#1232 Ask Scott and Jenny: Chapter Twenty-Three

June 21, 2024Scott Benner

Scott and Jenny Smith, CDE answer your diabetes questions.

• How do you keep a straight line on a CGM?

• With so many variables that can impact blood sugar, how do you know when to dose more insulin?

• What are the pros and cons of seeing an endocrinologist versus a general medicine doctor?

• How does diabetes affect a child’s learning? Highs and lows in particular.

• How do you approach doctors who discourage patients from having a tight range, especially when there is no burnout?

• What are the long-term consequences of hypoglycemia?

• How close is too close for a CGM and a pump site to be together?

• How do you train your type 1 kid to wake up for a hypo?

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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, welcome to episode 1232 of the Juicebox Podcast

welcome back to another episode of Ask Scott and Jenny today Jenny Smith and I are going to answer the questions sent in by you the listeners. And don't forget, you can hire Jenny at integrated diabetes.com 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. Don't forget if you'd like to save 30% at cozy earth.com You can use the offer code juice box at checkout to save 30% off of your entire cart. But if you want an extra little surprise go to juicebox podcast.com and click on the link on the front page. When you place your first order for ag one with my link you'll get five free travel packs and a free year supply of vitamin D drink ag one.com/juice box guys the surveys were down last month at T one D exchange.org/juice. Box I'm not blaming anybody you were probably busy school was ending etc. But now you're just sitting around staring at your kids and wondering when the hell they're gonna leave you alone. So go find 10 minutes where you can be all by yourself T one D exchange.org/juice box take that survey please. This show is sponsored today by the glucagon that my daughter carries G voc hypo penne Find out more at G voc glucagon.com forward slash juicebox. This episode of The Juicebox Podcast is sponsored by us med U S med.com/juice box or call 888721151 for us med is where my daughter gets her diabetes supplies from and you could to use the link or number to get your free benefit check and get started today with us med Today's episode is sponsored by Medtronic diabetes, a company that's bringing together people who are redefining what it means to live with diabetes. Later in this episode, I'll be speaking with Mark, he was diagnosed with type one diabetes at 28. He's 47. Now he's going to tell you a little bit about his story. To hear more stories from the Medtronic champion community or to share your own story. Visit Medtronic diabetes.com/juice box and check out the Medtronic champion hashtag on social media. Jenny, we are pushing through our ask Scott and Jenny questions I think pushing through is not the right phrase doesn't make us sound like we're here willfully.

Jennifer Smith, CDE 2:49
Correct. It does not even remember that I'm always like, what are we doing today? Scott?

Scott Benner 2:54
Yeah, that's okay. Well, we're gonna we're on topic or whatever. Well, there's no topic. We're just gonna go through people's questions. I'm just going through this document full of questions from people who listen to the podcast, so you're ready to jump in? Yes. Let's start with something a little nebulous. How do you keep a straight line on the CGM? Seriously, I am listening to the podcast and we are continually improving. And we've come so far, primarily because of the podcast. That's nice, truthfully, but the line just isn't straight. I just would like it to be straighter. And although our highs are less high, now, they are still higher than I'd like. So how do you keep a flatter graph? I mean,

Jennifer Smith, CDE 3:39
this is the one thing that I hear over and over and over and over in questions. Look at my numbers. They're not stable. They're not flat, and like you kind of standard deviation of 19. And you're averaging a 102 blood sugar. How much more stable? Do you want that to be? Exactly? I mean, I'm not saying this from a you know, it's not judgment, but it's like, we have to look at this as well, without any information about what this person's data or their data for their child. Maybe it is much more variability or much higher standard deviation than they really want. Great. Could you contain that a little more? Probably. And it does take work. It takes effort. It takes some experimentation with sounds like you know, this person is doing but a straight flat line. Even in somebody without diabetes. That's not the goal. The goal isn't straight straight. Yeah. Nobody's I mean, overnight, maybe right overnight, where there aren't the variables of exercise and food and extra Bolus, insulin and everything. Those are the drivers of the up and down. But in that environment, sure. Stable straight. Absolutely. That would be lovely to aim for. During the daytime. You're looking for more gentle rolls through the day, with a lot less variability a lot less. I started at 100 It goes to 190. Maybe it starts at 100. And it only goes up to 150. That's, that's improvement. Again, you're not looking at 100 stays 100.

Scott Benner 5:10
Yeah. So I think what can happen if you're listening to the podcast is that I don't talk about diabetes from like, this is kind of okay situation, I give you what looks good, right? You know, right, golden, and you try to get to it on your way to it. It's not going to be perfect right away. And so what I see in this question is progress. You know, that's, yeah, absolutely. I started somewhere, it's getting better. How come I can't get to it? And I just think that the answer is time and experience. Yep. If you have the, the nuts and bolts, if you have Pre-Bolus thing, and, you know, timing and amount, and using insulin and stuff like that, then it's just at that point, it becomes repetition. Rack, you know, it becomes not getting complacent and saying, Okay, well, when we eat this, my blood sugar goes to 250. And that's just going to be that. Like, it's like, I wonder what would work here? Is it more insulin? Is it a little longer? Pre-Bolus? Do I should I come back in 45 minutes an hour later and try to get ahead of a fat rise, like that kind of stuff. But I do take your point, too, that some people can get overwhelmed with the idea of just this incredibly flat, right line that's supposed to be at I don't know, 85 forever and ever. And I mean, a person who doesn't have diabetes won't see that. Correct?

Jennifer Smith, CDE 6:32
Yeah, right. And even if you look at those who are following more of the low carb or even the ketogenic, their lines are not flat, so to speak. I mean, flat really means almost no, no variance. Yeah, at all. Right. So while their numbers look more stable, and I guess within a smaller, you know, standard deviation, there still is some little bit of up and down to that. So agreed. Sounds like progress has certainly been made for this person who's asking. And the goal again, then is I think it's even more defined by what are your target goals? Yeah. Where are you aiming to be above on the lower end? And where do you really want to try most often, to kind of hit a top end and not really sit there, but to have it come back down to the mid ground,

Scott Benner 7:20
I take a lot of direction from something you said to me a long time ago, about more like rolling hills, getting rid of sharp peaks, that kind of an idea. I mean, obviously, if you have a meal and your blood sugar jumps to 250, and you know, in 15 or 20 minutes, you didn't meet the need, you know, and it popped up. And now our goal was, let's get it back down without getting low, you know, as quickly as we can. I mean, listen, if you're eating a standard diet, right, like, I mean, I'm not talking about that either, unless you're gonna be like, very ultra low carb or something like that. And probably mixing in some old timey insulin in there too, and doing some other things. Yeah. Which is not not doable. I always kind of look at, like, thresholds. So for me, if Arden goes 141 50 and rolls back down again, at food I go, I wasn't perfect, but it's very good. And reasonable. Also, I don't want the 150 to be for three hours. I'm talking about, right, maybe a 40 minute window, you know what I mean? Just like kinda up and kind of down. Okay, right. And

Jennifer Smith, CDE 8:25
the exact in that example, too, if she's starting at 140, she grazes 150. And then over, you know, an hour she comes back down and she lands at 140. Bolus did its job, right. And your timing did its job, something else might not be quite right. If it doesn't get back down to target, which might be 100 instead of 140. Right. But again, your little bump up and down. Yeah,

Scott Benner 8:47
was lovely. My example actually, I'm maybe I misspoke. I'm talking about she's between 80 and 100, or something and she eats and she rolls the 140 and goes back if Arden was 140 all day, I would definitely I would be like yes, I know you're missing something.

Unknown Speaker 9:02
Something's not right. But

Scott Benner 9:03
again, not messing it up. Just something's you said it better. There's something's not right. Basil is not right. We haven't corrected in the right place. There's food we didn't account for somehow with insulin, right? Because if I'm stable at 140, all day, I certainly could be stable at 90. Yeah, you know, it's just somewhere along there, something's moved. So I would say to people, like, if you're on it, if you if you've got a background, you're building your understanding. I think the next goal is just to kind of give yourself some grace and just chill out and let time pass a little bit. Now if it's getting worse and worse and worse, higher and higher. You might have to worry about your weight, what you're doing, I think, correct

Jennifer Smith, CDE 9:41
and doses maybe things have adjusted maybe if this is a child the child is grown or they've added something else into the mix in terms of activities, or stress or whatever it might be right. But again, I know the big bottom line is that flat, completely flat with no variance is really not. It's not the goal that you're aiming for unless you really just don't want to eat anything.

Scott Benner 10:08
Never have a carbohydrate again in your life which is again you want to I'd start with me just you know Yeah. If you take insulin or sulfonylureas you are at risk for your blood sugar going too low. You need a safety net when it matters most. Be ready with G voc hypo pen. My daughter carries G voc hypo pen everywhere she goes, because it's a ready to use rescue pen for treating very low blood sugar and people with diabetes ages two and above that I trust. Low blood sugar emergencies can happen unexpectedly and they demand quick action. Luckily, G voc hypo pen can be administered in two simple steps even by yourself in certain situations. Show those around you where you store Chivo Capo pen and how to use it. They need to know how to use G Bo Capo pen before an emergency situation happens. Learn more about why G vo Capo pen is in Ardens diabetes toolkit at G voc glucagon.com/juicebox. G voc shouldn't be used if you have a tumor in the gland on the top of your kidneys called a pheochromocytoma. Or if you have a tumor in your pancreas called an insulinoma visit G voc glucagon.com/risk For safety information. diabetes comes with a lot of things to remember. So it's nice when someone takes something off of your plate. US med has done that for us. When it's time for art and supplies to be refreshed. We get an email rolls up in your inbox says hi Arden. This is your friendly reorder email from us med. You open up the email to big button it says click here to reorder and you're done. Finally, somebody taking away a responsibility instead of adding one. US med has done that for us. An email arrives, we click on a link and the next thing you know your products are at the front door. That simple. Us med.com/juice box or call 888-721-1514 I never have to wonder if Arden has enough supplies. I click on one link. I open up a box. I put the stuff in the drawer. And we're done. US med carries everything from insulin pumps, and diabetes testing supplies to the latest CGM like the libre three and the Dexcom G seven. They accept Medicare nationwide, over 800 private insurers. And all you have to do to get started is called 888-721-1514. Or go to my link us med.com/juice box using that number or my link helps to support the production of the Juicebox Podcast. Right now we're gonna hear from a member of the Medtronic champion community. This episode of The Juicebox Podcast is sponsored by Medtronic diabetes. And this is Mark.

David 12:59
I use injections for about six months. And then my endocrinologist and a navy recommended a pump. How long had

Scott Benner 13:05
you been in the Navy? Eight years up to that point? I've interviewed a number of people who have been diagnosed during service and most of the time they're discharged. What happened to you?

David 13:15
I was medically discharged. Yeah, six months after my diagnosis. Was

Scott Benner 13:18
it your goal to stay in the Navy for your whole life? Your career was

David 13:22
Yeah, yeah. In fact, I think a few months before my diagnosis, my wife and I had that discussion about, you know, staying in for the long term. And, you know, we made the decision despite all the hardships and time away from home, that was what we loved the

Scott Benner 13:36
most. Was the Navy, like a lifetime goal of yours?

David 13:39
lifetime goal. I mean, as my earliest childhood memories were flying, being a fighter pilot,

Scott Benner 13:45
how did your diagnosis impact your lifelong dream?

David 13:48
It was devastating. Everything I had done in life, everything I'd worked up to up to that point was just taken away in an instant. I was not prepared for that at all. What does your support system look like? friends, your family caregivers, you know, for me to Medtronic champions, community, you know, all those resources that are out there to help guide the way but then help keep abreast on you know, the new things that are coming down the pike and to give you hope for eventually that we can find a cure. And

Scott Benner 14:13
you can hear more stories from Medtronic champions and share your own story at Medtronic diabetes.com/juice box. So with so many variables that can impact blood sugars, how do you know when to dose more insulin? I can imagine this will get easier once I have a pump and I can slightly give my daughter more insulin but today we Pre-Bolus Traumeel or BGB for lunch was 116 but two hours later, it was 350 It's infuriating. And I don't know why this happens or what to do.

Jennifer Smith, CDE 14:46
Yeah, well, that sounds like the wrong dose. Yeah, man. It sounds like they're working on Pre-Bolus Right, that that was in the picture. You had a starting blood sugar that was in a nice place to begin with, especially if this you know, is a child Old that who is eating carbohydrates. And if your blood sugar is in the three hundreds after and I would say that the follow up to that is if you're in the three hundreds or if you're in the two hundreds, and it sits stuck there. Remember the Bolus, his job is to work that blood sugar back down, at least close enough to the target that you're aiming for. And if it does not, then the Bolus is the problem. Your timing, maybe you needed five more minutes. But a blood sugar shift of that much really indicates a deficit of insulin.

Scott Benner 15:30
Yeah. It seems simple to me. But yeah, I think that's the answer. If you if the food is overpowering the insulin to that degree, then there wasn't enough insulin there to resist it.

Jennifer Smith, CDE 15:41
And I will say that, for some kiddos, again, this is MDI. And there is a little bit of a difference, because you could potentially to get rid of those more extreme high blood sugars or to stay under a high value that you're aiming for after a meal, you may end up making the insulin to carb ratio more aggressive. But because you can't get the precision of dosing there, what you may end up having to do is on the back end, as that as that Bolus is bringing the blood sugar down, you may have to have an uncovered snack, in order for that to actually work all around, right? Because the dosing can't be as teeny tiny as might be needed to give just a little more. But on the back end, you have to kind of cover the extra then for MTI to be

Scott Benner 16:30
tougher with little kids, because such a small amount can move you so greatly, but I mean, 350 is to me, like Jenny said, it feels like way too high. You didn't cover the food correctly. Now, if that person was here to say to me, Hey, I counted those carbs, right? Like I did it right, then you start looking at, is there something about this food specifically, that needs more than Yes, other foods that have this carbohydrate count, which can happen all the time, like some foods are just, you know, they just need more. And so you have to do what they what they need not,

Jennifer Smith, CDE 17:02
not me or some little kids to you know, who really have a hard time. I mean, again, it sounds like they're doing Pre-Bolus Here in this example. But some kids, it's really hard for them to wait for that Bolus to start working, right maybe even the length of time that you as the observer or the caregiver knows you should wait. And in those I mean, I think you did you did with the glucose goddess, right? Yeah, interviewed her. That's where some of those kind of hacks if you will really become beneficial. Have your child start with the protein at the mealtime, have them start with the protein and the vegetables if they really can't wait, and especially if there's something more high glycemic, that's coming, put it at the end of the meal, so that you get a little bit of cushion for digestion and letting the insulin start to have a little bit more, you know, pull action. I've

Scott Benner 17:53
heard back from a number of people who have done some of those hacks, just you know, eating foods in different orders that they've they've reported back they've had some really interesting and beneficial experiences. So nice. Okay, what are the pros and cons of seeing an endo as an adult? Who has type one? Alright, hold on, this person has type one diabetes, she's saying what's the point of me seeing an endo? When I already have to see my other provider twice a year? And I'm getting meds from them? What am I gaining from my endocrinologist at this point? I go back and forth about this. So why can't I just get my doctor, I had this diabetes thing for freaking ever. Why can't I just get my doctor to give me some scripts? I know what I need? I think that's the question.

Jennifer Smith, CDE 18:34
It sounds like it? Yeah, it's a good question. I would say if you really feel like there is something that you need some extra help with, in the realm of diabetes, or maybe you have diabetes, and you have thyroid condition as well, or any of the other autoimmune types of conditions, then an endocrinologist really would be the more beneficial kind of person to go to truly, because while a general medicine doctor knows about all conditions, they really have general information about those conditions. When you have specialized needs, a specialist should be able to take the deeper dive with you answer more in depth questions, if there's additional medication, you know, even in the realm of using some of these newer injectable non insulin medications for things, primary care again, no is like the tip of the iceberg of information if you're going to really get the best benefit of some of these alternatives, going to an endocrinologist and not all of them will fit the bill you may have to search around right? And maybe that's the reason this person really relies on their primary care, because they feel like they don't really get anything extra from their endo anyway, which could be a little give and take there. Are you going to your endo and asking questions and they're just not able to answer. Search around find somebody new because you should have somebody like that on your team. However, if you're not really asking any questions you're expecting Um, to like, pull everything out of you, then maybe it's not an equal relationship. Right?

Scott Benner 20:05
I was gonna say that if in the scenario, the endo is just useless to them, you know, like not giving good information, there's still some benefits. For instance, I don't think a regular doctor would remind you once a year to get your vision checked. Typically, like little stuff like that, like, you know, if a new glucagon comes out, yeah, your regular doctor is not going to know about that. That's the little stuff there, I would think about like, I would think my concern would be not being enveloped in diabetes, and then getting left behind somehow, also, I don't know this person's situation. Now if this person is writing to us, and she's got, you know, a five, eight, A, one C, and she's just rolling through life, then my might say, yeah, you probably don't need an endo. Right. You don't have any big questions, but at this same person's rockin and eight right now, right here, your GPS, okay with that? I mean, maybe an endo would at least ping you every once in a while and go, hey, could we wrecked try a pump? Could we do this? Have you considered this? Like, you know, they're gonna know not to be happy with that number? And

Jennifer Smith, CDE 21:08
with that, again, depending on where the management looks like it is, is the primary care even looking at that? Do they have the tech that's available within their clinical, you know, space or their portals? Does it allow them to review CGM and pump data or even something like the hidden pen data or some of the smart device data? If it doesn't, you're really out on your own. Looking at all of that by yourself? Yeah, they may be able to write your scripts and write the labs that you know they think are needed, and you know, that you should be getting, maybe they even remind you go to the podiatrist every single year, right. But outside of that, the deeper things like you said, glucagon, goodness, you know how many people with type two diabetes on insulin are never ever told ever?

Scott Benner 21:55
About glucagon? Yeah, those are people who are going to an endocrinologist.

Jennifer Smith, CDE 22:00
And some of them are, some of them are going to primary care. And that's my point. You know, they may not, they may not know. So,

Scott Benner 22:05
like, I get the frustration. This person is not helping me move forward. Yes. But I think that then your point, go find somebody who will not stop completely. It's it feels to me, like there's more of a chance for something to tumble away from you. Without having that interaction. Now, maybe you're getting that interaction somewhere else. That's fine. Like I, you know, funny. I don't think anybody would think it was odd that I would say this, but I still feel weird about it. Like, even though I'm the one who has and runs a really big Facebook group for diabetes. I get with people think that and go Why would I help? You know, why not a community from it's really helpful. So if you have like community somewhere and you're hearing about things somewhere, that's fine, but I just don't want people to get complacent. That's my, my bigger concern. Okay, right. Well, here's a fast one that doesn't need an answer. How do I adjust settings on loop? We need an update with Kenny. Oh, remember my fox in the loop house episodes. And I am including this little thing here to tell you that there is a series with Kenny coming up at the end of 2024. That's fun. Oh, there you go. You just wait for that. Sorry, the answer is not in here right now. Next question. How does diabetes affect a child's learning in particular highs and lows? I have found my daughter seems to hit a wall. So she seems to hit a wall when her blood sugar gets around. 10 Oh, am Oh, oh, this person's 10 millimoles. That's a 181 80 blood sugar. It seems like anything she learned before she can no longer remember. And everything is just too hard to comprehend. The thing is, this affects my daughter's mostly during math. It stresses her out. When she gets stressed. Her blood sugar goes up more. I don't know how to help her with this. It's like when she's high. She has ADHD symptoms. And short term memory is no good. She can't retain anything I can outperform when she needs to. So Jenny, you and I have an episode about this. It's called altered minds. Maybe?

Jennifer Smith, CDE 24:04
Oh, okay. Maybe I do remember having a conversation about it. I mean, some of the questions and I think it we brought it in that conversation, it revolves around how often are they being pulled in school by a nurse or are being pulled out of that class, or a class to go and take care of something that is blood sugar relative, because then they're, they're kind of lagging in what the other students are actually getting, because they're not getting instructed in it. And they may have to play catch up on their own. So that's not really relative to the number in blood sugar, but it's more relative to the loss of what they're supposed to be getting by sitting in class. If this person seems to be more, I guess, mindful of when their child learns best, and it's When blood sugar is in what they're considering a target range. And, I mean, again, we've discussed the high levels and the low levels, you know, touching a high I level and then turning around and coming down isn't as detrimental as hanging high, right? Because that also means that your brain either hanging high or hanging too low, it doesn't really get the right amount of energy to retain and you know, incorporate all of that stuff on top of what they've already learned.

Scott Benner 25:20
I found it interesting. By the way, the episode we did was episode 485 is called altered minds. God, it was like three years ago time ago. God, Am I old, what's happening? Okay, let's not think about that right now. It came up because I noticed, and I'm sure you've noticed, and everybody else has noticed, too, but people don't believe this. They don't believe that wildly higher or lower blood sugars, impact people, or they don't want to believe it. I don't understand. I can never really wrap my mind around it. But a lot of people act like it's an excuse you're trying to use. Right? Right. My blood sugar's high. I can't I can't pay attention. That's an excuse. Well, it's not. And so we went into some great depths to talk about that in that episode. So I would say to this person's question, I completely believe this. You know, if the kids blood sugars, like you said, if it's like 9180, back to 90 again, then I don't see it as much but one ad for an hour or two hours. I don't disbelieve that at all. I've I've mentioned a million times that watching Arden in sports, her butcher got to a certain level, and she literally slowed down when she was running. Yeah, and her hand eye coordination changed and all this stuff. So here's what I would say. Imagine you've had a big turkey dinner. And you got that dopey feeling, and then someone brought algebra to you. Yeah, that's what it seems like to me. So

Jennifer Smith, CDE 26:41
or is teaching, you know, some type of fact for the first time, that's supposed to be building on what you've already known. But if all those things that you've already been taught, were built in certain levels of glucose, your reception for some of that stuff. I mean, it all builds on itself, what you learn, it builds, it builds, it builds. And so depending on where the blood sugar, even the variability in if you've got a child, or a teen who's got a blood sugar that looks like the Rocky Mountains up, down, up, down, up, down, up, down, and it's all day long. Absolutely, that's going to have an impact on their learning capacity that's happening

Scott Benner 27:18
right now. Don't hear that and go, Oh, I'm a terrible parent, like just No, yeah, go do the like, go to the Pro Tip series and learn how to stop that from happening. That's all, you know, again, get to it as quickly as you can. But at the same time, it is what it is. You're not gonna learn it overnight. I guess, again,

Jennifer Smith, CDE 27:34
this person sort of also brings in the fact that this particular class also stresses their child. Yeah,

Scott Benner 27:41
right in the process of it happening adds to it again. Now. That's true. I don't know how to help with that. But I have been married a long time. And I know just telling her to calm down is not the answer. No, it has not worked out when I was married in the first decade. Yeah,

Jennifer Smith, CDE 27:56
and those are, you know, those are some of the things with school aged kids that we look at, maybe this class is every Thursday, and Friday, or every Tuesday and Wednesday, or whatever it is. Sometimes if you look at your child's class schedule, you can actually tell that there's some pattern to times of day, one in particular that I always see in kids records is their weekend mornings look beautiful, flat and stable. They might even have like, a three times carb amount pancake breakfast on a Saturday, that looks nice and beautiful. And they get right into lunch looking lovely. Whereas their low carb breakfast on their school days, does completely the opposite. And it's the transition into their school day. It's either the anticipation or the excitement, kind of doesn't really matter matter. inch to age. But again, it might be relevant to dosing around a class like that. That's a really stressful class. Maybe that class causes a rise in blood sugar of 100 points, every time they cut goes and sits down. We'll assume that the class is almost like carbohydrate, then I never have to dose for it.

Scott Benner 29:05
You could try to come at it with an increased Basal if you timed it. Well, you could Bolus for the class if that's gonna happen. I you know, anyway, yes. Higher blood sugars can create situations the way you described. And yes, stress and anxiety or excitement can make your blood sugar go up. So I think, by the way, it's worth pointing out as we get away from that question, good on her for noticing it. Absolutely. Because a lot of people just go I don't know what's happening. Magic diabetes came again. Yeah, you're actually seeing what's happening, which is really cool. Okay, I have two here. I like both of them. How do you approach doctors who discourage patients from having a tight range, especially when there is no burnout? They don't seem to believe patients are getting good numbers without it being a huge burden to them. How can we get them to be supportive of having In a tighter range with with fewer lows, especially in front of our kids. This happens Jenny, this happens all the time. It does. Yeah, this is one of those things that I I used to be shocked by. But now I'm just shocked when I don't hear about it. Somebody all, I always get a note that says, Oh my God, listen, podcast, everything got so much better. So excited to go to the doctor, I went to the doctor, Doctor yelled at me for 15 minutes. I was like, what happened? Yeah, you must have gotten to these numbers by having lows

Jennifer Smith, CDE 30:27
in there reminds me too, that a lot of times doctors are still using that average of an E one C as a hallmark of how are you doing. And if you have an A one, c, that is 5.4, let's say pull a number out of a hat, that number to the doctor represents some stress in management, something is too overwhelming, you are on top of it way too often, you're just visually watching it 24/7, or there must be some low blood sugar. So rather than that doctor actually even looking at your data, they just make a call based on that one average that an ANC represents. So if that were the case, you know, for this particular question, then your job is to come with the records that suggest Hey, you know, we're doing really well, I my kid is in multiple sports, he has all the enjoyment of life that he could possibly need. We're doing this, you know, look at our records, we have, you know, 1%, low blood sugars, and they're not lower than 60. And, you know, my kid is not sitting out because we don't want his blood sugar to move. I think those are the explanations that in your mind, you're living them. So you may not have to verbalize them. But to somebody who's just looking at one number, you may have to just explain, hey, we're good.

Scott Benner 31:47
I think you have to have the wherewithal, it's tough to because can you imagine putting all this effort into something maybe for six months. And then you're finally like, this is my day, the person who judges me is going to be happy, then that judge the person is not happy. And it probably throws you off for a second. But I would just be like, Hey, let me stop you here, I get what you're saying. I see that you think it must be I 24/7 I must be staring at this thing. And like, you know, turning knobs and everything. But that's not we're not at that spot. Like it's just going well for us. We seem to know how to use the insulin and how to cover food and activity and we're doing great and so appreciate your, you know, yeah, right. But yeah, gonna be careful. If you're listening to this. Some of you before you can get that out of your mouth, they're gonna snatch the pump from you and start turning dials to take your insulin away to make your blood sugar higher. And then that's a and Jenny, I'm gonna use some colloquial language here. That's a mindfuck of its own. Okay, because now the doctors like let's make your agency higher. Because, right, you're gonna have a really horrible low or you're going to burn out. And everybody's not the same. Like, I appreciate that. Maybe you've met other people who have burned out doing this. That's not our situation. I have a bigger grasp of this. Yeah, right. Right.

Jennifer Smith, CDE 33:02
This might be kind of like a blanket statement. But quite honestly, any doctor who takes your pump from you to turn the knobs and dials, that is somebody to not stay with it. Really, it is, again, my personal opinion. Because to me, my devices, they're like a piece of my body. Right? That's like removing my arm and fiddling with it to make the muscle bigger, because you want it to look bigger, right? Don't Don't take my body part. If you think I should change something, I'll bring up my settings, we can talk about it. And I may make that adjustment. But I'm going to do it myself. Because one, I use this product every single day. I push the buttons by myself all the time. Don't push my buttons for me. Right? Right. That's a really big discussion to have. Because I think it's very unfair, somebody to take something from you that You very well know how to use.

Scott Benner 33:58
And if you don't know how to use it. And they do that. Now you don't know what happened. They probably don't know how what happened. They did either by the way. They're just like, let's see what this does. And now you're both lost, because you were already wasn't going well. Now you've changed something else. If it doesn't fix it. How do you even know where you moved from? Or what did you next?

Jennifer Smith, CDE 34:16
Or why it was fixed? Yeah. Why did you adjust this versus that? You

Scott Benner 34:21
made me think of something? Not to the question. But I'm going to talk about here. I think this is really interesting. Something about the way you just talked about don't take that from me. You're changing my thoughts. I realized like, like, you're basically saying to someone give me this thing that we've attached to you and I am going to decide what's about to happen to your body next. Right? And you won't know because I did it like so the unknown that so I never thought of it that way. Isn't it interesting? I've never ever thought about that way once. If I take Arden's pump from her and I go hey, I'm just going to do this. That's why adult type ones say things like Does she know you made that change is that Okay, it's about autonomy. It's not about Oh, right. It's not about diabetes at all.

Jennifer Smith, CDE 35:07
Oh, wow. Yeah. Because I think, you know, again, life with what is now almost 36 years with type one, I very much feel like my products are part of me. That's a weird thing. Because there are I call them like, my boys always have called them like my robot parts, right? But they even somebody who has a prosthetic limb, for example, like I would never, ever, as a provider, ask somebody if I can take their body part from them to check it out? Like no, that's, that's, it's the same thing for somebody with diabetes feeling

Scott Benner 35:43
that, like it would be as if, if I said to you, hey, give me your insulin pump Jenny, and I'm going to decide to make you 10% happier, or I'm going to make you 15% More aggressive, or less emotional, or like, oh, that's got to be the same weird feeling you have if you go on like an SSRI, and people talk about like, I don't feel my highs or lows anymore in that like, weird, disconnected feeling like you put this thing in your mouth, and then all of a sudden, you experience the world differently. Correct. Okay, well, this seems like a thing that I probably should have recognized 15 years ago. But I made a note to talk to Eric about I think this is a lovely, lovely concept to go deeper into with a therapist. That would be great to hear really interesting. Okay, look at us learning. Well, me, you are probably just, I always tell Erica, when we're doing stuff that every episode should be called. Watch Erica, watch Scott realize something that was taught in freshman psychology that he doesn't know.

Jennifer Smith, CDE 36:43
Because Scott wasn't paying attention. I

Scott Benner 36:45
wasn't even there. I just had that feeling now, like you might have been looking at me like, yes, really never occurred to you. How about you? Okay. All right. Here's the question. Why don't we just tattoo this on people's foreheads? Oh, I hear this so much. What are the long term consequences of having too many low blood sugars? I hear there is a cognitive impact. But I don't know more. But it seems like it's not discussed enough. Seems like it's not as discussed as much as the consequences of higher blood sugars. So what are the long term effects of hypoglycemia? And every time we try to talk about this, the problem ends up very similar, right, like there, first of all, are no long term studies. There's no, right. That's

Jennifer Smith, CDE 37:27
the hard thing. Yeah, it really is. I get this question a lot, actually, again, with the women that I work with in pregnancy, we focus heavily on highs similar to outside of that right outside of pregnancy. But a lot of the doctors also focus on spending too much time low. Okay, then, yes, we could address that. But unfortunately, in terms of studies, there are not numerous published studies about the long term impact of low blood sugars on the cognitive function then of the child Once born, right. And the studies that are there actually define define the the number of lows under a blood sugar of 50 as being the resultant reason for cognitive impairment or assumed connection of cognitive impairment. And so when we're looking at, like, when you're living with a blood sugar 55, that's, you shouldn't bottom line, you should die. Don't do it. Don't do that. But again, the studies aren't, they're suggesting, oh, a blood sugar of 68. That sucks sustained, is that creating long term, there's nothing to prove that it isn't. But there's really nothing to prove that it is, in fact, that's a many people without diabetes, wake up with a blood sugar somewhere between 65 and 95. Right?

Scott Benner 38:46
It would be inhumane to take a control group of people drive their blood sugar down with manmade insulin, keep it there, and then wait to see if it gives them problems. That's why you're not going to see a study about that. Right. And everything else is, you know, to some point up for interpretation, because you can say to somebody like I'm seeing a cognitive decline in you. Did you have a lot of lows when you were young? Like, you know, I mean, what are you going to do? That's not a thing you can really track? So we know, it's 70 the number that we just know, you're okay. Up above it. Like, is that just the

Jennifer Smith, CDE 39:20
why it's the bottom line? Yeah, that's really and you know, in terms of long term, I think we need more long term studies because some of the information that is out there, like if you go to CDC and some of the other, you know, general research reporting kind of databases, they have low blood sugars, in terms of frequency of them length of them over and over types of effect, leading to the potential for a risk of dementia later in life or the earlier onset of dementia. And again, a lot of them also are done in type two diabetes, but blood sugar to blood sugar Diabetes, diabetes, so we kind of put them all in St. Pat's. Are

Scott Benner 40:04
you willing to tell people what number you worry for yourself? Like, where do you go, Oh, I can't let this be.

Jennifer Smith, CDE 40:11
Huh, I'm comfortable. But I think it also, I like to be above 65. That's a, again, an easy statement. If I am sitting and working at my desk, if I'm sitting in like, doing not much reading a book or whatever, and I'm sitting at 68. And it's a nice flat, stable 68, I'm gonna leave it alone. Like, why am I going to do something about that, because I also, and maybe in the past on more of a manual pump, maybe I would have knowing what's coming in the hours ahead, done something correctively. But now that I have an algorithm AI D algorithm based system, it's really not gonna honestly even sit there long, because I've got my target set above that, and it should be kind of bias

Scott Benner 40:56
a little way, it's gonna let you write some natural body function is going to bring your blood sugar back up. And

Jennifer Smith, CDE 41:01
I think because we have enough of those on the market, regardless of the system that you're using, I think all of them are very conservative in terms of the low blood sugar values that, you know, to sit there for a lengthy period of time, likely not going to happen with most of these systems. And a lot of people are still in the know about, well, my blood sugar is dropping, I need to treat it and with an AI D type of system. Do you mean, like, treat it in? It's too hot?

Scott Benner 41:30
I mean, I guess I'll share too. For Arden, I think a lot of it is about I don't want her to get dizzy. Right? That's sort of the way I feel about it. And, of course, so much about it is also just like you said, it's direction like is this a very stable number that's not moving? Is it never gonna go down from here, because there's no insulin on board. That makes a big difference to you know, if I see again, on an algorithm, if I see art and dip below 70 into that, like mid 60s range, I'll just wait and see what happens. I'll go look, and I'll be like, Oh, this thing already knew this was gonna happen. It's been taking basil away for 20 minutes. And so, you know, I think in the next couple of, you know, the next couple of checks, it's going to start to head back up again, based on what I know, but also know that CGM is are still a little behind reality. And so like, there's I don't know how to say that this makes me feel better. When I see the 65. I think, well, it's not 65. Now, it was a few minutes ago, maybe right? And everything I'm looking at makes me feel like it's heading in the right direction. Now, if I saw 65, and everything I was looking at made me feel like it was going to keep going lower than I would react and

Jennifer Smith, CDE 42:43
he would, yeah, absolutely. And I have to say, you know, in terms of asking about like a target, I would say I have targets also based on certain scenarios in my day, right? If I'm heading out to go and do something with my boys in the afternoon, or whatever, I have numbers above which I would really prefer to be or a stability place that I would prefer to be. From a driving perspective, I always like to be at least 80. Yeah. So there are some, I guess adjustments to where I would navigate and make an adjustment to get my blood sugar to start coming up. Yeah, even if I didn't have my algorithm system. So

Scott Benner 43:23
I want to say if Jenny's number sounds like if you heard 80, and you were like, cute lady. Just think of it as aspirational. That's really how I think of the whole podcast, like, if you're not there, just know that that's possible. And then get as close to it as you can and are comfortable with like that, to me is how to think about this stuff. And

Jennifer Smith, CDE 43:43
he's done. You know, I've worked with a number of people, not just guys, but people who are in construction, right? There are some places that you may have to navigate your targets, especially again, if you're eating a typical, like diet, right intake, that we may have to adjust your targets from an overall safety standpoint, so that you don't get that like that dizziness, or that sort of fumbling with your fingers or lack of cognition, you know, to be able to actually 10 stories up in the air. You're watching on the steel beam, right? You're sitting at

Scott Benner 44:18
a desk talking to people about diabetes, so you can just be like, I'm gonna have a sip of juice right now. And you know, and if you get woozy, you're gonna fall off of your stool, not off of a, you know, a building, right? So right, it makes sense. Couple of quick ones here. This is an easy one. How close is too close for a CGM and a pump site to be together? Oh,

Jennifer Smith, CDE 44:37
that's a good question. Most of the systems they suggest about five inches three to five inches is what I what I know. Do I know people wear them closer without any issue? I do. Do I know that? We in our own office space have tried wearing them closer just to see absolutely we have and from our my personal This is not Linux, from my personal experience doesn't seem to matter without. I've worn them close together, especially when I was using when I trialed and was using Omnipod five, because of that very important piece that they sort of hammer into you is that line of sight, right? So I followed all the rules, I was a sheep, I followed them to a tee initially. And really, like I had that that sensor sight on and I kind of moved my pad around that sensor pretty close so that it would always have that direct line of sight. Again, I really didn't pay attention to the three to five inch distance because yeah, what's realistic? actually sat around like

Scott Benner 45:45
that goes where it goes. I don't know, I'm not speaking for anybody specifically, I just know that what they have to tell you in the literature is what they tested during the FDA trial. So Correct. Yes. doesn't always mean it won't work. i The example I will always use is that you're not supposed to use a Peter in an insulin pump. But we've been doing it for like, 10 years. So

Jennifer Smith, CDE 46:07
correct. And you're in a pod? Yeah. I mean, a piedras should absolutely not be used in the tandem pumps.

Scott Benner 46:14
There's doesn't isn't it interesting there. It doesn't work in an omni pod. It's fine. It does. Except it's not FDA approved for that. Correct. Right. Yeah. Which means that on the pod never tried a Piedra in the pumping testing.

Jennifer Smith, CDE 46:28
Right. They just said don't use it. Yeah. They said,

Scott Benner 46:31
We don't have the money to test that. So go to hell.

Jennifer Smith, CDE 46:37
We can't test this piece.

Scott Benner 46:38
time or the money for your pager, which none of you are using except Scott and five other people. So yeah, by the way, you should try it. It's pretty good. Do you? Are you real tight on time? Are we can I have like 510 minutes? I'm gonna give you one last one that okay. I just don't know that there's an answer to oh, how do you train your type one kid to wake up for a Hypo? Oh,

Unknown Speaker 47:00
do you wake up for your hypose? I do. What happens? alarms,

Scott Benner 47:07
you feel it? Jesus talk to you what happens? Exactly because of

Jennifer Smith, CDE 47:11
so alarms? I think a lot of it may or may have some relevance. I mean, adulthood. I'm also a mom, think once your mom and a feather on the floor wakes you up? So quite honestly. Right? Exactly. Like I used for children. I slept, I could have slept, the train could have taken half the house off. And I was like dead to the world. Outside of my alarms, my alarms, I always have woken to my alarms, right? I from a, I guess from a maybe what my brain remembers, I try like on a monthly basis to change the alert sound, a different sound to a different sound so that it's always something different. That's waking me up, right? I also have the volume turned up so that I can hear it from kiddo standpoint. Kids sleep hard. If you've ever got I mean, most people who have kids who have diabetes, go in and have a problem even like waking their kid enough to like, drink part of a juice box or whatever. Some don't even wake their kid they can like put the juice box in and they just suck and they like fall back. And they're

Speaker 1 48:18
still asleep, essentially. A banana in her sleep. Yeah. Right. Yeah. So

Jennifer Smith, CDE 48:23
So it tells you in this question, it tells you how hard kids sleep. And so I don't know, in terms of training, some of it could be relative to using some of the devices that vibrate isn't a sugar pixel has something that connects to the device that you can slide underneath your pillow and it actually vibrates along with the very alarming noise that goes off i That's the sugar pixel, right. Is that sugar pixel? I

Scott Benner 48:52
believe so. Yeah. Like this little vibrating pad. Listen, there's all kinds of things you can try. Here's what I learned. I raised the kid from two years old to she's just about 20. She didn't wake up for anything. It didn't matter. It was on us. Like, right. She left for college, and half of me thought she'll be dead in three days. Like yeah, like, I mean, what's gonna we're gonna leave this. We're gonna hear anything. Oh, she should be dead by Thursday. You know, and what she reports back to me is that once she knew it was on her, she wakes up. And I was I don't know if that's a maturity thing or and now having said that, there have been, I mean, she's been she's half almost completely done her sophomore year. Wow. In college, and there are in the last two years, I'm gonna guess probably 2025 times I've had to wake her up. Sure. You know, like, I've had to call her and be like a Arden you're low. And she's dead. But and trust me, it's this. Hey, Arden. Your love. Low L oh, you're low juice. Drink get juice. Okay. But then she I'm like, stay on the phone. I'll be okay. And then she hangs up, then I sit there in a panic for 10 Min. Like, did she fall by? Numbers? Yeah. Drink the juice? I don't know, what I would tell you is, I don't know how you train somebody to do that, like, people are different in any mean. They

Jennifer Smith, CDE 50:20
are you can try many things. I mean, it's almost like, you know, like the potty train. I like the overnight potty train. Let

Scott Benner 50:25
me throw Cheerios at them when they're little kids, right? Some

Jennifer Smith, CDE 50:28
kids just get it pretty easily. And other kids, you really have to wake them up, like every couple of hours, right? Or the alarm is going off. You hear the alarm? And you know, maybe the training is that you go in the room and you put the alarm right by their ear. I mean, these are all like, I don't know, option as

Scott Benner 50:46
an adult. Have you ever woken up in the morning looking at your CGM and been like, Oh, my God, I was late last night? I had no idea. I'm gonna say yes. But you don't recall it.

Jennifer Smith, CDE 50:55
But I don't recall it. And again, low defined on a term of I was low. Now with an algorithm for like, you know, seven plus years? No, probably before that. Yes. Yeah, absolutely. Before there was anything. Yes. Now I also have a husband who is also a lighter sleeper. And so he hears my alarm.

Scott Benner 51:20
Wake up, wake up. Yeah, I have to tell you, I've had probably three times in my life, woken up in the morning thought, Oh, my God, I slept all night. It's great. To get on my phone. I'm looking through things. And you see that overnight for like 45 minutes Arden's budget or was like 40. And you think, Oh, my God, I didn't know that at all. That's crazy. And then the first thing you do is you look to see if she's still reporting a blood sugar. Because if she is she still alive? And like, Oh, my God, so I get that, like feeling that leg. I slept through it. It's my fault. We're all gonna die. Like, like that feeling. But I just overall, I have not found it to be that much of a concern. I think the most comforting thing I can say that with a lot of planning, don't get me wrong. Right. Yeah. But putting the right things in the right order. It hasn't been that much of an issue. If you don't do all those things. It's obviously could be a huge problem. Yeah. You know, I assume that people will say the show are putting a lot of effort into this stuff. So they

Jennifer Smith, CDE 52:19
are I mean, from what I've heard and seen, and with all the questions that always come in like this, there's a lot of, especially for parents of kids think there's a lot of consideration, you have Forward Look, you're saying yes, I'm doing this now. I'm happy to do it. I'm the parent, they're my child, I will 100% Do this for them. But at some point, they're not going to want to be here with me. Right? Some point they're going to want to be at a friend's house or a sporting event over a weekend or something that I'm not going to be there. Yeah. And I have to be able to have confidence that they're going to be able to acknowledge an alarm or an alert, I understand it. Absolutely. I

Scott Benner 53:00
would say to you're going to feel like that's not fair. The world's not fair. You're gonna have all those feelings. You gotta get past that because this just is what it is. So I appreciate that. Okay. Well, I appreciate you sharing all of your thoughts with me today. Thank you very much.

Unknown Speaker 53:15
Yes, thank you. I'll talk to you soon.

Scott Benner 53:25
Mark is an incredible example of what so many experience living with diabetes, you show up for yourself and others every day, never letting diabetes to find you. And that is what the Medtronic champion community is all about. Each of us is strong, and together, we're even stronger. To hear more stories from the Medtronic champion community where to share your own story. Visit Medtronic diabetes.com/juice box. A huge thank you to one of today's sponsors, GE voc glucagon. Find out more about Chivo Capo pen at G voc glucagon.com. Ford slash juicebox. They spell that GVOKEGLUC AG o n.com. Forward slash juice box. Arden has been getting her diabetes supplies from us med for three years. You can as well us med.com/juice box or call 888-721-1514 My thanks to us med for sponsoring this episode and for being longtime sponsors of the Juicebox Podcast. There are links in the show notes and links at juicebox podcast.com to us Med and all of the sponsors. If you have type two or pre diabetes, that type two diabetes Pro Tip series from the Juicebox Podcast is exactly what you're looking for. Do you have a friend or a family member who is struggling to understand their type two and how to manage it? This series is for them seven episodes to get you on track and up to speed In episode 860 series intro 864 guilt and shame, Episode 869 medical team 874 fuelling plan, Episode 880 diabetes technology episode 85 GLP ones metformin and insulin, and an episode 889 We talk about movement. This episode is with me and Jenny Smith. Of course, you know Jenny is a Certified diabetes Care and Education Specialist. She's a registered and licensed dietitian, and Jenny has had type one diabetes for over 30 years. Too many people don't understand their type two diabetes, and this series aims to fix that. Share it with a friend or get started today. Thank you so much for listening. I'll be back soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording.

Unknown Speaker 55:52
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