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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 health care plan for becoming bold with insulin. The pen is America's only FDA cleared smart insulin pen and app system. In pen works like other pens, it's just a lot smarter, you can use it in pen, like any other injector pen. The difference in pen is that it tracks each dose and delivers your data to a secure app on your smartphone. So finally, there's no complicated math and no log book to update. In just a moment in pen user, Fiona Wylde is going to tell you a little bit about why she loves her in pen. And then we're gonna get right to ask Scott and Jenny. But if you're interested in finding out more, I urge you to go to companion medical comm or click on the links in the show notes for the ones that are available at Juicebox podcast.com.

Welcome to Ask Scott and Jenny. In today's episode, I Scott and Jenny Jenny Smith from the diabetes pro tip series in defining diabetes. You know Jenny, Jenny works at integrated diabetes. She's a CDE, a registered pump trainer CGM trainer dietitian, she has type one, I bet you that Jenny's the kind of person that would never throw a piece of gum in a wastepaper basket without wrapping it in a tissue first. Right after in pen user, Fiona Wylde tells us how her in pen helps her remember her basal insulin. Jenny and I are going to talk about your a one c test. What's better? Is it the clarity report from Dexcom? What that tells you? Is that what they give you in the office? How do you know what the trust and what not to? It's actually a bigger topic than you would think. And then in the middle of that Jenny ends up having her own question for me, which I answer.

Fiona Wylde 2:11
They also give you your long acting reminders by take lantis. So it'll give me a reminder of like, Hey, we need to take your lantis. And then you can record that in the app as well. So it says okay, I just gave myself X amount of units of lantis. Like it's all recorded in there. And that's good, too, because that kind of goes back to my thing of Oh, oops, yeah, I forgot to, you know, give myself an answer, give myself that. Because with pens, it is kind of easy to forget. Or it's easy to just like give yourself insulin and walk away from it. Because you don't have something attached to your body for the constant reminder. I definitely feel a bit more free, which is really nice. But it's easier to skip some things too. And that's why the in pen, make sure that you don't skip steps that, you know, maybe are easy to forget, but helps you plan for the steps that you didn't forget. And then it helps you plan for the future as well.

Scott Benner 3:09
Okay, now, Jenny, this one's interesting, because you said you wanted to do a pro tip episode about this, but it's a

Jennifer Smith, CDE 3:16
well answer the question maybe Yeah, the one I'm thinking of Lissa

Scott Benner 3:19
asks, my agency in the doctor's office is always much lower than my Dexcom. GMA, for example, my doctor said my agency was 5.7. But my GM for 90 days is 6.4. Which do you think is more accurate? Is that the one you were expecting?

Jennifer Smith, CDE 3:36
That's the one I was expecting. And it's a very, very common question. In fact, it's, it's a question that I get a lot from also from people that I work with. They're like, I see my CGM is telling me this and I went in and I got this a one c done. And my a one C is higher, my agency is lower. Right? So, you know, essentially, GMA and do you do Scott know what GMA stands for? Sure.

Scott Benner 4:04
It's gross mountain infrastructure. No, I don't know.

Jennifer Smith, CDE 4:10
Gi is glucose management indicator makes belts. Right. And if you remember with that within Dexcom for a while they had IE, a one c estimated a one C, right? Well, and then for a while, they got rid of any estimate whatsoever that was completely gone from any of your clarity reports. And then they they they did all of this, you know, hashing and thinking and putting together something new and they came up with this GM I termed concept, glucose management indicator and really what it means is clarity kind of has its own secret sauce, sort of algorithm that it takes your glucose within a range, you know, whether it's a 14 day 30 day 90 day, and it estimates based on where your glucose trend has been within that defined time period. So one, if you are looking at a time period of 14 days, and you're getting your GFCI, perhaps you've had really, you've taken all of the pro tips that we've done, and you've put them into work and you're like, I am knocking this out of the ballpark, I've got this beautiful like looking average, it's come down considerably. Your GM I, for that 14 day is going to look great. And then you go in, you get this agency and ah, e one C is higher. And you're like, well, that, that doesn't look great. Why is that? Well, the timeframe is different, we have to remember that a one C is averaged over a 90 to 120 day time period. Right?

Scott Benner 5:51
So is that what 90 to 120? Because some people get it done every 90 or every 120? Or is it because no it because it bleeds into that period, right?

Jennifer Smith, CDE 6:01
It has to do so 90 to 120 days is a one C is where a one c comes from mainly because of the life of the red blood cell. So doing a little biology for you, your red blood cell has hemoglobin attached. And when we look at how much glucose has attached, that hemoglobin part, we read a one c over the time period of life and have your average blood cell your average red blood cell which is about 90 to 120 days for most people. So we have this long timeline of how much glucose has kind of stuck there. And you can tell an average blood sugar value then based on that. So the problem is that of course, as we've talked before, a one c isn't the end all be all of glucose management, right? It doesn't give the time and range it doesn't give how much variability you're having to get that average it's just a one spot check in right and same thing with this GMAT. The GMAT is also just an average of where your CGM data trend has been over the course of whatever defined time period you have populated into your clarity report for that evaluation. So if you're looking at 14 days might look phenomenal. Or if you've been on vacation for 14 days, and you've been eating all of the pizza and Margarita is on the beach and whatever and not paying attention. You could have this high looking and you're a one c could actually have been much better because your time period before that you were doing a phenomenal job. So therein lies some of the difference there. Um, I guess

Scott Benner 7:46
I have a question. Wow. Okay. So imagining in your mind this, I think most of us think of it as a as, excuse me as a 90 day period, we had our agency checked and 90 days later, we do it again, if I had what, what you just described, not 90 days ago, but three more weeks past that if those three weeks were magical for me, my agency was five in those three weeks. And then the next 90 days, it was more like Melissa is describing it, you know, the GM is telling me the last 90 days was 6.4. But when I got it back, it was 5.7. Is it because some of those first 14 days might still be? Do you see what I'm saying? Like is the blood looking back further than my last doctor's appointment?

Jennifer Smith, CDE 8:35
possible? Actually, it's actually waited, I think what you're asking a little bit opposite. So if you the older red blood cells don't have as much impact on the ANC value right now today as the ones closer to today. So if you're a if your glucose was like, not where you want it to be three to four months ago, but in the past month, you've really reined things in and you've gotten it down and you've nailed it and you've got this beautiful looking standard deviation and everything is in range. This time period in the past month has more weight on actual a one C then 234 months ago because there aren't as many of those red blood cells hanging around to give data point two does that make sense guys?

Scott Benner 9:26
But then how is she seeing a 90 day GMA, that's higher than her actually one say. So take her out of it for a second when that happens. What what's the likelihood of the like what is like

Jennifer Smith, CDE 9:40
if her well, and that could have relevance to accuracy that has her CGM.

Scott Benner 9:46
I think I think Jenny hasn't had a signal on her Dexcom for a while. Is that what that?

Jennifer Smith, CDE 9:50
Oh, I haven't. I'm really really annoyed right now. This is I actually called in a sensor. We talked about this. I called you yesterday really annoyed, right? So, um, yeah, and this sensor has been wonky since I put it in yesterday. I'm back numbers. And now I have signal loss. And I've had signal loss three times this morning attempting to reconnect, wait up to 30 minutes,

Scott Benner 10:14
really put your phone up, shut off the Bluetooth, and then turn it back on again. So open your phone, close all your apps that you're not using except for Dexcom. Where you can close them off you want right now for a second. And then you know that you can leave. Then go into your settings. Oh, yep. And shut off the Bluetooth. Yep, then turn the Bluetooth back on. Open the Dexcom back up. And then this is where I tell Artem because Arden wears her Dexcom sensors on her hips. I'm like shove that phone right up your ass. Just stick it right next to the to the next to the transmitter. And leave it there for a few minutes. I bet you it's back in five or six minutes.

Jennifer Smith, CDE 10:56
Okay, that'll be awesome. If you are I see. Good to know people in the right places. Right?

Scott Benner 11:02
I'm right about that. I'm amazing. So and by the way, you just said something. I'm gonna ask Jenny a question. I'm gonna make myself a note. Okay, so I'm so sorry, with where the heck were we with?

Jennifer Smith, CDE 11:14
I know we're talking about accuracy. Yeah, I and so that's where some of that may have relevance. You know, I some people have really awesome consistent accuracy. They could do a finger stick occasionally. And they're like, yep, my CGM is right on with that finger stick. But you know now in today's world with G five, and now g six and whatever is coming out after this. with FDA approval without having new finger sticks. Many people literally aren't doing finger six anymore. Whatever is appearing on their CGM is what they're using. Well, unfortunately, CGM can be off. They may not be as accurate as what your true body blood glucose your blood cells are telling. So let's say this person's a one C is higher than the actual a one c comes out to be CGM, GM is higher. It could be that the CGM is actually reading higher than their true glucose trend is reading in their body.

Scott Benner 12:13
Yeah, I'll tell you that. Um, so that's an interesting issue. And what it made me think was what if she's she doesn't say here, whether it's a G six or a G five, right? What if she's calibrating with a meter that's less accurate than the CGM and she's lying to the CGM and to the CGM, like. So there's a lot of scenarios here. I'll tell you right now, that's why you have to put effort into getting whatever the best meter on the market is just get it I'm we have the,

Jennifer Smith, CDE 12:40
the Contour. Next One, that's

Scott Benner 12:42
the one I have. It's it's I don't think I've ever tested with that contour. And it hasn't agreed with a CGM that I believed was accurate at the time,

Jennifer Smith, CDE 12:51
the next most accurate is going to be the Accu check guide me. That's another one. That freestyle light by Abbott also does a really nice job accuracy wise, I think within the first with the top five that are on the market, those three are within that as far as accuracy rating.

Scott Benner 13:09
Because it's small, and yeah, it's it's got a nice bright light. For me, it doesn't take much blood to get it to go, No, and it's got second chance, I forget what they call it. But if you hit some blood, and it's not enough, you have like a fairly long

Jennifer Smith, CDE 13:23
time period, I think it's like 15 to 20 seconds to get another

Scott Benner 13:26
prop on more time than you need. So. Okay, and plus, I guess the other thing we have to consider, too, is and Maddie comes in and says that a nurse practitioner at her work told her that the A ones c machines are actually allowed to be up to point 5% off. So even there, it's just a bunch of things you don't consider like what if it's a little bit of all those things? You know, I don't know that to be true. And

Jennifer Smith, CDE 13:54
is it clear clarity? Therefore, the a one c machine would also be Is it an A one c machine that's an office a one c where they do your finger stick in the office and derive it, you know, within the next 10 or 15 minutes? Or is it a lab value a one c? That would be a good clarification to make for which a one fee is allowed to be your have such variants

Scott Benner 14:16
which would we prefer lab value right to for accuracy,

Unknown Speaker 14:19
lab value

Unknown Speaker 14:20
for accuracy?

Scott Benner 14:21
What about the finger sticks? How close are they do you think? in the office,

Jennifer Smith, CDE 14:26
the finger sticks can be a little off. I know my office when I when I used to see my endo in DC, they always did an office a one C and I always asked them at the same time to do a lab because I just I wanted I wanted the accuracy from it. There was always for me, my average change was about a point three. So if my agency was like, six in the office, it was usually like a 6.3 if it was like five Point either off, it was usually like a six from the lab value.

Scott Benner 15:04
I'll tell you how I think about it too. Like I listen, I don't I don't make any secret of an art and say when Caesar are fantastic, right, and they've ranged between five, two and six, two for over five years now, if we go in, and it's five, two, and then three months later, it's five, four. I'm not like, Oh, my God, I'm just like Arden say, once is great. You know, I mean, you know, I don't see a difference between a six two and a six, four, you're doing terrific. You know, like, it's not a lot to knock yourself up over, you know, not an OT, and then can Ott. Cool.

Jennifer Smith, CDE 15:38
By the way, I just want to let you know that your trick work. Of course, it's all have data. Yeah.

Unknown Speaker 15:44
Don't you worry, Scott,

Unknown Speaker 15:46
why not know that trick.

Scott Benner 15:47
That's how I got the podcast. That's fine. Good, too. All right. So Jenny's got her data back, we're all good. And that's a good Listen, there's a good one for all of you if you're using the Dexcom g six right now and you experience a signal loss and it tells you wait up till 30 minutes to reconnect close all the apps on your phone like crash them you know how to crash an app right? And then shut off your Bluetooth and settings. Wait a spilling off the wait long, turn it back on reopen the Dexcom app and then take that phone and stick it near the transmitter.

Unknown Speaker 16:21
The transmitter if

Scott Benner 16:22
people are apt to blame Dexcom which I'm sure they have culpability in this in some way or another but Bluetooth is a very in faxing problem call there's a lot it's a big part of this. So Bluetooth is is you know, it's got its problems. So that's why some people see better or worse results with different phones. If you'd like to learn more about the in pen, you can always go to companion medical comm where there are links in your show notes or at Juicebox podcast.com. And if you'd like to check out Fiona on Instagram, her latest picture is of her racing in China. She says it's pretty cool to be racing at the 2008 Olympic sailing center. She's Fiona underscore wild on Instagram. Fiona the classic way ephi Oh Na underscore, you know is like a dash but it's lower. And then wild Wi l d. Check her out. If you're on MDI and you want to stay that way, but you wish she had a little more control. Check out the in pan with your internet connection probably on your phone. companion medical there terrific. If you'd like some perspective on how not musical I am if that didn't just do it for you. Consider this in my head. The tune to Sweeney Todd was playing when I did that. I know right? There's no correlation whatsoever.