#1271 Bold Beginnings: Using a CGM

August 5, 2024Scott Benner

Bold Beginnings will answer the questions that most people have after a type 1 diabetes diagnosis.

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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 1271 of the Juicebox Podcast

Welcome back everybody today Jenny Smith and I are adding to the bold beginning series with this episode about using CGM. Please don't forget that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan or becoming bold with insulin. If you are a loved one was just diagnosed with type one diabetes, and you're looking for some fresh perspective. The bold beginning series from the Juicebox Podcast is a terrific place to start. That series is with myself and Jenny Smith. Jenny is a CDC es a registered dietitian and a type one for over 35 years. And in the bowl beginning series Jenny and I are going to answer the questions that most people have after a type one diabetes diagnosis. The series begins at episode 698 In your podcast player, or you can go to juicebox podcast.com. And click on bold beginnings in the menu. If you'd like to help with type one diabetes research right from your own home, and you're a US resident who either has type one or is the caregiver of someone with type one, go to T one D exchange.org/juicebox. and complete the survey. It's that simple to help. type one diabetes can happen at any age. Are you at risk, screen it like you mean it because if just one person in your family has type one, you're up to 15 times more likely to get it to screen it like you mean it. One blood test can help you spot it early. And the more you know, the more you can do. So don't wait. Talk to your doctor about screening. Tap now or visit screened for type one.com To get more info and screen it like you mean it. This episode of The Juicebox Podcast is sponsored by the Omni pod five, learn more and get started today at Omni pod.com/juice. box. Check it out. The episode you're about to listen to was sponsored today by ag one. You can drink ag one just like I do by going to drink ag one.com/juice box. Check it out. Jenny. Good morning. How are you?

Jennifer Smith, CDE 2:27
I'm well how are you?

Scott Benner 2:30
Good. Thank you. I'm excited to add to the bowl beginning series. Yay. I think that it is maybe the most popular series, certainly among newly diagnosed people. But in general people seem to really like it. It made me think a little bit. And by the way, this is a little tease about a way to kind of refresh the Pro Tip series, which Oh, yeah, when we're done here, I'll actually run my idea. I mean, make a note here to myself to tell you

Jennifer Smith, CDE 2:58
what I was talking about this a while ago just because of all of the new technology. And the algorithms that have really shown up compared to when we did majority of that.

Scott Benner 3:09
No, it was a handful years ago. Yeah, I think there's a nice way to refresh it. But the whole beginning series, we're just going to add to it today. I'd like to talk about basically wearing CGM, the accuracy best practices, that kind of stuff for people because I think you get diagnosed or you have a child who's diagnosed and all of a sudden you're wearing a device. This is obviously very new and different for somebody. Right? And then there's some quirks about wearing technology that aren't obvious in any mean and and ways to manage. That's a good way to say it, right?

Jennifer Smith, CDE 3:42
Yes, they are kind of, I guess quirks is a good? Yeah.

Scott Benner 3:46
So you know, I think no matter what you're talking about here libre ever since Dexcom. CGM is right. They're going to tell you Look, put them on. And it's going to tell you what your blood sugar is. And it will and they're great. They're absolutely fantastic. But you might then take your meter out, check your blood sugar and say, Oh, my meter says I'm 96. And my CGM says m 115. Which is it. So let's talk a little bit about how CGM work first versus how blood blood finger or excuse me about how BGM 's work. And then we'll, we'll lay it out for people so they understand give them some tips and tricks to get through and set up some expectations forums, that make good sense. Sure. Okay. So I'm gonna start by asking you some technical stuff that I don't understand as well as you do for certain. I use my, my blood sugar meter, and I check a drop of blood from my finger. And it says, I'm 96. Why is it possible that my CGM doesn't read the same? It's

Jennifer Smith, CDE 4:52
possible because your blood glucose meter is reading the glucose in your blood? which is, technically the more accurate it is the more real time right now. So your glucose then kind of shifts out, moves through our interstitial fluid that surrounds the tissues in the cells and everything in our body in order for the glucose to kind of move into cells. That's a very simplified explanation, right. But sensors, CGM EMS do not measure blood glucose, they measure the glucose that is in that interstitial fluid. And that's the reason that you can see a difference between a blood glucose and a CGM value, because they are not reading glucose in the same fluid in the body. And that glucose again from the blood has to kind of move out transport through the interstitial fluid. And so many people know the term or the thought of leg. In CGM data, a lot of people talk about that. And that data can leg then finger stick is here. CGM is higher than this or lower than this. The reason is because there's a lag in that glucose, sort of transport, if you will, into the interstitial fluid. And as we'll probably talk, it's another reason that hydration very important, really, really important.

Scott Benner 6:28
So very high level, not technically, someone one day said, Hey, there's glucose in your interstitial fluid. We can measure that and help people with diabetes using insulin. I'm going to read this interstitial fluid is the fluid that surrounds the cells in your tissues. It plays a crucial role in transporting nutrients and waste products between blood and cells. Yes, when you're using a continuous glucose monitor, it is important understand how the interstitial fluid relates to blood glucose monitoring. And Jenny's already brought up there's a lag, right? And that's lag could be five to 15 minutes from a finger stick. Okay? Correct. So somebody figured out, probably not that hard to figure out if you're like, you know, a scientist or you went to college or something, that there's glucose in there, we can measure it and we can help people not have to poke their fingers all the time and still get close enough to what's happening that it's really valuable for them. Okay, so interstitial fluid similar to blood plasma, it says, but without the high concentrations of proteins found in plasma contains water, electrolytes, glucose and other small molecules. Correct. So then, if you're dehydrated, then that fluid is not where it needs to be volume wise, I imagine. So Right. Why does that mess with the reading. I partnered with ag one because I needed a daily foundational nutritional supplement that supported my whole body health. I continue to drink ag one every day because it works for me. Ag one is my foundational nutritional supplement. It gives me comprehensive nutrition and it supports my whole body health, drink, ag one.com/juice box. When you use my link to place your first order, here's what you're gonna get a free welcome kit that includes a shaker scoop and canister, five free travel packs, a free year supply of vitamin D, and of course your ag one. So if you want to take ownership of your health, it starts with ag one. Try ag one and get a free one year supply of vitamin D and five free ag one travel packs with your first purchase. Go to drink ag one.com/juice box that's drink ag one.com/juice box. Check it out. My daughter is 20 years old, I can't even believe it. She was diagnosed with type one diabetes when she was two. And she put her first insulin pump on when she was four. That insulin pump was an omni pod. And it's been an omni pod every day since then. That's 16 straight years of wearing Omni pod. It's been a friend to us, and I believe it could be a friend to you, Omni pod.com/juicebox Whether you get the Omni pod dash or the automation that's available with the Omni pod five, you are going to enjoy tubeless insulin pumping, you're going to be able to jump into a shower or a pool or a bathtub without taking off your pump. That's right, you will not have to disconnect to bathe with an omni pod. You also won't have to disconnect to play a sport or to do anything where a regular tube pump has to come off. Arden has been wearing an omni pod for 16 years. She knows other people that were different pumps, and she has never once asked the question, should I be trying a different pump? Never once Omni pod.com/juice box, get a pump that you'll be happy with forever.

Jennifer Smith, CDE 9:50
Well tell me what happens when you have a really teeny tiny amount of water that you try to put a whole bunch of sugar in Does it stay fluid or what happens? Oh, it gets more viscous concentrated, right? It gets kind of sticky it gets. So not only are you impacting everything else that needs to be transported in your body in the right way, which, I mean, that's a whole just physiology discussion. But honestly, electrolytes play a big role in transport of even glucose and other sort of nutrients in the body. So when we're dehydrated, that concentration of all of these can kind of get slow in movement, as well as more concentrated, right. And so that can shift glucose readings. It's also the reason on the opposite, where people again know this term, it's like a compression low, right? Where you're laying on your sensor, what you're doing is compressing that sensor so much that all of that all but a good majority of that interstitial fluid gets shifted away from the sensor. And so what ends up happening is glucose levels drop. And not until you roll the child or the person over or they get up and kind of things get moving again, fluid comes back to normal, you know, levels that it should be at, then that glucose number jumps up, and is actually where it should be. So as you can see, hydration and proper hydration in the whole body can make a really big difference in

Scott Benner 11:22
so like a compression low as an example, almost like putting your foot in a puddle and you displace the water. So if you press hard on the sensor, you're displacing the interstitial fluid, which contains glucose, you're pushing that away from the sensor. And then that's why all of a sudden, you look low out of nowhere, because you technically push the glucose away from the sensor. And now suddenly, there's less there than actually exists in the body. Right? Interesting. Hey, here's a little side note that you'll probably pletely agree with. Only about 30 to 40% of adults meet the daily recommendation for water intake. And the remaining 60 to 70% may not be adequately hydrated with varying degrees of mild to moderate dehydration. So, my point bringing that up is is I think most people hear that and think I'm not dehydrated, but you very likely could be especially kids to who you know, correct.

Jennifer Smith, CDE 12:18
And honestly, you know, having worked with a good percentage of athletes in the past very heavily. Our biggest recommendation for hydration is that when your body finally gives you the signal that you're thirsty, you are definitely dehydrated,

Unknown Speaker 12:34
okay? You should not

Jennifer Smith, CDE 12:36
have thirst so to speak. That's like oh my gosh, I have to get a glass of water right now. You are not hydrated. Well, you're under hydrated at the point that your body is giving you signals right?

Scott Benner 12:51
I'm just gonna say here your urine like should be what? Oh, yeah, how do we measure our hydration by the color of our urine?

Jennifer Smith, CDE 12:58
Your urine should be like very light pale lemonade.

Scott Benner 13:03
Makes me want to sing lemonade. A cool refreshing drink. Clear or light yellow typically indicates good hydration, pale yellow. Also a sign of good hydration suggests that you're well hydrated but not overly so bright yellow can indicate mild dehydration and the presence of excess vitamins. Oh yeah, that's true too. If you take a multivitamin your your pee could get bright right and

Jennifer Smith, CDE 13:25
especially B vitamins. So I always recommend Do you know that you're really doing a good job of hydration and you've just taken like your multivitamin or a B complex or something like that. And your pee is like this golden color.

Scott Benner 13:39
dark yellow often indicates dehydration and that your body is currently conserving water. It's interesting and amber or Holly, honey colored, strong or sign of dehydration important to drink more water orange dye to people's Wait a minute. Orange can be the sign of severe dehydration and brown could indicate severe dehydration or the presence of certain medical conditions such as liver disease. pink or red is blood in the urine. Wait a minute, Jenny. This has nothing to do what we're talking about but blue or blue or green. unusual colors can result from certain medications or food dyes rare genetic conditions bacterial can and then cloudy or murky could indicate a urinary tract infection or kidney stone.

Jennifer Smith, CDE 14:21
Okay, but and from the color that even that pink it may not definitely be blood. If you have had a fair intake of bees recently. Beets or berries a fair you know an intake of those can definitely discolor the urine. Beets can also really discolor sort of poop. So just as an FYI.

Scott Benner 14:43
What color does beets make my poop? Kind

Jennifer Smith, CDE 14:47
of like? It's almost like a reddish color. Yeah, so there you go.

Scott Benner 14:52
Sorry. We go over it like this because being hydrated is super important for your CGM working by It's also very important for your insulin working as well. So we might as well talk about it here, because you're getting a double benefit. If you're wearing a CGM, you're gonna get more accurate readings. And if you're using insulin, which if you're listening to this, you're very likely are your insulin is going to work better. So can we take two seconds on that tell people why well hydrated body uses insulin more effectively?

Jennifer Smith, CDE 15:20
Absolutely. Again, it's a transport component, right, we're injecting or infusing insulin into what we call the sub q tissue. So the layer that sits like right underneath the skin, which is why your little cannulas or the even the insulin needles on your pens or your syringes, they don't really go in very far, they're not terribly long. The idea is that with proper hydration, and fluid movement in the body, that that insulin along with the chemicals that help it to get used in an appropriate timeline, it works along with the hydration of the body. And again, if you're under hydrated, things are not gonna be moving as easily I, I considered dehydration, especially like in circulation, it's kind of almost like molasses in winter, right, things move really slow. Once you get hydrated, things move and flow the appropriate way, your insulin, all of the nutrients, all of those things, they get moved to the right places in the body, in the timeframe that the body is meant to do it.

Scott Benner 16:24
I was going to mention that extreme temperatures can affect the rate in which glucose diffuses into your interstitial fluid. So that is a potential impact for your CGM, right things are also different, like blood flow. So like sedentary versus exercise again, increases. Yep. Right. So some best practices, first of all, be aware of lag time. Right? And that's an interesting one, because here's a real world example. Arden's blood sugar will, you know, dip down to 63? And I'll send her a text and I'll say, Hey, did you do something about this? And she'll say, Yeah, I'm good. I did, you know, I drank this, or I ate this or whatever. And then five minutes later, the CGM will still say 63. Or it'll go down again. And then I get the tap, tap, tap. It's my wife. She's low. And I'm like, no, no, I know. But she's already had something. Well, this thing still beeping at me. Right. And I'm like, Yeah, I know. But I think we did enough. Like, I think we did enough. It's gonna come back. You gotta wait. I find sometimes you need to wait 10 minutes? At least Yeah, to see. Yeah. And if you go, go ahead. Well,

Jennifer Smith, CDE 17:29
I was gonna say, and it could also be longer depending on what you've used to treat that with, right. Thus, the reason that we really recommend dextrose are really simple sugar, something that's going to get in get moving fairly quickly. Because if you don't, then not only is the CGM potentially lagging, but it might be also even behind further because of what you ate not being fast enough to reliably start bringing that blood sugar

Scott Benner 17:58
up. But in a case when you have done that, when you've taken in that simple sugar, and it's bounced like, say you're 63 and CGM says 63. You wait a couple of minutes after you drink your juice, and you test and you get a 75 test. And you think, Okay, this hit, it's coming, right? The CGM is not suddenly going to say 6075. As a matter of fact, that next time it it reads, you could end up being 1520 points higher than the last time, right. And so I just want to say here, you really still need a really accurate blood glucose meter, and you should use it. I know. And listen. Dexcom is a sponsor ever since as a sponsor, I think CGM are fantastic. I don't know what I would do without them. You still need a really good meter, and you should test your blood sugar. That's

Jennifer Smith, CDE 18:45
100%. Yeah, I 100% disagree. And I Oh,

Scott Benner 18:50
you just said I 100%. Disagree.

Jennifer Smith, CDE 18:52
I 100%. Agree. I 100%. Agree I was what I was gonna say. In terms of, you know, like disagreement is, I disagree with the fact that people are really heavily relying on only their CGM. And that they're really only waiting to do a fingerstick when their own body symptoms are telling them something that seems off compared to the CGM value. I mean, I think if I were the one setting up any of the sensor systems, my recommendation doesn't get into calibration because there's a whole strategy with calibration and that kind of stuff as well if it's needed, but my best practice is doing a finger stick when I get up in the morning. Yeah, just to see because just to see it because it gives me a visual of the CGM has been here all night. I have no food in my system. I have no excess of insulin from boluses or anything that could really be impacting right now. I do a few You're sick before I get out of bed. So I don't have that quick shift in blood sugar that could happen for many people, right that foot on the floor. And they compare. And if it's off with, you know, within this set comparison, I may calibrate, but 99% of my mornings I'm not calibrating. I'm just comparing and saying, yeah, it looks great, fabulous, even

Scott Benner 20:24
like, but what you don't want is to get out of bed with a blood sugar of 140. And your CGM is like, Oh, you're 95. And then rack, then the whole day just 45 Points off everything that you do that the first Bolus you make, you know, leads to probably arise, you know, because you didn't have enough insulin. And this just doesn't, this doesn't stop. And even if the CGM comes back in line eventually great, but it just throws it. I'm just a big fan of testing once a day, at the very least,

Unknown Speaker 20:56
yeah, yes.

Scott Benner 20:59
Getting older means a world of change. But some things still stay the same, like being at risk for type one diabetes. Because type one can happen at any age. So screen it like you mean it. If just one person in your family has type one, you're up to 15 times more likely to get it too. And 50% of type one diagnosis is happen after the age of 18. So screen it like you mean it. type one diabetes starts long before you need insulin. And one blood tests could help you spot it early and lower the risk of serious complications like diabetic ketoacidosis, known as the Ka. So don't get caught by surprise. Screen it like you mean it. Because getting answers now can help you get prepared, the more you know, the more you can do. So don't wait, talk to a doctor about how to get screened. Tap now or visit screen for type one.com. To learn more. Again, that's screen for type one.com. And screen it like you mean it.

Jennifer Smith, CDE 22:01
You know we have Dexcom Hello, and I know the other systems have something else but Dexcom has clarity reports, right? And so clarity reports will give you an estimated what they it's not an agency but an estimated average, right? They call it a GMI. A glucose management indicator and that gives you a value close to what a one C would represent from an actual blood draw. And in comparison, some people get really frustrated. Well, my agency came back at this but my GMI according to clarity was telling me that I should be here or here. And it's frustrating. My first recommendation is or a question is, are you doing finger sticks,

Scott Benner 22:46
right?

Jennifer Smith, CDE 22:47
If you're not doing finger sticks, let's start doing several finger sticks a day. Because I would almost say that in the majority of those cases, the CGM is what's off. The CGM is not on with the finger stick enough. And so your GMI is then reporting an average. That's not actually what's really represented in your blood. Yeah, right. So I think they're in the case of things being really different. It's just a good strategy to do even more than one test a day for even if it's just a week, if

Scott Benner 23:24
I'm listening to this, and I'm more newly diagnosed, what I would want you to take away from this is, this is maybe some of the best technology that's ever existed for people with diabetes, agreed that and algorithm pumps are going to change people's lives with type one. And you should not walk around bemoaning, oh my gosh, I'm 95 and it says 110. That's astounding, be very happy. Okay, right. But the next thing they're going to think, is, well, if I'm really 95, and it says I'm 110, and I'm on an automated system, is it not going to give me insulin based on 110? And, you know, like, should I be fearful that I've never come up with a better answer other than to say that my daughter has been on different algorithms for a long time. This has never been an issue. And I know that is not a comforting statement. Right? To me, it's the same question. It's the same answer as back in the day when somebody would have, you know, four different meters. And they would like take pictures they'd like they test their blood sugar with one meter. Then with the next one that would the next one, the next one, they get four wildly different numbers. And they say great, now which one of these should I use? Right? I'd pick the most accurate one. You know, like, go look online, see which one of them they have is most accurate and go with that. But at some point, do you don't remember that moment? Probably because you were a kid when you were diagnosed, but I remember the moment of like swallowing hard and going, this is the meter. I don't know if it's right or not, but I gotta go with it because I gotta go with something. Like I'm not in the hospital. She doesn't have we're not using a $10,000 blood glucose meter. and I really mean like, this is the one I have. And if you know what I'm saying like it's a real big leap to make

Jennifer Smith, CDE 25:05
it is and unless you really know, as you already said, you can look up accuracy online, right? There are charts and in diabetes daily, there are a whole bunch of different places that have accuracy chart by different brands even have the off brands right that are on there for an evaluation. I always say choose the one that is not only on your insurance plan coverage wise, but also choose the one that's on that list that is the highest accuracy according to this chart.

Scott Benner 25:36
Yeah, there's like three meters at the top of the chart, listen to contour next gen is a longtime sponsor of the podcast, and it's the one we use, it's a very well ranked and rated meter and

Jennifer Smith, CDE 25:47
and they've rated top of the charts for years. Yeah, particular meter I kind of right up there with it is, I wish I could use that one. My insurance doesn't cover that one. It prefers accucheck brands. So I use the guide or the guide me that one has very similar to the contour accuracy readings. So again, look, because that also translates into if you're going to be calibrating as you brought up, I checked one this meter and then I checked on this meter, and I checked on this meter, and I have three varying results. And this day, you're using this particular brand and this day you're using this particular brand at work to calibrate your CGM. Don't Don't do that. Pick one, pick a meter and use that one to always calibrate just

Scott Benner 26:32
freaks you out in the beginning. Like it just does. Like you know, you're fairly newly diagnosed. You're like, well, this meter says my blood sugar's one thing. The CGM says another thing, then you start going well, which is it? And right, I always tell people I'm like, I don't know. Is it a $4 meter and an A Dexcom? I'd probably trust the Dexcom more, but like I don't think it's a more or less it's an understanding of once you have as accurate as you can blood glucose meter CGM. Then understand the lag time really seriously. Look at your hydration. You know, you know, are you in an extreme temperature situation? I listen, I'm wearing a CGM. Today. I got in the shower and my blood sugar went up 45 points. I have a working pancreas. Do you really think my blood sugar went up? 45 points. Right, right. So there's that stuff to remember it also, when you put it on is really important. So going back to CGM Jenny, I talked about this before we started. Again, I want to say again, I don't want to scare anyone away. Definitely get a CGM. Okay, but the first day ain't as good as the second day. Ain't as good as the third day. And then all of a sudden, when you get to the end of the sensor, it could trail away again, some people have great luck. Some people's physiology works great with them. And some old time Oh, my God, yep, just boom, all good. Yep, I saw Arden had a g7 go bad in the last three hours last week. And other than that I've seen they go right, she wears them right out to the end every time. And the longer she's wearing them, the better they look for her, like accuracy wise. So but keep that in mind, too. If you're in a 10 day window or a 14 day window, it's boring. But there's that little sensor is under your skin. And it's in there. And it takes a little time to what's the word people use marinate,

Jennifer Smith, CDE 28:13
marinate,

Scott Benner 28:14
again, yes, right? Like get set, who cares what's actually technically happening. Dexcom added what to the g7. It's a like a grace period.

Jennifer Smith, CDE 28:25
There is so after the 10 days, you have a 12 hour grace period that the sensor will continue to work before it's fully expired. And in that grace period, it will continue giving alerts and alarms and all of the regular stuff. They've just given, you know a period of sometimes life is what it is, and you planned to be home at 2pm to change it and your train got stuck or you're just stuck in traffic or you had to go pick up your dog or whatever happened. And now you're either without a sensor because it has fully expired or now with g7, you've got 12 hours beyond that 2pm that it's still going to help you until you can really get home.

Scott Benner 29:07
And so I'll tell you what I tried to get Arden to do and she fights me all the time about it. But you know, I'm always like, look, put a new one on now while the old ones still working. And just let that thing sit in there for a while and get accustomed to its surroundings. And you know, because if it if it doesn't work as well, in the first couple of hours of the first day for some people, then let's try to buy some more time there and then we'll swap it back on the end by taking the free 12 hours on the backside if we can, right that makes sense to me. So people call that like marinade era needing a new sensor right you just you all you do is you open up the g7 pop it on and then you don't do anything else. You don't start it up often hold on to the box hold on to the sensor then when it's time to switch you scan that one and jump to the other one. And you might very well see better numbers coming back from it the longer it's been in. We try to do it for a couple of hours at least but she's just He's just tough. She's young. You don't I mean, I'm like, I'm like, it

Jennifer Smith, CDE 30:02
doesn't mean a million other things. Yeah, it's

Scott Benner 30:04
hard for to get but it's a great, it's a great tip. Is that something you can do with libre? Do you know? That's

Jennifer Smith, CDE 30:10
a really good question.

Scott Benner 30:12
No, if you can, I don't think so.

Jennifer Smith, CDE 30:15
I don't know. Okay, I would honestly because Libre is similar in that the device also is like G seven that it just pops on. There's no additional transmitter to pop in, or it's like a one and done kind of habit on it. I think it could be possible because you still have to enable that CGM to get started with the app. I would expect but I don't know for sure. I. Honestly, the majority of people that I get the opportunity to work with are either Dexcom or you know the small number who get really good accuracy with Medtronic Guardian system, which is nice.

Scott Benner 30:53
How do you find the predictive alerts work for CGM? Like the ones who tell you you're going to be low in a while? Do you notice that they are helpful?

Jennifer Smith, CDE 31:03
I think that they can be helpful what I've seen the best though, and it goes back to hydration. It really goes back to the reliability of your fluids moving the way that they're supposed to through the body. And that data that then gets transmitted from blood into the interstitial fluid, it's going to register a shift that's going to trigger however, you've had that predictive alarm set. Either you get you have it set really conservative or really aggressive to alert your alert you sooner or later to that drop happening that could predispose you to the low. Where

Scott Benner 31:40
are you at on calibration? Do you calibrate?

Jennifer Smith, CDE 31:44
I calibrate if necessary? Yes. The majority of my centers, I've had really, really good luck, if you will, with my Dexcom. For a long time,

Scott Benner 31:58
I'll have ordered and calibrate once in a while doesn't come up that often. I think you really have to pick through what works best for you. Like some people will say, look, I put that thing on six hours into it. It says I'm 65. And I'm 90. And I calibrate. And some people will tell you like don't calibrate on the first day. And you know, in Dexcom, all the CGM companies, they don't really talk about how to best do that. So I would say this,

Jennifer Smith, CDE 32:21
they do tell you that you can calibrate. And most of them, if you've read the fine print in their owner's manual, there is a defined strategy to what they recommend for calibration. And how far outside of that could actually create sort of a setup or where the sensor is just going to fail itself. Because you have over given it information. And the algorithm that's changing that sensed goes to a number to tell you what it is, it gets all messed, you could just

Scott Benner 32:54
confuse it. You could confuse it you find sensor placement because you know, there's the places where they've tested the sensors. So they can say you can wear it here, but people move them all over the place. Do you find that you have better sights some than others for accuracy?

Jennifer Smith, CDE 33:08
I do. You know, again, leg sight isn't technically approved. I don't wear it. I also don't wear my pumps on my thighs either. Neither of them work ever for me. But people find special places that do definitely work. Many times. They're the approved sites. And the majority of the time. They are not technically approved sites. My recommendation is tested. This is another opportune time to use your glucose meter. And make sure that it is actually really serving you. Well there. And then if it is great, keep using it. I mean, we all have limited real estate on our body. Yeah,

Scott Benner 33:50
I don't know that Arden has ever worn a Dexcom on our arm. Seven gees. Oh, nice. You bring them on or like size for hips or budget, upper body kind of thing. Yeah, like there. So let's talk a little bit about the quality of your management is also going to add to the quality of your CGM accuracy. So if your blood sugars are not constantly bouncing up and down or super high or super low, you are going to see, I think more stable accurate readings back from a CGM, correct. Yeah, yes. Okay.

Jennifer Smith, CDE 34:21
Absolutely. And with the difference between those coming again speaking Dexcom, specifically, those coming from G six to G seven, where there is no longer smoothing of the data. Right. That balance could get worse, visibly in the data points with somebody who has a lot more Rise Fall happening looking a lot more like a roller coaster. Those numbers again, data points on the CGM graph, they could look a lot more jagged and up and down even as the glucose is going up and down compared to somebody who has a lot smoother trends. addition from data point to data point.

Scott Benner 35:01
Yeah, that and then my point is that if you do simple things, like we talked about in the diabetes Pro Tip series, like Pre-Bolus, your meals, you know, have your settings closer, you're not going to see as much variability. And you're going to see more accuracy out of your CGM as well also do not calibrate while your blood sugar's moving. So correct. If you're rising very quickly falling very quickly. That is not a good time to calibrate. No, this thyroid have impact on CGM accuracy at all? Or do you think it just has impact? Because right, like, as I looked into it a tiny bit like, so you can have like, an overactive thyroid, right, which would maybe speed up your metabolism as an example? Like, would that maybe move glucose through you differently? You know, it's an interesting, I just, I don't know if it's right or not it just like it popped into my head. I'm like, I wonder what medications people are taking that might have an impact on this as well? Well,

Jennifer Smith, CDE 35:54
I do you know, obviously, and most people who are Dexcom users know about acetaminophen. And in fact, while they cleared that push to avoid acetaminophen, I think it was once G six came out, they still will ask you, if you are trying to return a failed sensor, if you had used acetaminophen, my expectation is that they're looking potentially maybe for a dose, that's more likely going to fail a sensor comparative to just using you know, 500 milligrams of something once a day, and you had no effect whatsoever. I know Vitamin C is another one, you know, higher doses of vitamin C can certainly affect the accuracy. I think it's a FreeStyle Libre, too, for vitamin C, and you know, a lot of people might not even realize that they're using a large amount of that. If they're, if they're taking some type of a powder that includes a high amount of vitamin C, they're not technically just taking a chewable or a daily might vitamin, they may not think that they're really going to have a problem. They may not realize it's in something else that they're eating. Okay, those are the two things I definitely have impact. So with

Scott Benner 37:10
overactive underactive thyroid, I'm just kind of picking through some of the notes I made earlier. It's gonna more change like, like underactive thyroid, slower metabolic rate could delay glucose uptake into cells, which could affect how quickly changes in your blood glucose are affected. All I'm saying is that if you have hypo hyperthyroidism, it's not crazy to think that you might see Genki readings from your CGM. Or maybe it's a little different for you than it is for other people. Maybe listen, if I'm wrong, that's fine. You have to imagine there are other things impacting this, it's not as easy as I put the thing on and the thing don't work. You don't mean like it right. And that's what I think always happens with people's they just kind of don't see the bigger picture. And I understand why. Right? Because you don't buy tires, and think, oh, they were out faster. But I drive faster than other people like you just think I bought more than other more or like the roads are worse or whatever. Like you just think like I bought the thing they said 30,000 Miles 60 It didn't last, like you know, there's reasons why things happen. I don't know what they are sometimes. Yeah, you just need to think bigger when you're trying to decide how to make this thing work the best because this is going to be a very important part of your life with diabetes until they come up with something different. And I don't know if there's something different to come up with. A CGM might be the greatest advancement for people using insulin, you know, in the last 20 years.

Jennifer Smith, CDE 38:34
Absolutely. Yeah. Yeah, absolutely. In terms of that accuracy to, you know, and calibration and whatnot. There are strategies, like I said, in the fine print of the books to if it's this far off, this is one to add a calibration. I know in the realm of people with diabetes, there are so many conversations about when to calibrate how to calibrate how many calibrations to put in, should I change the number from this to this to make it closer to the actual to put into the system so that I don't confuse it. I mean, there's so many different things. My first recommendation is always go by what the system is telling you as allowable for a calibration and try that

Scott Benner 39:15
first. Right. Follow the advice from the company about how to handle it.

Jennifer Smith, CDE 39:19
Correct. Exactly. And then, you know, Bob on the corner who has his own proven strategy? You know, what, if you've tried the strategy, they don't seem to be working, maybe try Bob strategies, but I, I wouldn't necessarily rely on them. 100%

Scott Benner 39:35
working for you, you have a second over adhesive stuff. Sure. Okay. So some people are going to have adhesive allergies. And it's not crazy to say that everyone sort of while some of you are going to have significant adhesive allergies must be no big surprise. You have autoimmune issues and your body tends to overreact to things. So skin preparation, doctors, so it's tough, right? Because they're going to tell you to clean your skin The alcohol. Yes, and for some people may be a person with very oily skin that might be really important. But for some people who have more sensitive skin taking out those oils could lead to, you know, dry skin, that kind of stuff. We are more like light soap and water, pet dry people. We don't use alcohol to clean the sights. In that idea somewhere might be something for you. So if you're noticing your skin getting very dry, bumpy, scaly, I the first thing I would do is I'd get away from alcohol, if you're using it to see what happens, not a doctor not advice, etc, and so on. It's what worked well. For us. There are skin barriers. There are skin tag, Tara DERM. What's the other one IV?

Jennifer Smith, CDE 40:43
Well, there are a couple that help with stickiness. So if you're having a problem on the end of things not staying stuck, okay, there's some things that are patches for that, or perhaps IV prep, all those kinds of things that actually help at here. But then there are more patches, IV 3000. And those types of barriers that are hypoallergenic, they're typically clear, they come in multiple different sizes. And essentially, you would clean your skin with whatever method you're going to do, let it dry with that on the skin, creating a thin barrier. Upon which then you're going to apply the sensor you're gonna pop the sittin sensor on over so the sensor adhesive is not technically touching your skin, right.

Scott Benner 41:31
So you're just trying to create a barrier between you and that adhesive because some people, some people are never going to be bothered by it. Some people are terrible, they can't wear it, you feel horrible for them. Some people can't get it to stay on, some people can't get the tip come off. And you're gonna you're gonna, you're gonna hear people online like well, I don't know why they don't make it more like this or they're trying to make it down the middle. So everybody helps most people. And you might have to make some, some adjustments. hypo allergenic tapes, adhesives are a way to get around sensitive skin. There's these holders like some 3d printed like holders I've seen people use Yep.

Jennifer Smith, CDE 42:10
And that's actually for the people who really can't do an adhesive. So what happens is they'll put a dressing on, the adhesive will essentially not be on their skin. And in order to hold especially like the pad or in the infusion set, or even the sensor on the skin. That sort of 3d printed is almost like a it's like a cage that sits on top. Yeah. And then there's a band that goes around to actually hold that in place

Scott Benner 42:41
where you can use different adhesive that doesn't come on your device that maybe you can deal with. Yep, keep moving your sites, if you're having reactions is can be helpful. hydrocortisone creams and histamine, stuff like that. Like if it gets to that point for you. You know, there are ways to manage it. And for those of you who can't, I mean, I'd say if you absolutely can't figure it out, like if your skin just doesn't work then I think you got to look at ever since for the implantable CGM right because they have their transmitter is on a silicone based I think I'm saying that right silicone based adhesive, which I don't think causes much. dermatologist. dermatological. Is that dermatological? Is that right? issues. If not make up a word. A good

Jennifer Smith, CDE 43:27
word. A great works for me. Yeah, good.

Scott Benner 43:31
Okay, so anything we're not talking about here that you can think of anything we must. I think

Jennifer Smith, CDE 43:37
the only thing that I would say in the same line of thought that we're just talking about would be really make sure that after you remove any adhesive, whether it's a CGM or a pump soldering, you really clean that site. Well, they seal a lot of times just a basic like, clean over it with like, again, like an alcohol or something to kind of get the sticky stuff off, but you never really completely getting off all of that residue. And there are some really good residue removers there even some that are more like essential oil type, you know, or homeopathic that work really well that are just good for the skin. I also think keeping skin really, overall, people with diabetes can tend to have drier skin, and so making sure that you're overall really well moisturized as well. But does that sound

Scott Benner 44:31
weird? Either on the cocoa butter or whatever. Yeah, coconut

Jennifer Smith, CDE 44:35
oil actually. I mean, it's great for a million wonderful things and it is you know, it's a wonderful

Scott Benner 44:44
kid, you know, you can refinish leather products with coconut oil. I did not know that. It did it with an ottoman once it worked very well. Treat yourself like an ottoman Jenny is saying and moisturize your skin

Jennifer Smith, CDE 44:56
and moisturize your skin and especially those sites that get used and used and used, really make sure that they get nicely cleaned and hydrated. How about from

Scott Benner 45:06
your perspective, nutrition or vitamins that would help with that? Anything that pops the mind? That's an outside of the box question, but because I'll point out that hypothyroidism could lead to dry skin as well. So if you're under medicating your thyroid and you're experiencing dry skin, that would not be crazy if your TSH was if you're one of those people walking around with a four and a half TSH, your doctors like it's fine, which probably isn't you probably want to push it under 2.1. But like that could be a thing. But I mean, are there like when people take multivitamins? Are there foods that help with with skin? Health? Or am I just making that up? Um,

Jennifer Smith, CDE 45:48
well, I'm quite sure I'd have to go to my skin health kind of guide. But I mean, there are certainly things that are very good overall, even in the in terms of aging, which is not what we're really talking about, but it kind of goes right along with keeping your skin healthier, more stretchy and keeping things more elastic. Rather than getting paper thin kind of skin. There are definitely nutrients and food in terms of supplemental, I'm always wanting to save try to eat it in food as much as possible. Rather than pulling out a whole bunch of expensive stuff that you may not actually be in need of. Jenny,

Scott Benner 46:30
I asked our chat GPT overlords. They said that benefits of vitamin A produces cell production helps repair vitamin C boosts collagen production. Yep, vitamin E acts as an antioxidant. omega three fatty acids reduces inflammation keeps skin moisturize supports skin barriers, function. Zinc can add in skin repair and reduce reduction of inflammation. Bio 10 B seven supports healthy skin by improving the skin's hydration collagen, protein essential for repair. Vitamin D plays a role in skin cell growth and repair. So yeah, I mean, eat well. Always a good advice, but you know, all these things could be valuable for you.

Jennifer Smith, CDE 47:15
And interesting, a very valuable thing about all the rest of those is that they are highly recommended and people with diabetes anyway. Yeah.

Scott Benner 47:23
If you're taking care of yourself, you might be taking care of your skin by mistake already. Right. Cool. Yep. All right. Well, I want to thank you, I'm gonna let you go. But then I'm going to tell everybody to hang on for a second because I'm going to go over some things that I have in my notes that I'm not sure if we hit or not so fabulous. There'll be more right after this. Okay, thank you. Alright, guys, Jenny's gone she had to get going. But I put together so much like stuff to talk about in this episode that I just wanted to kind of roll through it very quickly. And make sure that it's all highlighted for you. So very, I'm gonna go through very fast. These are things you should be researching maybe on your own. Super simple stuff, right. Sensor insertion, clean the site, use proper placement. Rotate your sites, calibrations, like Jenny said, Follow the manufacturer's guidelines for calibrations, and try very hard only calibrate during stable glucose levels. Do your best to keep the sensor dry. I know you can be in and out of water with them. But you know, the better you keep them, maybe the better the adhesives going to stay, you know won't be moving around that could end up helping you stay on top of when the sensor expires, right? You want to know when it's going to shut off? Are you noticing janky readings and you're more towards the end? Maybe that's why take a look at maybe swapping it out a little sooner. If you don't know what's happening, all the company ask questions go online, find Facebook groups, go to the Juicebox Podcast Facebook group, ask other people who are users, you might get some great information from them. Skin Health hydration superduper important a balanced diet. Now just not just a balanced diet for your skin but a balanced diet so that your blood sugars aren't bouncing all over the place. You're monitoring your blood sugar with the CGM, which just works better. If your blood sugar is not super variable. You're always going to need adequate sleep. Keep your stress down, get mental health support. Remember that alcohol consumption moves your blood sugar around CGM is going to bounce around with it. Now you're a little loaded and the things jumping around might be harder to pay attention to. I'm not saying that alcohol changes its ability to work. I'm saying alcohol can have impacts on your blood sugar. And now you are trying to decide what you're seeing on your CGM when you're inebriated, and it's bouncing around a little more. Scrolling down super important. I know we went over it probably felt boring to you but understanding how interstitial fluid works, what it is and how the CGM is monitoring it really important especially for understanding lag time. And that's impact on what your readings might be versus your blood glucose meter. I can't suggest enough a quality blood glucose meter contour next.com/juicebox Great, great, accurate meters. There are other medications impacting your readings Jenny mentioned acetaminophen, also beta blockers could have an impact. Check into that with your doctor or online. So regular monitoring consistent medication use regular endocrinology visits. Some other stuff to keep in mind the Dexcom G seven has a shorter warmup time of just 30 minutes, you can plan your sensor changes to give yourself some marinating time very helpful. Between me and you. I don't care what the company says about never needing a calibration. You need your meter, you should be checking your blood sugar and seeing if there are drastic differences. Just so you know. Okay. And then you can make a decision about calibrating but you want to make sure that you understand what's going on. That's libre three Dexcom all of them adhesive skin prep barrier methods, hypoallergenic adhesives, rotating your sights, making sure you get all the adhesive off, and managing reactions if you have them. Finding a health care provider to help you with this may be necessary. If you're having significant allergies to adhesive. You can consult a dermatologist, look for barrier creams, non adhesive alternatives, medical grade silicone tapes, all these things might be possible. This would be a time to get online find other people who have this issue and see what's working for them. That's it.

Did you know if just one person in your family has type one diabetes, you're up to 15 times more likely to get it to screen it like you mean it. One blood test can spot type one diabetes early tap now talk to a doctor or visit screened for type one.com. For more info. The conversation you just enjoyed was sponsored by Omni pod five. You want to get an omni pod five you can you wanted to make me happy, do it with my link, Omni pod.com/juice box. I'd like to thank ag one for sponsoring this episode of The Juicebox Podcast and remind you that with your first order, you're going to get a free welcome kit, five free travel packs and a year supply of vitamin D. That's at AG one.com/juicebox. Are you starting to see patterns but you can't quite make sense of them. You're like, Oh, if I Bolus here this happens, but I don't know what to do. Should I put in a little less a little more? If you're starting to have those thoughts? You're starting to think this isn't going the way the doctor said it would I think I see something here but I can't be sure. Once you're having those thoughts. You're ready for the diabetes Pro Tip series from the Juicebox Podcast. It begins at episode 1000. You can also find that at juicebox podcast.com up in the menu and you can find a list in the private Facebook group. Just check right under the feature tab at the top it'll show you lists of a ton of stuff including the Pro Tip series, which runs from Episode 1000 to 1025. 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. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com