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Scott Benner 0:00
This episode of The Juicebox Podcast is sponsored by in pen from companion medical. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And Always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. Welcome to ask Scott and Jenny. In today's episode, I, Scott and Jenny Jenny Smith from the diabetes Pro Tip series and defining diabetes. You know, Jenny, Jenny works at Integrated diabetes. She's a CDE, or registered pump trainer CGM trainer dietitian. She has type one, Jenny is the she's the full pack Jenny's the goat, I think that's what we're saying. Right greatest of all time. That's why she's here on the Juicebox Podcast. So we're doing something new on Fridays, they're still going to be some defining diabetes. But we're going to go back and forth a little bit between ask Scott and Jenny and defining. Anyway, in these segments, Jenny and I will be answering your questions. This all began as Jenny and I were talking about new episodes for diabetes pro tip. And I said, Let's do an Ask Jenny thing. She's like, I'm up for that. I said, you know, I'll ask people on the Facebook page if they have any questions for you. And they did. But the questions were sort of never ending and really good. It's interesting how listening to the podcast is making people think about deeper questions. The day after Jenny and I recorded, I woke up thinking, well, that really went well. I love that we should do more of that, you know. And I got an email from Jenny, you know what it said? Jenny told me we should do that. Again, that's a guy was thinking that too. So we were like, You know what, instead of making this a protip thing that happens once in a while, and we can't just make it one episode. Because there's so many questions in an hour, I think it would just get overwhelming. You'd forget what you heard. I said, Jenny, let's break these up into smaller episodes, so they're a little more digestible, and keep doing them. You know, I'll put up a thread every once in a while and we'll get new questions from people. Jenny was like, that's a good idea. I said, Jenny, why are you talking like that? And then I realized I was texting with her. And she wasn't really talking. I was just making up that voice in my head. Anyway, welcome to ask Scott and Jenny, answers to your diabetes questions. For those of you who think that Jenny and I have practice this ahead, you'll know for certain in a second that that's not true. I did send any of the questions so she could look at them. There's no I don't

Jennifer Smith, CDE 2:31
think I did not. I think I looked at like a couple and I was like, Okay, we'll just attack these as we get to that, because I can't, and it was like, 945 at night, and I was like, my brain has no bandwidth, or reading or Okay.

Scott Benner 2:48
All right. Well, I'm just gonna start what I see is the top right, so I think I can get first names. Lionni asks, she says, I just started listening to the series with Jenny and you in the last month and love it. My question, how do you combat that morning glucose rise, no matter what time of the morning, I wake up, as soon as my feet hit the floor, my sugar spikes, Basal increase causes lows, and doesn't fight the rise quickly enough. I know hormones get released when you get up, but still haven't figured out how to stop it from happening. So I'm not fighting highs all morning and delaying food. Good question. Good question. I have very little to add to this. But I think I should go first because I think it will lead you please. I have Arden's you know Basal program set up for a normal day being alive, getting up at a certain time going and doing something summertime comes along or Saturday comes along and she sleeps in. Now all the sudden her Basal insulin that kicks in at like 630 in the morning, so she can get up for school demands too much at some point. So I wake up a little earlier. And I dial her Basal back for a very long time, usually by 30% Does it most days, if she's trying to get low, there might even be moments in there for half an hour right to shut it off completely, to create, like, like there's so I have to mess up on the loss so that she can. So that's the sleeping in idea. But the reason I bring it up is because what it taught me is that opening your eyes, makes your blood sugar go up. And I know technically that's not true. But I think there's something about being awake and alive and aware and anxious and in a hurry and all the other things that come with being alive and having your eyes open, make you need more insulin. So now you can tell her like the technical reason for all

Jennifer Smith, CDE 4:36
that. Yeah. I mean, you alluded to some of it really, it's like, you know, what we kind of commonly referred to as the dawn phenomenon, right? And while most will say oh, it happened somewhere, you know, starting around maybe three or 4am and continues through, let's say maybe 8am. Most people really see it heaviest. Once they do wake up, it's almost Like the feet on the floor, and my blood sugar is rising, and I haven't even like said hello to my dog yet. And my blood sugar is like skyrocketing, right? And this listener reader poster,

Scott Benner 5:12
essentially, is a listener, but she follows okay for Facebook.

Jennifer Smith, CDE 5:16
Awesome. So both fabulous. So essentially, it has kind of the right idea, we would typically say, go ahead. And if you are, in fact getting up at about the same time, every day, like Arden's example, her normal school day, she's getting up six o'clock in the morning, if that's your typical, and you start to see a rise by 615, the accommodation in Basal is appropriate. But in this setting, perhaps the Basal hasn't been adjusted high, soon enough to accommodate for when the rise is going to start. So you know, if the rise is starting at 615 in the morning, and you have your Basal set to increase at 6am 15 minutes of more Basal isn't going to offset arise in 15 minutes, it's not going to do it, like we talked about in the Basal, you know, setting episodes, you really have to get about an hour lead way before you expect to see a rise or a fall happening in your blood sugar. And so in this instance, again, you'd probably need to do a, an increase in your Basal around 5am. If you want an offset arise that you know is going to happen by six 615 To get started, because then by then the Basal be high enough, it'll stop it from happening, you won't have the spikes.

Scott Benner 6:37
This is an example of like what I'd say about like anything you're doing with Vincent currently isn't for now it's for later,

Jennifer Smith, CDE 6:43
it's for later, right. And if you are getting low, you know, she mentions, well, I've tried the Basal thing and it's causing you to go low, it may be again, the timing, it may be that the Basal isn't adjusted high enough, soon enough. And if you're adjusting it six o'clock to accommodate for a rise 15 minutes later, but then it doesn't need to be high anymore by 8am. By that's why you're low is because it's high hitting you at a point when you now no longer need it to be too high. So it's kind of a mismatch of timing. The kind of the other compensation like you bring up, you know, for Arden's sleeping days for adults who are on their own. And I, I did this, you know, with my pump early on, I figured out the same thing. My work days were very different than my weekend days. Not by much. I mean, I'm not I wasn't a teen, it's not like I was sleeping until 11 o'clock versus getting up at six o'clock. But even if I slept in by an hour or an hour and a half, that Basal accommodation that I had set, it was it was too much. So I actually created weekend or day off profiles. And on Friday night, I would set my weekend profile to start running. And it accommodated for that time of day that was just longer in asleep,

Scott Benner 8:04
I would say to for any pump companies that may be listening, you have to be able to they need to be automated. I agree. Or you can't make me remember Friday night to turn on my Saturday Pro. I had

Jennifer Smith, CDE 8:14
reminders on my phone. Yeah. And then my reminders specifically said it wasn't just alarm going off. It was turn on weekend Basal. On Sunday night, I had an alarm that said turn on weekday Basal. Otherwise, I would forget,

Scott Benner 8:29
of course, people for people who are thinking about it on this level, there's no safety concern with allowing them to change their Basal programs automatically. So my last few thoughts about this are basically Liana, what what, what Jenny's saying is, is that you're throwing a punch an hour after the fights over, you know what I mean? You're putting your insulin now, the extra Basal, but it isn't working right now, all of a sudden, an hour later, when you kind of don't need any more. Now all of a sudden, it's there. She's thinking maybe and by the way, right? You know, this is our guests off of four sentences. The other thing I want to say, right? It's interesting to me like Leanna, she says, I know hormones get released. This is what I always talk about. Don't spend so much time trying to figure out why it's happening. Just stop it. You know what I mean? Like, when the bank robbers coming in the door, we don't try to figure out the psychology of why he thinks it's okay to steal from the bank, someone just really needs to stop, right from stealing. So I get it fixed, then if you want to, you know retcon it and think you know, analyze it, then do it. But don't worry. In the moment you need more insulin when you need more insulin. Okay.

Jennifer Smith, CDE 9:37
And another I guess another accommodation just to finish it to is for people who do have more shift kind of work and let's say as you brought up it's hard to remember to change a Basal pattern and to remember you needed on Tuesday for this shift in this, you know, Friday for this shift in a weekend and a day off and whatever. The other potential accommodation that does work for some people is it You know, by evaluating what the rise is that you get, as soon as you wake up, let's say you always know that you get a 5070 30 point rise in blood sugar, you can actually use your correction factor in an opposite way, then you can say, Okay, if one unit drops my blood sugar by 50 points, and in the morning, I have this consistent 40 To 60 point rise in my blood sugar. But when I wake up, if I take a unit of insulin right now, I should be able to offset that rise, because we know it's going to take about 15 to 20 minutes to get a Bolus working. Usually that rise is going to be seen, if it's going to start it's going to be within about 15 to 30 minutes of waking up in the morning. So if you can take that Bolus to offset with a figured amount of insulin, it's another way to accommodate if your days are very different in when you wake up. So you're over bolusing the morning. So you're over Bolus in the morning without ever playing with Basal. You're just accommodating for the rise that you know is going to be there

Scott Benner 11:04
like that. Okay. Do you need a breath? Yeah. All right. I'm good. Here we go. Jennifer asks what I think is a really interesting question. She says so garden, did she, this must be a brilliant question, right? She says so carbohydrates begin digestion in the mouth and absorption can start in the mouth. But the amount of time that the food actually stays in the mouth before you swallow it isn't that great? Then it goes to your stomach. There's about three hours before it moves on to the small intestines for digestion finishes, and then the majority of absorption happens. So my question is, why do we Bolus for the insulin upfront? Why don't we Bolus heavier on the end so that three hours afterwards to catch it when it's being absorbed by the small intestines? Now? I think there's a this is an interesting question, because I think it's possible Jennifer asks, and answers her entire question. What she needs is someone to come along and tell her she's right. Or maybe right so there's a lot in here. So for food does not spend very much time in your mouth by now. The quickest way to stop a low blood sugar is your chipmunk. You just run around with your nuts. He pocketed your key. Yes. Run around with your nuts in your mouth and looking for a hole. That's what a chipmunks right, saving for a rainy day. Anyway, jeez, this is gonna go off the rails, we need to be more structured than this. But so she's you know, I just the other night, a person who's been on this podcast, you guys haven't heard her yet, but contacted me privately. And she said, I just Bolus eight units. And I meant to do point eight, and I'm alone. And I don't know what to do. And I've drank juice, but my blood sugar is like I think it was in the under 40. And so I started like rattling off like, get some of this, get that get this well the person's like, like keto or low carb or something like that. Like I don't have any of that stuff in this house. I was like, okay, so I was like now I'm like, Oh God, now I'm on the hook. Like I'm really thinking right? I said, Oh, sugar bowl. And she goes, Yeah, I said take a teaspoon of sugar. Just melt it in the saliva in your mouth and keep it in your mouth. Like don't smile, it just keep it there because your cheeks super absorb really quickly. Right? So I guess this is an interesting question. And we'll get to Jennifer's overall question, but how is it when my blood sugar is 50 and it's not falling? And I drink, you know, 1015 carbs of juice? How does it pop up so quickly after that? Where does the majority of that absorption happen? Because I'd imagine that just doesn't even make it to your stomach because you start seeing it hit pretty quickly. Do you know?

Jennifer Smith, CDE 13:44
And well in that in her question, and this kind of bring up component of a meal, right? If you're drinking something like juice, the reason for juice being recommended, or any very simple carb source being recommended as a true treatment for a low blood sugar. Or, you know, the reason that you want to Pre-Bolus if you just decide you're going to drink juice and you're not low is because you do need time, because that is going to work fast. That sugar gets absorbed. In the absence of fats and proteins and fibers and other things. Sugar itself gets absorbed pretty quickly. And it gets it gets absorbed essentially, you know through the whole passage and a liquid sugar source things like a gel or a goo or the juice or even like you said liquefying like in fact, something I learned years ago was if I choo choo choo choo choo, the glucose tablet up and needed almost like liquidity in my mouth and then swallowed it. It was a lot faster and why I came to this probably in those strange moments of low blood sugar where you're like, oh, let's try this and your brain is like floating through mud and like, whatever. But I figured, you know, I figured out what works a little better. So that liquid component to it, it gets absorbed a lot faster. And in a very simple sugar form, it's going to get absorbed through the digestive system much, much faster. Now with a meal, she brings up a good point with a meal. Why am I taking this big upfront Bolus? For food, that probably is going to hit me at least some of it is going to hit me a fair amount of time later, right. Thus, you know, a lot of the reason that they truly built in especially for pumpers, that feature of a combo or an extended or a duel or a square wave Bolus, two pumps, that's why it's there. The problem is that you've been taught how to use your pump, but you haven't really been taught how to use your pump, the insulin works, you've not been taught, this is how the insulin works. This is the component of a meal. This is why the insulin needs to be matched to this kind of a meal. This type of food, you know, together. This is the type of Bolus you might need. I mean, the science behind it is more in depth than the education that's being provided it is. So again, this brings up a very good question and potentially, you know if that's if that's what this person is seeing, then yes, an extended Bolus, if you're using a pump is probably in your best advantage to try to figure out writing down some of your common meals. Seeing what is your CGM trend look like trying to match accordingly. You know, maybe I need 30% of my meal Bolus right now. And maybe I need 70% of it drawn out over two hours to accommodate that kind of digestion.

Scott Benner 16:53
I think I think this this question from Jennifer made me think she's never heard an episode where I do Arden's lunchtime, insulin and Arden's blood sugar's already like 80 Because that's the exact situation where I go, Okay, we're gonna use 13 units now. But it's 0% up front and the rest over a half an hour an hour. Because I need I needed to start happening. But I needed to, I need the impulse out longer shot longer, right? Yep. All right. Yep. For now. I think that answers Jennifer's question. I also wrote down that if this wasn't a regular episode, I would call it floating through mud, because that's the most interesting like analogy I've heard for being low ever, like the idea that you're floating, but very slowly.

Jennifer Smith, CDE 17:33
That's how I feel. When I it's one of the best descriptions that I've like been able to come up with for how I have felt long term because symptoms change for low blood sugar for many people. But I've always had this feeling that I'm sort of like, floating or slogging through mud. Like, I feel like I'm moving exceptionally throw the very slow, but my thoughts at the same time are running extremely fast. They're like they're spinning and spinning and spinning and spinning. But I feel like I'm just the slow like, I'm like the slowest, slowest slot on the planet.

Scott Benner 18:13
For your life, but you're changing your chair.

Jennifer Smith, CDE 18:15
Yeah, yeah, it's just, it's, it's a weird sensation.

Scott Benner 18:20
The way you said that.

Jennifer Smith, CDE 18:22
floating through IDs like that.

Scott Benner 18:25
At the beginning of the podcast, I told you that this episode was sponsored by in pen by companion medical. And I want to tell you a story about how that came to pass. So things don't happen as quickly as you might think. About a year and a half ago, companion medical came to me and said, we'd love to come on the podcast and talk about this new smart pen we have it works with Dexcom. It's really terrific. And it's called in pen. I said, Yeah, that's nice. But I can't have you on the show. Because my daughter doesn't use it. I don't know anything about it. And that means a lot to me. I can't take an ad from somebody that I don't really know. You know what I mean? You guys don't even realize it. But there are people who try to come on the show all the time to push what they do in the world. You know, I'm a physical something, I do this for people. And if I don't have direct knowledge of what they're doing, I don't let them come on here. I don't let people just come here and sell to you. So anyway, I kept talking to in pen. And the more I heard from them I liked but I still didn't have any like real world data to back up having them on the podcast. So I told them if you want to come on, that's great. You'll have to sponsor the whole episode. I want people to know for certain that this is an ad. No mistakes, right? I'm not saying I use him pen or I stand behind it. But if you want to come on and talk about it in pen, do it. Just make sure people know this is like a paid for episode and way back like a year ago. They did just that in episode 174. In the year since then. I can't tell you how many of you I've heard from her like Scott, I heard about impact on the podcast. It's amazing and everyone's telling me about how well what's working for them? And what a great thing it is for them. And not only that, but I'm going to talk past the music here for a second. But not only that, but major props to Omnipod for never saying to me, Look, you're taking ads from us. So you can't do like a pen to. Nobody does that this is a very open community. We're building here on the podcast, and it's very collaborative. It's fantastic. So anyway, you know, Omni pod doesn't stop me from taking other ads, you hear people come on here all the time and say I wear a T slim or, you know, I use a libre CGM. Nobody ever gives me trouble about it. When I set these things up with the sponsors, I was clear upfront, you know, I can't stop somebody from saying they use a product that's not yours. If someone starts saying something about your product that you don't like, I'm not going to stop them. I can't do that. And everyone agreed, which, you know, is great in theory, but it's actually happening in real life, like in real life, none of the sponsors have ever called me sent me a note or anything and said, Hey, we didn't like what that person said there, please, you know, could just stop that. That is never happened on this show. I would never let that happen, which I liked. Because I like this information to be, you know, unfiltered for you. Anyway, in pen came back a couple of months ago, and there said, you know, we really would like to buy ads on the show. Is it possible that you'd be open to that now? I said, I gotta tell you, I've heard from so many of your users such great experiences, I think I would. But let's not just lay an ad in the middle of the episode and clog the whole episode up with these ads, right? Let's do something interesting for my listeners. So what I decided was, I'd like to talk to an in pen user, and then break up their story kind of a mini episode, over a number of weeks. And that's what I'm going to do on these Friday shows these episodes on Friday for a little while, are going to be sponsored by in pen, and you're going to hear from one of their users. Now, I think we found a really cool user with a really amazing job. And I don't think we have the person exactly nailed down yet. So if the wait a second longer to make sure that she's on board, should I even say she I'm not sure. Anyway, I'm pretty sure it's gonna happen. So this episode of The Juicebox Podcast is sponsored by in Penn by companion medical, and for now, there's nothing for you to do, unless you'd like to learn more. And you can go back to Episode 174. And listen to the conversation I had within Penn last year. Coming soon, of course, the story of an impending user and some links, you can click on To find out more. Thanks so much for listening to ask Scott and Jenny. Be sure to go follow the Facebook page bold with insulin so that you can ask a question next time the opportunity arises. And please don't forget that Jimmy Smith works at Integrated diabetes. Not only has Jenny lived with type one diabetes since she was a child, but she holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps, and continuous glucose monitors. All of that is nice. But here's what you really need to know.

I like the way Jenny thinks about type one diabetes management. I love it. Actually, she fits right in with how I vibe. If you'd like to hire, check her out at integrated diabetes.com There are links in your show notes. And at juicebox podcast.com. Thank you to everyone who sent in their question. We look forward to doing this again and again. This is going to go on for a while guys. I have a feeling this is going to be pretty popular. I'm tempted here to sing along with the music until the end of the show. Because I hear from a lot of people that you like that. But privately I want you to know that I believe you're mentally unstable for thinking that and I will not be encouraging this with anything today.