#1239 Ask Scott and Jenny: Chapter Twenty-Four

June 28, 2024Scott Benner

Scott and Jenny Smith, CDE answer your diabetes questions.

• What are the methods to help support an elderly parent who has type 1?

• At what point is it justified for me to ask for u200 insulin?

• What do I tweak first and last to smooth out these highs followed by lows? Do I look at my insulin timing first, my basal, my correction factor, my carb ratio?

• How do I extend a bolus like a pro?

• How do you eyeball carbs?

• With all the automated systems, is getting your meal bolus exactly right going to be as important moving forward as it is now?

• How would you go about putting a pump on your child if they are dead set against wearing a pump?

• What is new in insulin choices and how do they work with pumps?

• How do you handle refrigeration of insulin?

• What about hot tubs? Do you get into a hot tub with your pod on? Could your insulin start to deteriorate?

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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 1239 of the Juicebox Podcast

Jenny's back everybody and we're doing another episode of Ask Scott and Jenny. That's pretty much it. Although Jenny loses power like 20 minutes into it. So there's a whole kerfuffle. 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. We're always complaining we want things to move forward. We want better research, but they need to know what to research and what people think. And that's where you come in. T one D exchange.org/juicebox. complete the survey help people who are trying to help people by answering simple questions that you know the answers to I promise. T one D exchange.org/juice. Box takes about 10 minutes to complete the survey they're looking for people living with type one diabetes where US residents and people who are caregivers, T one D exchange.org/juice box be part of the solution. 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

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. 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 the ever since CGM. Ever since it's gonna let you break away from some of the CGM norms you may be accustomed to no more weekly or bi weekly hassles of sensor changes. Never again will you be able to accidentally bump your sensor off. You won't have to carry around CGM supplies and worrying about your adhesive lasting. Well, that's the thing of the past. Ever since cgm.com/juicebox. Jenny, we are going to do a ask Scott and Jenny episode today. All right, I have questions. You have answers. Let's get started.

Jennifer Smith, CDE 2:52
I might hopefully have answers.

Scott Benner 2:56
This first one I know is a near and dear problem to your heart. So I'm going to start with this. I would be interested in methods to help support an elderly parent who has type one. They have a CGM and Ron MDI, they're 95 years old. Wow. Yeah, that's awesome. Yeah, great. Yeah, that's awesome. Yeah, but you talked about this all the time that the devices aren't really designed for people with slower motor skills, eyesight, stuff like that. And obviously, at some point, this woman got back to MDI, but do you have any thoughts about how to help somebody with this?

Jennifer Smith, CDE 3:35
Yeah, without any of the details, you know, there's, there's got to be a lot of assumption this person is helping their parent did you say it is right for an elderly parent, an elderly parent, if the person is living with them, you know, an automated system may be very good to consider. Because at least at that point, you've got some protection from both the end zones that you're trying to aim to stay away from the highs and the lows, you can also navigate some targets that are even a little bit more conservative, if you're really worried. It may give some ability to have them have some time on their own, while you may go to work, or do the things that you need to do. And so you don't always have to be there for you know, things like bolusing, right? There's a whole host of other things to consider if you're looking at nursing home and those types of care situations, which are very difficult, difficult to navigate with any type of technology. But if you're the main caregiver for an aging or an elderly, you know, parent, or loved one, some of it can be a little bit easier with some of the newer technology that we have because you have visibility then to what's going on. Are

Scott Benner 4:49
you thinking islet? Are you thinking like Omnipod five what is your

Jennifer Smith, CDE 4:54
islet could be the easiest again, depending on what I mean this person is older Are the 95 years old, if clearly had I what I'm assuming is a long time with type one, depending on where they are in their ability to consider things appropriately like mental status, you know, if they're already knowledgeable about carbohydrates, then something like maybe Omnipod five, where they could truly just Bolus for their meal and go about it right might be easier than, you know, I start starts to kind of fail and drawing up a syringe or even dialing up a pen and having the dexterity to be able to push the end of the pen in appropriately. All those things are considerations as we age. So a pump may be easier in terms of button pushing, I would say that the eyelet for somebody who has a little bit less ability to count would be a really nice potential option.

Scott Benner 5:53
You might also think if you've known some older people, they don't eat a ton anymore, either. There's not a lot of food being taken in, you know, maybe that like small meal or snack button on the island would help or, or even, you know, there's part of me wants to say like, what about one of those patch pumps that you just squeeze it and give you two units? But I don't even know maybe two units is way too much? There? No it? Yeah.

Jennifer Smith, CDE 6:15
And or because it's squeezable, again, from a dexterity standpoint, not be able to do it might not be able to do it. Or maybe they can't acknowledge how many pushes they've given I, ya know what I mean? I mean, these are all the things to definitely explore.

Scott Benner 6:32
I interviewed in the cold wind series. So it was an anonymous person who was a nurse in a facility for older people. And if you end up in one of those situations, what's going to be is that they're going to come, they're going to give you a predetermined amount of insulin. And they'll check your blood sugar three hours later, and maybe they'll give you some more if it's high enough. And that's pretty much it. Yeah,

Jennifer Smith, CDE 6:55
you will be in most cases, not all, but in most cases of those living situations for the elderly. Typically, technology is not, is not allowed anymore. Yeah, I've had a couple of rare cases where the family members were close enough. And they would be the ones that came in and did the pump site change, or they were the ones that came in and did the sensor change or whatever. But even there is something happens at two o'clock in the morning. Nobody on staff knows what to do with the system kind of left until your family member can get there. Yeah, and there are a lot of rules and regulations and things that have to be put into place. So it is it's a I've told my boys don't bother me at all. They're way too young to even understand you know what that is. But

Scott Benner 7:51
while you it would be nice if one of you didn't get married, and just hung around with mommy, we'll flip a coin later and figure out who it's gonna

Jennifer Smith, CDE 8:00
be nice if one of you has a basement room that's furnish really lovely, and I promise I won't eat very,

Scott Benner 8:07
mommy's writing this five and a half a one c out till the end. Dammit. Right. Okay, well, I mean, it's, listen, it's a tough thing that hopefully we're all going to have to figure out how to deal with and I don't know that it's going to be an easy answer.

Jennifer Smith, CDE 8:21
Right. And I think you know, for this woman, obviously 95 years old, has lived a long, full, hopefully very wonderful life with what sounds like really wonderful family members who want the best to open. And my hope is that, you know, for the younger people with diabetes and technology use that technology just keeps getting better. And at the point that you may need some type of care, it'll be to the degree that there's not much that you really have to do to use it.

Scott Benner 8:52
So that'd be nice. Alright, let's move on to at what point is it justified for me to ask for you 200 insulin, my 11 year old daughter routinely uses over 100 units of you 100 Novolog every day. And she is already on two Metformin pills a day, the large dose of insulin hurts going in especially the long acting to SIBO. On days we go untethered, could switch into a different type of insulin have a difference as to the kids getting such a large Bolus under the skin to that even that isn't is unpleasant. Yeah. Okay. What

Jennifer Smith, CDE 9:28
do you think, in this 100%? Correct, they should be asking for you 200 insulin, also kind of questioning. They're great that the Metformin is in the picture already. I would actually recommend them ask their clinician, how much of an impact do you think this is actually having? Right? Because and that would take some comparison, which sometimes in kids is harder to do because they are growing and so insulin needs will naturally increase as kids To grow anyway. But from pre use to current use of metformin, has insulin really not shifted much? Maybe it's not doing much. And maybe there are other things that could be considered along with you 200 insulin, that'll take care of the volume at the site. Yeah.

Scott Benner 10:20
What else do you think would help? Well,

Jennifer Smith, CDE 10:22
again, things that are being considered in use things like GLP ones. Yeah. I mean, they're, they're, they're, you know, certainly not as tested in the youth. They're certainly something that I have heard and seen being used off label. It really takes an endo team to consider use for something like that. You know, the other consideration, and this is something that's also very near to what I navigate with people every day is evaluating food intake. Right? Yeah.

Scott Benner 10:59
Yeah. You don't know. Because it's not in the question. They didn't say, they didn't say she's using 100 units, and we're eating 300 carbs a day, this could be right. This could be 50 carbs, and and this problem, which would indicate that it might not matter how low carb you go correctly? Are there knowable, physiological reasons why this happens to some people? Or do you just have to say it happens to some people?

Jennifer Smith, CDE 11:25
I think it's easier to say that it just happens to some people, you know, when you're considering type one was never included, or I guess, resistance was never included, along with type one, until maybe 510 years ago, let's say, in general, where we really started to see the potential that someone with type one diagnosed type one, right, could potentially have resistance along with that, not necessarily relative to lifestyle factors or whatever. more prevalent from a woman perspective, especially once they get puberty and they get into, you know, their adulthood where things like PCOS might be in the picture, polycystic ovarian syndrome, right, that definitely impacts resistance, regardless of type one. You know, I think that there are people that are more resistant, there is a reason for it. I don't think that there is a nailed down conclusive, this person with type one is very likely to also have resistance to insulin, right. Thus, we should consider these types of inclusive, sort of, let's call it alternative medications or management, you know, therapies along with just the insulin. Yeah,

Scott Benner 12:44
well, so I mean, people have heard me say it enough, probably. But I will add that, you know, I just paid cash for a GLP bed for Arden today. So it helps her immensely. She was not up to 100 units a day. But truth be told, like in three days, she could use a whole pod. You know, she could use 200 units in three days. And, you know, I've said before that I expect Arden to use 16,000 fewer units of insulin this year because of GLP. A lot less Yeah,

Jennifer Smith, CDE 13:17
it is And didn't you? I can't remember the age of the child. But you didn't you interview a mother?

Scott Benner 13:23
She's 15 Yeah. I just heard from her again. They're moving her basil down again. So I told you she was at seven units and no boluses On we go v. And I'm going to scroll up to her extra me. So she says she was a little bit older. She's definitely 15 Yeah, she sent me another graph. It is I would say with the exception of three excursions that go to 151 40 and 150. She is stable around 85 or 90, and never gets under her low alarm, which looks like it's set at maybe 460 at now, if I'm guessing, because I can't see the I can't see where the alarm setup. Wait, here's the rest 95% range, standard deviation 15 Oh, excuse me. 100% and range range 65 to 180. Average glucose 95 standard deviation 15. Scott, I thought you might want to see this. We're going to be dropping Basal from seven, down to six, it might go as low as five that's from 70 total units of insulin a day before the week before the week OB so

Jennifer Smith, CDE 14:41
and other considerations to which this you know, this parent doesn't necessarily post but as thyroid be evaluated, and or has it been managed? Well, if there is already a known issue in the picture, all of that can influence insulin sensitivity as well.

Scott Benner 14:57
So I forgot to say that actually A Thank you. Yeah, yeah, TSH mat, if you have thyroid issue, make sure they're managing your TSH under like 2.1. If your TSH is you know above that and somebody's telling you don't worry, it's in range, we're looking at it, you have symptoms, that I think those symptoms need to be medicated and some of those symptoms could be could be what Jenny's talking about here, which is insulin not working correctly. Okay, you have something else on that. Are you good?

Jennifer Smith, CDE 15:27
I don't know the thyroid was the only thing that I really wanted to add

Scott Benner 15:32
to that. Yeah. Okay. All right. Here's one this is going to be this might take up the rest of the time. What do I tweak first? And what do I tweak last? In order of operation to smooth out these highs followed by lows? How do I look at my insulin timing first my Basal like my correction factor, I carb ratio, what do I look at first when I'm seeing eyes, followed by lows. 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 vo Capo pen can be administered in two simple steps even by yourself and certain situations. Show those around you where you storage evoke hypo pen and how to use it. They need to know how to use Tchibo Capo pen before an emergency situation happens. Learn more about YG 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 GE voc glucagon.com/risk For safety information.

Jennifer Smith, CDE 17:12
What do we always start with? We always start first with basil. Basil in the right place. And if you're again, we don't know anything about these the system being used here, right? If it's a manual pumping system or MDI, look at the base Basal which you have adjustment, you know, to? If not, then look at where there is stability in a Basal only time period with an algorithm? And is it holding things in a pretty stable place? Maybe it's holding it a little higher than you want, but at least it's pretty stable. The expectation then is the Basal probably not the piece that's the most off. So then you could absolutely go to the factors that you can adjust which are insulin to carb correction factor, maybe active insulin time. Yeah. You know all of those things. But when you're seeing graphs, I think it's also important to make note of where did the Bolus go in? When did the food start to be taken in? What was the content of the meal? Right? Do you need a longer Pre-Bolus? Do you need a shorter? Do you need none? Do you need an extended Bolus? So there are steps to it, which is what they're asking. But if you're using the right carb count as precise as possible, I don't think everything is 100%. But as much as possible, you're doing your Pre-Bolus Strategy, you're getting high and you get stuck high and you have to correct that it's very likely that it's an insulin to carb ratio problem. You started in a great place it went up never came back down, which is the goal of the right amount of insulin for food is to get it down if that's not happening. The insulin to carb. Yeah, if you're starting at a normal place it goes up higher than you want comes down. But you get to target it's not the Bolus then it's the timing right yeah. And then from a correction factor which I always feel like it's sort of like it's like the stepchild in the corners forgot

Scott Benner 19:16
about their correction factor that

Jennifer Smith, CDE 19:18
a lot of a lot of people don't and I think actually they don't mainly because it's also less adjusted by most clinicians it's the factor that's not often shifted enough unless there's a very visible Oh yes, you corrected and it never brought your blood sugar down. Great. Let's shift this but a good visual love you test it you you find out oh, my insulin to CARB is great. It was the it's timing. Okay, well what happens if you start that meal with a higher blood sugar? You take the right amount of insulin, you time it and your blood sugar does come down but it never lands you at Target. Okay, you knew your insulin to carb was right because when you started with a target blood sugar and you Bolus right He brought you to target. This time you're starting high, and it never gets you down. That's your correction factor.

Scott Benner 20:07
Nice. Okay. That's a nice way to think I said nice because it's a clearer way to describe it. Yeah. Yeah. I mean, when I see this question, my first thought if the person was in front of me, I would probably first say, is this been like this forever? Or was this not happening, and now suddenly, it is happening. If suddenly it is happening, then I'm thinking your insulin needs have obviously changed. And I'm always with Jenny basil. First, make sure your basil is keeping you at the level you want. Also, that's a lot to consider too, because your comfort for Where does your blood sugar sit stable, and somebody else's might be different. If you know Arden's blood sugar is held stable at 90 overnight, then when we go to Bolus for something, she's got that consideration of basil happening constantly. But if you're a person who's like, oh, I want my blood sugar to be at 130 overnight, then the truth is, is you're deficient in basil, not a ton, obviously, because you found stability, but it's still not as much as your body really needs, or your or your blood sugar would be lower. And now you have to, so that's okay, if you want to do that overnight, like good on you, like whatever you want to do is fine with me. But then you have to consider that when you're looking at correction factor insulin to carb ratio, all the other implications because you're already late on Basal Correct, yeah, yes. So

Jennifer Smith, CDE 21:26
if you are thinking that way, it's actually great that you brought it up, because if you're thinking, I feel safe and healthy at 130, floating in overnight, coming into breakfast, and then you're frustrated, because during the day, your Bolus is aren't pulling you down to 100. Basil this week, it's likely that your basil is the deficit there, right.

Scott Benner 21:49
The way I've always said it, you'll hear me say it and like the Pro Tip series is that if your Basal supposed to be one unit an hour and you're using point seven, then every hour of the day, you're deficient point three. So after one hour, you're down point nine, you know, or after three hours down point nine and for six hours you down two units almost. And then you go along and you Bolus for something that your carb ratio says it only needs three units. Well, that's great, except in the last six hours, you're you're deficient two units of basil, you make a three unit Bolus for the meal. You're all you've done is replace the basil. And there you go, you're the blood sugar is off to the races. So I mean, Basil first, because I think nothing works. Well. If your basil is wrong, then I try another meal. If and then just like Jenny said, does it shoot up and then come back down? Maybe your Pre-Bolus was too short, you know, does it go up and stay up? Maybe it's not enough insulin, you know, does it take a while and then go up? Maybe there's no fat or protein in your meal? It's pushing you up? You're not considering there's a you know, keep messing with it. You'll figure it out? Well,

Jennifer Smith, CDE 22:53
and I think in this train of thought when you are trying to figure it out, I think it's beneficial to actually truly try to cover a meal that's not necessarily void of fats and proteins, but not terribly heavy in it either. Because if you're really trying to get a handle on, is it the insulin to carb ratio, then really what does our rapid insulin What's it formed to cover?

Scott Benner 23:18
How many times have you thought it's time to change my CGM? I just changed it. And then you look and realize I got it's been 14 days already a week, week and a half. Feels like I just did this. Well, you'll never feel like that with the Eversense CGM. Because ever since is the only long term CGM with six months of real time glucose readings giving you more convenience confidence and flexibility. So if you're one of those people who has that thought that I just did this, didn't I? Why well I don't have to do this again right now. If you don't like that feeling, give ever sent to try because we've ever since you'll replace the sensor just once every six months via a simple in office visit ever since cgm.com/juice box to learn more and get started today. Would you like to take a break? Take a shower you can with ever since without wasting a sensor. don't want anybody to know for your big day. Take it off. No one has to know have your sensor has been failing before 10 or 14 days. That won't happen with ever since. Have you ever had a sensor get torn off while you're pulling off your shirt? That won't happen with ever since. So no sensor to get knocked off. It's as discreet as you want it to be. It's incredibly accurate. And you only have to change it once every six months ever since cgm.com/juice box. Right now we're going to 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 24:53
I use injections for about six months and then my endocrinologist at nav recommended a pump

Scott Benner 24:59
Hello Have 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 25:09
I was medically discharged. Yeah, six months after my diagnosis. Was

Scott Benner 25:13
it your goal to stay in the Navy for your whole life? Your career was?

David 25:17
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

Scott Benner 25:29
loved the most, was the Navy, like a lifetime goal of yours?

David 25:34
lifetime goal. I mean, as my earliest childhood memories, were flying, being a fighter pilot,

Scott Benner 25:39
how did your diagnosis impact your lifelong dream?

David 25:42
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 away but then help keep abreast on you know, the new things that are coming down the pipe and to give you hope for eventually, that we can find a cure.

Scott Benner 26:08
Test it with a meal you've been good at in the past. Yeah, it's very countable links so that you're not guessing at the carbs. And then you'll get a good idea of whether or not your ratio is decent or not. And then you can start adding considerations for you know, higher fats and stuff like that down the road. Right. All right. Well, this next one will just kind of like piggyback right on to this, how do I extend a Bolus? Like a Pro? That was the question? Oh,

Jennifer Smith, CDE 26:35
like a pro,

Scott Benner 26:36
just live with diabetes for a long time and keep trying to extend Bolus this

Jennifer Smith, CDE 26:41
is gonna say lots of experimentation.

Scott Benner 26:44
I mean, I'll start by saying that I used to use a lot of extended Bolus is when Arvind was in school. And I would use them in creative places. The first way I use them that I don't think people would think to use is as a way to Pre-Bolus a meal at school. So Arden would we Bolus in her classroom, she and I together. But you know, you wanted a 10 or 15 minute Pre-Bolus. But at the same time, you're pumping insulin into this kid sitting in the classroom, she's not going to the nurse, she's gonna is she gonna go right to the cafeteria, she's gonna mess around is there going to be a line like, I don't know what's going on. So I wanted some insulin on my side. But I didn't have the nerve to just put it all in. Because what if you know all the what ifs. So what I would do is I Pre-Bolus the time, but I would do something like now, remember, Arden uses Omni pod. So this is kind of like language from their thing. But you can apply it to your own, I would do something like that I'd put in all the carbs or 70 carbs in this meal. And it would say, you know, however much it was gonna give her and I'd say Okay, put 30% of it in now, and the rest of it over a half an hour. So let's say it was a 10 unit Bolus, it wouldn't have been, but let's just say it was three units goes in, that's my Pre-Bolus. This last seven units is getting squeezed in real fast over the next 30 minutes, you get the initial pull from the first three units. And then as you get there, and you sit down, you start eating the rest of that seven units is in there starting to fire up. And that's one way I would use one, you can apply that to anything, just have to reverse engineering, you just have to say, I'm gonna have, you know, a high fat meal. And I know that my blood sugar is going to try to go up 45 minutes after I start eating. So how do I line up these extended pieces of this Bolus to combat the impact of the carbs? And that's to me, that's the whole thing. Like it's just, it's basically an extended Bolus is Pre-Bolus thing, a bunch of different variables through a meal. If that makes sense. That is how I think about it. But you might say it differently. Jenny, you're frozen? I thought you disagreed with me. That's hilarious. Hold on a second. All right. She'll be back in a second. She made such a face. Like as she froze. There wasn't like a real face. It just froze in a weird spot. Keep in mind, Jenny is from a Nordic state. Anything could have happened here. massive snowstorm out of nowhere. She could have been eaten by a Yeti. She's pretty close to Canada. She said, okay, all the power my house just shut off. She just texted me. Hold on. I'm gonna pause. Okay, hey, Tony, what's up? Not much. How are you? Good. So I just listened back to the last couple of minutes of this conversation. We're going to leave the part in that indicates that you lost power at your house. So first of all, let's take a second before we go back to where we were to talk about Will you will you share with people what you said afterwards, like when your power went out?

Jennifer Smith, CDE 29:47
What I share Yeah, embarrassing. My embarrassing

Scott Benner 29:51
information. Yeah, so the embarrassing thing that happened but the other thing too, were like, so Alright, so Jenny's power goes out, and she's texting with me. Oh, yeah, and I'm gonna tell you from my perspective, I thought gosh, I hope I'm not miss reading this but she seems scared I'm gonna offer to call her. But you're Listen, you're an adult, you have children a home, a husband, get car, you know, a job, people know you as thoughtful and like level headed, but tell people your fear.

Jennifer Smith, CDE 30:24
I fear is that, you know, like, all the scary people hiding, like, potentially in the dark room that you like, and I think I texted you when you texted you know, are you okay? You seem kind of scared. I was like, so yeah, I was the teenage kid who sat in the kitchen with my friend's parents talking to them, rather than watching the Friday the 13th movie that all my friends were watching, because I was too scared to watch it. So and I've still never seen any of those movies. So I have would have had to have my power goes out, right? Like, okay, check the power box, is it just mine, right. But in the meantime, I like have to go into the dark, dark room in my basement in order to see. And it's not like around the corner in the dark room. It's like across the room in the dark room against the firewall where the spiders live. And all those things, right? So it means I have to open the box, and maybe somebody's hiding it. I know that this is all gonna think oh my god, Jenny is a crazy person. I really not a crazy person. I'm old enough to not have this be the case in my brain anymore.

Scott Benner 31:34
So I call her because I'm like, I really think she's scared. And I'm like, we know each other really? Well. I got Oh, wait you to be scared. You know, it's like so we're on the phone. And then I immediately like I slip into who I am. So I'm like Jane, listen, go head over to the fuse box. I'll stay on the phone with you. And when this guy attacks, you do your best to describe him so I can tell the cops later. She's like, Oh, great. Thanks.

Jennifer Smith, CDE 31:58
And I did I was brave enough. Yeah, I take the flash went into the room. I'm like, yep, none of the fuses are blown. It's all good. And then I texted our neighbor. And it was like a power outage or a car had hit a pole or whatever. And it was out for a good number of hours. But yes, God saved me in my I have to go into the dark room.

Scott Benner 32:16
I did feel that no. Okay, so now we'll, I'll tell you what, we'll pick up where we left off. And at the end of this, we'll tell the people about the embarrassing thing that happened to you after that.

Jennifer Smith, CDE 32:27
Are you sure? Really because that's kind of embarrassed? No, I

Scott Benner 32:30
know, but we don't want to pile on right now. So we're just gonna say this. I don't know where we left off. We were talking about extended Bolus isn't like how to extend a Bolus, like a pro. So yes, like, I gotta be honest with you. Like, I don't know what we talked about. So if you all feel like we didn't do a good job of that, send me a note. And we'll do extended bonuses again, sometimes, but it's gonna be too disjointed to go back and try to figure out where we are and come in.

Jennifer Smith, CDE 32:53
And I think that we had, I mean, we did something about how to do extended why I think we're talking about scenarios as to why you do an extended Bolus. And even some of our algorithms today that don't even allow an extended Bolus and unless you choose to go back into manual mode to utilize that for what you know what you need to write.

Scott Benner 33:12
Okay, so let's just go on to the next question, which is, what to do if you really don't like to count carbs, and you just want to eyeball it, but your guesses are always right. Laugh out loud. I'm just trying to think of things because honestly, you have answered so many of my questions that I've elicited. Okay, so she wants to know, how do you eyeball carbs? I guess is the is the overarching question. Yeah, you really count. Like do you look on boxes and weigh things

Jennifer Smith, CDE 33:39
I would say a lot more of mine is eyeballing. And also, if there is a packaged item, I don't buy packaged items that I haven't purchased before we're really in what we bring into our house, we're careful about a lot of ingredient stuff. So I tend to buy the same things over and over because I know that they work and because I've done that I already know like how many crackers is this particular brand, so I don't really look at it anymore. I just know it from previous use. But other things you know, like fruits and vegetables and stuff that don't come with a label on them. Those become more of an eyeball and there are some things that I use a food scale for to use carb factors and get a more precise count things that I don't eat all the time and that my guesstimate I'd rather have a little more precision like a sweet potato in winter or something like that. But a lot more of my I would say a lot more of my meals are they're intelligent estimates because it's I've been doing it long enough that it works yeah.

Scott Benner 34:44
Or you can just look at a plate and go this is usually about when I have meatloaf it's usually about 50 carbs because I have potatoes with it and there's carrots here some gravy

Jennifer Smith, CDE 34:52
and or that I've made the recipe before and the recipe had nutrition information. And I can all again it's like a mess. Emory component,

Scott Benner 35:01
I should say that I don't mean that the the, I'm guessing, like, oh my gosh, there's definitely 50 carbs here. I think of it more as like, well, there's the insulin that 50 carbs and the pump will give me his worth of impact from food here. I know that sounds weird, right? Like, I don't actually guess the carbs so much. Although I do count sometimes. But it's more like, like if like, you know, if you had hunks of chicken in there were breading on it. And french fries as an example, I would basically just count the french fries and go, you know, 246-810-1215 1820, and then 510 1520, like here for the nuggets. And then I look and go is their sauce, their sauce five more, you know, is this greasy? Maybe another 10%? Here we go. Like, you know, that might be how I would do it.

Jennifer Smith, CDE 35:46
And that's kind of along the lines of when we do more like advanced estimate counting kind of information for people. They're easy tools, like a woman's fist is about the size of a one cup portion. So again, you're not going to carry measuring cups in your purse, but you do have your hand attached to your body. Yeah,

Scott Benner 36:06
I right hand, I was just wondering how big my fist is, like,

Jennifer Smith, CDE 36:09
it's a woman's fist, not a man's fist. A woman's fist is about a cup. So if you know how much from measuring things like pasta, or rice or other carbs worth a cup portion, and you're out in a restaurant, you can say, well, it looks like they're three of my fists of pasta on this plate, you can estimate that a little bit more precisely based on known factors you've had before. Right? I'm

Scott Benner 36:33
gonna ask a question to kind of piggyback onto this one. Now, I want to say before I start, there are times when I ask questions, because I know the answer to them. And I want to have the conversation. This one I don't know the answer to and I may be pulling this out of my butt. And I might not be right. I'm starting to wonder if with all these automated systems, if getting your meal Bolus, exactly right is going to be it's going to sound crazy, but as important moving forward as it is now. Because if I'm having 50 carbs, and I guess 45, and I start heading up, the algorithms gonna start pushing insulin pretty quickly, right?

Jennifer Smith, CDE 37:07
Correct. Depending on the algorithm, some are more aggressive than others, some will turn that around faster, and you won't have to adjust with extra insulin, some are a little slower, and you just have to wait for enough give to get in the picture to make a difference there. But in the case of looking at that data, then somebody who doesn't really just want to rely on the system catching the five gram difference, or the off count or whatever. Some people are great with that, and others are gonna say, Okay, I'm gonna look at my data, I'm gonna say, well, it looks like the system is always giving a lot after my breakfast meal, I probably need to either count more with precision, or maybe my ratio isn't quite right. So I think there are two ways to think about if people want a little more precision in their dose settings. And then other people were, if the system is going to help them, and they're okay with this part, this type of a Rise Fall, they just let it happen. And then, you know, until the system isn't containing it the way that they were used to, and a setting then may need to be shifted for them because something has changed.

Scott Benner 38:16
If you count the carbs get it right, and then it doesn't work, then your settings might be off. Correct, right, or you're getting some impact from food that you're not giving its full weight to.

Jennifer Smith, CDE 38:28
And I think with and on the same like line of thought I think with depending on the do it yourself systems, right, that are now in heavy use. They are leaning to the adaptation of settings in a way that's much more aggressive than the other adaptive systems that are on the approved list here. Right? So settings are going to adapt based on total daily insulin, or a set of data that says it looks like you're trending to needing a little more coverage, it looks like you're trending to needing a little bit less. And some people have found that they don't even Bolus with some of these systems. Yeah, right. They don't even announce anything. And depending on the system they're using, the system may use this particular piece of the algorithm versus this beta based on the rate of change, and the other settings that they have told it to work with,

Scott Benner 39:25
right? So like if on the pod five, for example, sees like a bigger use of insulin over two days. Then on that third day, it may just start being more aggressive because it expects that's what you need. Also, Arden who's wearing IPS which I think she's going to switch from soon to another branch of it. But that one has dynamic, everything. It's dynamic, Basal dynamic, insulin sensitivity, dynamic card ratio, I have it all turned on and it works pretty well. Okay, and you know what, let me just tack on to the end of this. The other idea about Being on the algorithm is an algorithm is let's say your basil is a unit an hour. If you miss your Bolus a unit heavy, there's a world where the algorithm can still make up for that by just keeping the basil off longer after the Bolus co said, like almost like five units were further food. And oops, I put in six units. I'll just keep the basil off an hour longer and make up the difference there. Basically, I Pre-Bolus the next hours worth of basil with the over Bolus of the food, the mistaken overhauls to the food, there's a lot of different ways to think about timing. Once the algorithms involved, it's giving and it's taking away. Right.

Jennifer Smith, CDE 40:39
And I think that's the it's the more automated use of eons ago, the the term coined by John Walsh was the super Bolus option, right, where you give a lot more upfront, and then you would manually set a temporary Basal decrease or suspend assuming the upfront coverage was to stop a quick rise on the back end, you took away what you added in the front. But now our automated systems can absolutely do without you even exactly

Scott Benner 41:07
what it's doing. Yeah. Okay, this one's not going to be easy. So we'll just jump right into it. Because there's a lot of has a lot of just opinion here, but how would you go about putting a pump on your daughter when she's seven years old, and she's dead set against wearing a pump. I know what the right approach is, she's eight months into new diagnosis. I co parent, our daughter is split 5050. Between me and my ex, he told her, it will be up to her when she wants to wear one. And she's sticking to that. And as you can imagine, that's messed up my plan pretty good. So this is interesting, because I just had a conversation on the podcast the other day, I interviewed a physician whose child has type one. And she shared with me. She said, I agree with you, Scott, I've heard you say this on the podcast before I don't let kids make medical decisions. And I'm like, okay, and she goes on, I get the other part of the conversation too, with autonomy and body positivity and like those other concerns. And she's like, but from my perspective, after she wore it for a little while she was okay. And the getting over the hump is what she thought was the problem. And I was like, it's interesting, because I feel both sides of that. I do too. Yeah, you know what I mean? Like, I wouldn't want to make anybody do what they don't want to do. But you also me how many stories you hear about like kids like, no, no, no, no, no. And five days later, like, this is fantastic. I haven't used the needle in five days. So, you know, I don't know, what do you think about that?

Jennifer Smith, CDE 42:41
I do very much agree with the doctor you talk to, in general, the adult brain isn't really completely adult until like to age 25. So we talk about kids, they're really, they're under informed in a way that they're that it's also because they're not at the level of understanding the depth that an adult truly has in understanding benefits here reach bar. Yeah, kids also, you know, have kids with diabetes who have caregivers who are navigating it with and for them pretty much they can't understand or grasp the gravity of what their parents are doing for them. Right. And some of the navigation as that sounds like this parent is kind of emphasizing is they need some life back to they need some assistance with dosing that can be a lot more precise, and potentially offsetting feeding insulin because it doesn't have to be there in such imprecise doses. Right. And so I also agree in the fact that many times kids adapt pretty quickly. They may really dislike it to begin with, maybe it's a week worth of complaining and annoying. But as you said, less injections, man, for the most part goes over pretty darn well. Yeah,

Scott Benner 44:10
I think there's going to be outliers, obviously. And there's yes, there's a spectrum here of of how the response is going to be for sure. Now, if my kid was having a complete meltdown, and you know, like, running into walls and screaming, I'd be like, okay, hold on, like, let's wait, but, but just the kid who's like, I don't want to do that. Well, of course, they don't. I mean, any you put on a pump every day, if I gave you the choice, would you want to do that? Like, you know what I mean? Like nobody wants to do that. Like, it's hard because you get this diagnosis. And, you know, we're very much fans and telling people like you're going to live a perfectly normal life. I think that's true. It's not gonna stop you from doing anything. I think that can be true. But, you know, most people don't walk around with a couple of things stuck to their arm or their hip or their belly or something like that. Right? There's an adjustment to be made there and a Um, acceptance that has to come. Right? You know what I mean? So I'm not, I wouldn't be a fan of just looking at a kid one day and being like blurting out, like, Hey, we're getting the CGM for you, you're doing it, I don't care what you think. Yeah, I think you gotta like, you gotta parent your way through it and support them. And like, there's got to be love there and compassion. And we're gonna do this together, and I know you're wearing it, but I'm gonna be here. And, you know, I wouldn't be I'm not a fan of just like, do it. But I'm also not a fan of letting an eight year old make a decision about their

Jennifer Smith, CDE 45:33
health. Yeah. And I also think that there is a way of discussing that piece that you want to bring in, in a way that makes sense at their level, at their age level, at their education level, you find the things that are really important to them that maybe they've had an issue with, because they always have to check in, because they have to take an injection, or they, you know, are taking more time out of class, and having to always go to the nurse versus push a couple of buttons and text, right. So there are some things on their level that you, you could explain to the extent that you've complained about this, if we did this, it could take this down a notch, it could improve this, we wouldn't have to get up at two o'clock in the morning and do an injection. If that was something that was in the pit, you know what I mean, you also

Scott Benner 46:28
have to be ready for when they're, I mean, there's downsides of everything. So when a downside of a pump comes up, you have to be ready to deal with that to not just act like it's surprising you like one day, it's gonna get ripped off, like your site will get ripped out, or it's an omni pod, or they'll get popped off or your Dexcom is gonna hit a door jamb or something like that. You don't want to be ill prepared for when something like that does happen, because otherwise the kids going to be like, See, now this is a hassle. And you're going to be left by going like that. I think you have to tell them upfront, like it's not going to be perfect, but Right. We'll try to measure our wins here and see if they're not greater than the ones we're having right now. Right? And then you know, half joking. Money always helps to you can just

Unknown Speaker 47:09
grease the skids crazy. bribery. Yeah.

Scott Benner 47:12
How would you like a Lego at a pump?

Jennifer Smith, CDE 47:16
Really big $600 Star Trek or whatever, right?

Scott Benner 47:19
Do you think a new baseball glove and a CGM would go over. I mean, I very famously, and one of my episodes, older kid wasn't Pre-Bolus in his meals. And he was almost out of high school if I'm remembering the conversation correctly. And he wanted to start a business of chopping trees when he got out of high school and needed a chainsaw. And I said, the mom was like, you know, I'm going to end up having to buy the chainsaw initially, because the kid doesn't have any money. And I do want to help them. He's got a truck gonna get off on this thing. I said, Why don't you sell Pre-Bolus for $1? Like in a jar, and tell him look for the first 600 Pre-Bolus says, I'll pay you $1 For each one of them get to 600 I'm done paying, you can buy your chainsaw. And I don't know if they ever did it or not. But I felt like a genius that day. That's a great idea. Right? Like, everybody gets something you got something to work towards you feel like you're doing something for yourself. Yeah, the moms being supportive, because they were just stuck in a battle. The kid wasn't gonna do it. And, you know, I mean, I'm not saying you should bribe people. But I think what I'm saying is, is you can like wave shiny things in front of kids and make them forget what they care about sometimes. And maybe this is one of those situations if it is now if you have again, some over and above problem. sensory issues. Like you know, I'm not I'm not certainly saying just be like, screw you take the pump. You

Jennifer Smith, CDE 48:40
know what I also in this situation, it is a hard one because it seems like parental they're not really on the same page. It's almost like a give from one parent. I think it was the dad who was like, Yeah, whenever you are ready, whatever kind of again, the you make the decisions child right? Where the mom's like, you know what, this is going to be better most of the time, it's going to help much more of the time. It's going to make things easier, more of the time. And it's hard because they're completely on opposite.

Scott Benner 49:15
Yeah. Listen, I'm over 50 So I'm going to sound old, but in the entire time I was growing up no one ever wants to ask me what I wanted ever in my whole life. Oh, yes. Didn't ask me what I wanted for dinner. They didn't ask me. I would buy like you got shoes that somebody was like hear these? You didn't get to go. Oh, no, thank you. I prefer they Oh, no. Here's your shit.

Jennifer Smith, CDE 49:37
Absolutely. That's so funny because I thought of that the other day when I was making dinner, and we were talking about it. My older son and I and then I thought about it. I was like When did my parents ever asked me like never know ever. It was just presented. This is what you get to eat tonight.

Scott Benner 49:58
I've had 25 minute Converse. patients sitting in our car outside of our house trying to decide what restaurant to drive to with for people where I didn't think we were gonna come to an agreement, I thought we're gonna have to go back inside. If I was lucky enough to go to a restaurant as a child, I certainly didn't get a say into which one it was.

Jennifer Smith, CDE 50:14
No, we were taken wherever we were going to be taken. And then that was it.

Scott Benner 50:19
Also, while I sat at that restaurant, my father smokes cigarettes at the table. So like, the world's gonna come a long way. But I don't know, listen, this is a tough one, like being a parent. You know? I mean, I think my answer is compassionately act like an adult and bring them into the conversation as much as humanly possible. But get them to where you think, you know,

Jennifer Smith, CDE 50:41
and also expose them, right? It's a concept that's very odd to think about. It's, it's not something that they've maybe touched or felt they might have heard adult level talking about it. They might have heard about it in their endocrine visit. But nobody's let them touch it, see it interact with it. You know, from a mom standpoint, check with check with the pediatric that you that you work with? Do they have a pump exploration day? Would you go there? Because you're also then going to probably see other kids who already have a pump? Yep. And that visibility makes it a lot easier for a child to be like, Oh, I guess I'm not the only one considering this.

Scott Benner 51:25
I can't tell you how many can you show me your pump? posts go up on Facebook that can somebody please show my daughter like this? Or that? Like I've actually I've contacted Arvind recently, and I was like, Can I put a picture of you up with your pump on like this little kid, you know, and then I got a nice note back like, oh my god, like, you know, thank you. She's, she thought Arden was pretty and now she'll do it. Like, you know what I mean? Just like that. Yeah, that's simple, you know, make a difference. Yeah, absolutely. Does. What is new in insulin choices? And how do they work with pumps? Um, there's nothing new that's on now is there like is loom jab and fiasco are the newest and there are a few years old with

Jennifer Smith, CDE 52:01
pretty much the newest and they're just considered more, I guess, ultra rapid acting right. And most people see a difference that use them. Not everybody does. And some people see wider variability. But yeah, I mean, in terms of insulin, they're the more rapid acting I would say the next would probably be the inhalable insulin.

Scott Benner 52:26
A Frezza. Okay, yeah. That's pumped, though. But yeah, that's new, right? That's new. You just said something I'm gonna like, because there's not much to say here like the insulin is what it is right now. There's nothing new they work in there. As far as working in pumps. There's one right a pizza doesn't work in a

Jennifer Smith, CDE 52:44
pizza you cannot use in the tandem, tandem one right tandem.

Scott Benner 52:48
And they'll tell you, you can't use it an omni pod. But Arden's been using an omni pod for like eight years. So. But that aside, you just said something really interesting. Like, don't don't let me lose my thought here. We see people some have luck with it, some don't. At what point do we wonder? Is it the insulin? Or the people's knowledge of how to use the insulin? Like why do we so easily say, oh, that works? For some people, it doesn't work for other people. And we say your diabetes may vary and all that stuff. But what if what's really happening is like you're using it wrong, or your settings are way off. And then you tell me a Novolog doesn't work? Well, if your Basal should have been a unit an hour, and it's a half unit of hour, I could see where you would say but because you see that all the time with like, human algorithm pumps, like, right, this thing doesn't work. And then you look at their settings, and they're so whacked, it would have no chance to work. We never really talked about that. I think out of kindness, really. But you know, all those stories you hear in the space about this thing's better than that thing like says you. And how do I know you use that correctly? Here? Is that a thing you think about while you're helping people?

Jennifer Smith, CDE 53:55
That is interesting. And I think in terms of looking at somebody who is trying one of the newest, more rapid acting, whether it's be asked for loom Jahve, who has been appropriately using the just regular rapid acting insulins, whether it's a pee draw, or Nova log or human law or Novo rapid or whatever, right? They've been appropriately using it, but like they're at the point where that Pre-Bolus is becoming for whatever lifestyle reasons, it's hard for them to maintain that. And I think on many levels, whether it's a kid level, a team level, or even a really busy, you know, adult level in a job that doesn't really give them a long time for a break or whatever, right? And so if they're already trying their best, one scenario that it is working to their advantage is that now that they're using it, we can see the difference in their post meal, blood sugar, even some people who may not have much ability from a previous standpoint, if the medication is going to work for them, we're definitely going to see that that again, that post meal or post food intake is much better contained than it was using the other. Yeah, insulin,

Scott Benner 55:13
I come to that question a lot, because I see people online, and they're at wit's end, and I need a cure this look, this happens to me every day. And I think I think if I was there, I could fix this. Like you don't I mean, like, I know, I can't do it remotely, because you're too far spun off center, and you've got too many preconceived notions about what you think is happening. But I really think there's an answer here that I recognize that person might not be able to get to. But I do think sometimes, like, I think if I was there, I could figure this out. And I might be wrong on some of them. But like, I think in a great number of them, it just is I hate to say, I don't mean user error, but it's the quickest way to make the point, you know, so

Jennifer Smith, CDE 55:55
right. I can give my n of one with fiasco specifically. And honestly, with loom job, yes. worked beautifully for me for about five months. Yeah. And then all of a sudden, I was changing settings to the degree that I had never seen that type of insulin, what I was assuming was resistance. And knowing a little bit, it was pretty soon after fiasco came to market where there was some information essentially, about, it seems to work for some people. For some people, it has a little bit of a waning effect, et cetera. And I was one of those. Yeah, I went back to my long term, used human log, and had to dial everything back back. Why do I insulin right away, it was within 24 hours, I was low and having to dial things back down. loom Jeff just didn't. It was variable like variability. I had never, I'd never seen variability like that before. It was almost like it didn't have the upfront quickness for me. But as soon as it got going, it trashed my blood sugar.

Scott Benner 57:01
Okay, it was bizarre a long time to get going. Then it was like turbo after that.

Jennifer Smith, CDE 57:05
And then it was really, really, really fast for me. So I just stick with my human login, select what works.

Scott Benner 57:13
Alright, let's stick with insulin for one more question. Yeah. How do you handle I'm just going to ask you, I'm not going to I'm not going to read the question. How do you handle refrigeration of insulin? So obviously, you keep it refrigerated when you're not using it. But once you open it, do you keep the open vial refrigerated? Yes. Okay. I do too. Do you have to?

Jennifer Smith, CDE 57:36
Technically no, you have, again, based on what the package insert that nobody reads says 28 to 30 days and then a vial at room temperature should be thrown away. That's what they say. Right. Now, I have long term because that's what I learned to do. Long term, insulin was just kept in the fridge, you took it out when you needed to use it, you put it back in the refrigerator. I travelled for years and years with a ice pack specific bag for my insulin to go in and go places and whatever. And to this day, I still use some type of like insulated pack. The only time I haven't is when we hiked the Inca Trail. And there was no ice ash, there's nothing you could do. There's nothing I could do so but I use the frill. And that worked well because I could get water and at least it kept it cool enough room temperature is what they say. Right? But in general at home or in you know, I keep it in the refrigerator or take it out fill my filled syringe, put that on the counter to get to room temperature and my vials back in the fridge.

Scott Benner 58:41
Have you seen people sharing that article that says that insulin lasts longer than 28 days on refrigerated?

Jennifer Smith, CDE 58:46
I haven't read that article, but I didn't know people are sharing. Oh, yeah.

Scott Benner 58:50
So you but you've seen it as well. Right? Yeah. It wasn't an actual study, wasn't it? I believe it was yes. So I'll just say this. Like, we keep our insulin refrigerated. If we didn't, our house is pretty consistently around 70 degrees, like winter summer, like it's about around where we keep it right. So if we left it out, it wouldn't see any harsh conditions. And there have been stretches of Arden's time where we've done that to like just been like, Oh, it doesn't need to go back in there. And it sits out. I use insulin until it's gone. I don't track how many days it's been open if I'm being honest. So and there's no way you use a vial in 28 days. Right? Right. Yeah. Okay. So you keep using it.

Jennifer Smith, CDE 59:34
How often do you change your Landsat? That's the same question.

Scott Benner 59:38
Like so if you want to follow the rules, God bless you, you should follow the rules. And if you want to try some other stuff, I mean, I think it's up to you you have autonomy, you should you should do some experimenting and see what's my other question around insulin I was gonna

Jennifer Smith, CDE 59:54
say and I think that the reason that I also feel confident in going I'm going beyond that 28 days. And really, I also I mean, I suck all of that insulin. Like down to the last little nibble, right? But I feel confident doing it that way, because I have kept it refrigerated. Okay. If I travel in this is just my strategy when I travel and it has been in like a Freo or something like that when I get home, and thankfully I have I have access to enough insulin that you can do it. Yeah, I just get rid of that vial and I started a new one.

Scott Benner 1:00:31
That's the same for us. We have access to insulin, and I would do the exact same thing. We've gone on like Island vacations where eventually like, a weekend or you're like I couldn't get this thing into ice anymore. And but it keeps working fine while you're there. And then you get home and you're like grommet open and no one yes. Yeah, I mean, okay, what about hot tubs? You get into a hot tub with your pot on? I do. And it's okay afterwards. These are all the things people worry about.

Jennifer Smith, CDE 1:00:57
There all the things people worry about. And when people ask, you know, my best is, what is your blood sugar look like hours after? Is it doing what you expect it to do? You know? And if it is, then that didn't have an impact. If you're rising, or if you Bolus for a meal, and you're not getting the response that you typically should expect? Then change it out. Right? Yeah, it's it's less of a, what should I do? Should I you know, whatever. I mean, hot tubs are hot. You're not going to technically be boiling your insulin, right, but exposed to extreme temperature like that. And if you're completely submerged for a really long time in a hot tub. Sure, it could start to impact. Yeah, absolutely.

Scott Benner 1:01:45
But if you were in there, I mean, Arlen gets in a hot tub. Sometimes she's in there for half hour an hour. I don't think anything of

Jennifer Smith, CDE 1:01:51
it. Like I don't even think I've ever sat in a hot tub for an entire like an hour like I Yes.

Scott Benner 1:01:56
Because you're not a young person. Yeah, kids, you got other things to do. Right? I guess I'm not. Because after 15 minutes, you like, this was nice. I have things I gotta do. My feet up, what is that? Also, you know that a summer, it can be 90 degrees outside, and you can be outside for hours and hours of your pump on or you're not pod on. And the insolence still 98 degrees and you leave it on for days. So Right. All right. Okay.

Jennifer Smith, CDE 1:02:25
I mean, I have I have a lot of questions that come that way, too. You know, we've been, we're going on a beach vacation, or we're going here and it's gonna be really hot and really humid. We're going to be outside. Okay, I can't tell you exactly what's going to happen. Could your insulin start to deteriorate? It could? Sure. Is it going to happen every time? No. What do you do you watch your blood sugars and the response that you would typically expect? And if it looks odd, just change it out?

Scott Benner 1:02:52
Yeah. Yeah. And by the way, are you one day going to get, I don't know dehydrated, your insulin is not going to be as effective. And then you're gonna think Oh, my God, the insolence bed. And like, you know, like, it's gonna happen to you like along the way, the best thing I can say to people is that a lot of the things you're worried about, much like in the rest of life, eventually you won't be worried about them anymore. But you have to go through them enough times to see it happen so that you can kind of leave the fear behind and go, this is just how this works. It's fine. If I leave it out, or I don't leave it out. Now listen, if I didn't air conditioning my house in the summer, and it was always 90 degrees in here. I wouldn't leave insulin out of the refrigerator. I just go back. That's not that mean, just common sense. has to come into play at some point. All right. You know what? I think if I'm not mistaken, we are down to one last question on this list. About that. We've actually gotten through this list. That's That's incredible.

Jennifer Smith, CDE 1:03:49
Yay. Is it a long question? I've got about five minutes.

Scott Benner 1:03:55
Yeah, we're not doing it then. No, you're done. Okay. All right. Yeah, so instead Jedi see you just and let me say, We're gonna delete this out. Yeah, just yourself. Okay. And here's why. Because now instead of we're going to tell the story about what happened. So Jenny's power went out. And then she had to take the kids were,

Jennifer Smith, CDE 1:04:14
oh, I had to go pick them up. At the end of my day, I have to go get it to get the kids from school. Right. And power is still out clearly. And I do have to like preface by saying, I'm still in the state of my, my power is out. I had to totally stop this podcast. I had a whole bunch of emails I still had to respond to in detail. So I'm in this a little bit of like, annoyed, flustered. I go in the garage, and I hit the garage door button and then like, cried I'm locked into the garage because it's the electricity doesn't work. So I tech Scott, and I'm like, Oh, my God, my garage door won't open. He's like, Yeah, pull the string. I'm like, oh my god I'm

Scott Benner 1:04:57
so first of all, she texts me and I was like, oh my I got like, I'm really in this with Jenny Now, like it but it's a first of all your terminology is fantastic because you're like, I'm locked in the garage and I'm like, No, she's not. And then I'm like, Okay, I'm like, oh, Mike, okay, find the the motor and pull the cord down. It'll click, and then you can push the door up on its own. And like, I explained how it all works and everything. But that's not really where the embarrassment is. Right? That's just the thing you never bumped into in your life. Where's the embarrassment?

Jennifer Smith, CDE 1:05:24
Or the embarrassment is the fact that so I tell and I got to school a little bit like, late it was like, two or three minutes later, right? And telling the kids why I'm a little bit late. And my youngest.

Scott Benner 1:05:37
That's your oldest kid, your youngest kid.

Jennifer Smith, CDE 1:05:40
How old are young? My youngest kid who is seven, your seven year old? Go ahead. I seven year old? Yes. Before I even told them. How I actually got out of the garage or what I had to do. I was telling him I'm locked in the garage, bla bla bla. And my little guy is like, well, mommy, did you just have to pull that cord? Oh my god, where were you? 20 minutes ago, when I was panicking. My

Scott Benner 1:06:05
favorite part of the story is but later Jimmy says to me, my kid knew how to do that. Good times.

Jennifer Smith, CDE 1:06:12
I think it was frustration because I have maybe if I had looked around in the garage, I'd have been like, oh, look, there's hard to pull here but

Scott Benner 1:06:22
just I want all you people to remember you're getting your diabetes information from a lady who felt like she was locked in her garage because the power

Jennifer Smith, CDE 1:06:30
thank you for making me feel very,

Scott Benner 1:06:32
you're the one that said you had a couple of minutes left that you could have easily said I had to go. Cool. Thank you.

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 define 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 ever since CGM for sponsoring this episode of the podcast. Are you tired of having to change your sensor every seven to 14 days with the ever sent CGM? You just replace it once every six months via a simple in office visit. Learn more and get started today at ever since cgm.com/juice. Box. A huge thank you to one of today's sponsors G voc glucagon, find out more about Chivo Capo pen at je Vogue glucagon.com Ford slash juicebox. you spell that GVOKEGLUC? Ag o n.com. Ford slash juice box? You have questions Scott and Jenny have answers. There are now 19 ask Scott and Jenny episodes. That's where Jenny Smith and I answer questions from the audience. If you'd like to see a list of them, go to juicebox podcast.com up into the menu and click on Ask Scott and Jenny. I know that Facebook has a bad reputation. But please give the private Facebook group for the Juicebox Podcast. A healthy once over Juicebox Podcast type one diabetes. The group now has 47,000 members in it, it gets 150 new members a day is completely free. And at the very least you can watch other people talk about diabetes, and everybody is welcome type one type two gestational loved ones, everyone is welcome. Go up into the feature tab of the private Facebook group. And there you'll see lists upon lists of all of the management series that are available to you for free in the Juicebox Podcast, becoming a member of that group. I really think it will help you it will at least give you a community. You'll be able to kind of lurk around see what people are talking about. Pick up some tips and tricks. Maybe you can ask a question or offer some help Juicebox Podcast type one diabetes on Facebook, the episode you just heard was professionally edited by wrong way recording. Wrong way recording.com 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. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.