now not only were those settings not okay, when I had a stable lower blood sugar, they're really not okay, now. And all that gets boiled down to a doctor by like, oh, yeah, when your blood sugar is high, you need more insulin. Okay. valuable, but not not nearly the whole story. That's all. I got upset during this one. I apologize.

Jennifer Smith, CDE 43:15
No, it's all 100%. Correct. And I think you know, the point being that in general, you have to give the right information in the right timeframe. But starting out somebody with information that is lacking enough definition, that is going to set them up for going down a path of I don't understand, I don't understand I don't understand. So I'm just going to do the basic that I was told to do, because I don't know what else to do. And nobody's helping me. And then they also don't know what questions to ask to make it better. Even if it's with a, you know, a health care practitioner that's trying to do something for them. That person might be so in the dark that they don't even know where to start to ask.

Scott Benner 44:04
Yeah, I just I'm stunned that with the prevalence of diabetes, such as that is that the simple ideas aren't better understood, and communicated. Like Jenny, I'm not going to like I hope this doesn't sound different than how I mean it. This podcast is insanely popular. I know. It's not a podcast made by like a big company or like a, you know, 20 people. It's like, I make it I have you on and a couple of people and I have guests on and like I you know, I pay an editor to like, make sure it sounds good. Like, it's not a big operation, right. The fact that so many people listen to it should be an indication to physicians. We are not doing a good job with this. Like that's that's, it should because if people understood it, it wouldn't be needed. It's not a comedy podcast. It isn't fun to watch Listen about talk people talking about diabetes, like their list. They're trying to save their lives, you know?

Jennifer Smith, CDE 45:06
No, you're right. And in a broader sense, I think if there was, like a lot of the way that many people might even often come to the podcast is actually just by doing a search for more in depth education about diabetes, or type one diabetes, or support for diabetes, or whatever it might be. And obviously, it probably comes up pretty much first on a Google search, along with maybe a couple of other options, right? But right, the baseline here is that without the right information, people are left wanting almost with a almost with a subconscious idea that they haven't been given everything they need. And then they go searching. Yeah, wouldn't you rather that they get the right information from you to begin with, so that you don't have to repair all the misinformation, they may have gone down a rabbit hole of information online, perhaps they didn't find the podcast, but they found somebody else's. This is how I manage my diabetes and the like eating lettuce leaves all day or? Right? You know, if they're coming back to you like that, you're like, oh, oh, okay. All right.

Scott Benner 46:13
That's not right. Yeah. I didn't mean for you to just eat cabbage. Sorry, right. You haven't led them in a good direction,

Jennifer Smith, CDE 46:21
right? They're doing a search because you haven't given them the information they need to begin. Isn't it

Scott Benner 46:25
funny, too, that a doctor will tell you don't go online to find out stuff? You know, like, Why do you think I was looking? I was looking, because I completely understood it. And I just wanted to see if there was more. Like, I don't know what I'm doing. I'm dying, physically and mentally. And I'm trying to save myself. And by the way, those are the people who are lucky enough to take that extra step. Correct. Most people just sit down and go, This is my lot in life, and they take it.

Jennifer Smith, CDE 46:51
And this must be the way that it is because the doctor and I don't mean that rudely. But the doctor told me to do it this way. I do it this way. And as you said, this must be the way that this just works. Yeah, they don't go down the road of search.

Scott Benner 47:06
I guess this is what living with diabetes means. I have an eight a one C and I feel cloudy all the time. And I guess if I get lucky, maybe I'll just get frozen shoulder and I'll get to keep my toes like that's literally what's going through their head. And none of that's necessary timing and amount. I don't know, Jenny, the Pro Tip series is 26 long. It's maybe 20. You know, 20 hours worth of listening. Everybody listens to it and comes back and says Am I even seasonal oh six is now. I just understand now, Jenny and I did a talk. Let's finish with this. Because I know you have to go. Jenny and I did a talk in front of some people in Austin, Texas recently. And we were invited to talk. And we said, we'll do that. But we're not going to put a slideshow behind us. We're not going to do this the way we normally do it. We did two solid hours of conversation. Just you and I to the audience. We went on a lunch break. And we came back and did three hours of q&a. No one left. Right. Everybody came back. Yeah. My my ego made sure No, I checked hard. Okay, like everyone was there. Okay. Well, my point is, is that if I said to a doctor, hey, we're going to offer this thing of five hours worth of education about diabetes. They'd go, nobody wants that. But they do. They want it desperately. You know. And so we go down there, and we just have conversation. We're not talking at them. It's not bullet points. We have this big conversation. Jenny said you saw someone online who said what after that about pizza?

Jennifer Smith, CDE 48:36
Yeah, it was a The question had been raised about how to navigate pizza with a specific algorithm driven insulin pumping system. And I gave some baseline direction with some things to pay attention to. And when to put insulin in again, timing of insulin is the baseline here. So when to put it in and what to watch for. And from what I remember, the comment online was just back, hey, I did do a GT sat and look at what we got. I was I was very excited about that. I was like, thank good. Yeah. And

Scott Benner 49:08
I heard back from a family whose daughter went out into the world afterwards, they were going all over the place eating a bunch of stuff that you know, generally speaking is not easy to Bolus for, right. And the person said, like look at this graph and showed showed a nice, like graph of stability over the next day. But their indication was not that we even said something so specific, like they didn't go like put, you know, Peg a and hole B, just having the conversation led to her making decisions that lead to better outcomes, just hearing people talking about it. And I'm not asking a doctor to do that. But I am asking, if you don't think you're providing that to somebody, then you have to lead them somewhere where they can get that it's very, very important for diabetes. So like, if you can't figure this out, or you don't have time, or your system doesn't allow for it or whatever your reasoning is, that's fine. But don't just shoo them away, like, give them somewhere else to go. It's really valuable for people. So

Jennifer Smith, CDE 50:07
and I, you know, something valuable, I think I don't think I know that I see when I work with those that I get the opportunity to privately is when there are questions that come up that are their questions to me, too. I'm more than happy to say, You know what, I don't know, I'll have to look or I'll have to ask my colleagues, you know, I may have great resources with the other educators that I work with. And we all have wide ranges that we have good information in. We don't, each of us doesn't know everything. Sure. And so we use these each other as resources. And as a clinician, you have to be willing to say, I don't know. Yeah, it's okay. But I'll find the answer for you. I'll help you.

Scott Benner 50:51
I don't remember that. I honestly don't remember the context. But while we were at that talk, I remember putting the microphone to myself pace and saying, Oh, wow, Jenny just said something. I don't remember what I said. I didn't know that. I just learned something here. And like, even that

Jennifer Smith, CDE 51:06
was about honeymoon, something early morning. Basil needs.

Scott Benner 51:09
Right, right. Oh, yeah, I don't remember the the exact I do remember that. I don't remember that. But it's not even important. What's important is that in front of in front of a few 100, people who kind of see me as a person who knows what I'm talking about, I was happy to go, Oh, I didn't know that. Right, like so that they can go, oh, well, he doesn't know it is stuff I don't know and feel comfortable about that. And then I turn to you. I say tell me more about that. Like, that's fine. You need to make people comfortable doing things like that because they're embarrassed to but that's the other part of it. I don't know if we'll get to talk about that in here. Yeah, we will. We're going to do like, kind of like mentality humanity stuff. I'll save it. Okay, I'm gonna let you go then. Awesome. Thank you so much, of course.

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