#355 Ask Scott And Jenny: Chapter Thirteen
Answers to Your Diabetes Questions…
Ask Scott and Jenny, Answers to Your Diabetes Questions
How do you estimate how long an increased temp basal will be necessary based on the amount of fat, carbs or protein in a meal?
Is there a strategy for eating food in a certain order?
Let’s talk about artificial sweeteners, sugar alcohols and the impact on blood sugar.
What happens when you fly with an insulin pump?
Let’s talk about the first years of diagnosis and the impact on long-term health.
Is it true that younger children are harder to control? Tips on pre bolusing kids, not comparing your graphs and asking the right questions.
How do you calculate your bump and nudge ratio?
You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Pandora - Spotify - Amazon Alexa - Google Play/Android - iHeart Radio - Radio Public or their favorite podcast app.
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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.
Scott Benner 0:00
Hello friends, welcome to Episode 355 of the Juicebox Podcast. Today's show is an hour of ask Scott and Jenny. I'll tell you about Jenny in a second. But let's look at my notes here about what's involved in this. Out.
Unknown Speaker 0:18
Increase babies.
Scott Benner 0:21
I can't read my own writing, but this is a thing. Well, alright, hold on. Let me count the scribbles. 1234567. Jenny and I are going to talk apparently about seven different things about type one diabetes today. And all those questions were sent in by listeners just like you. I'm sorry, I cannot be more direct than that. I tried to make a list. I wrote them down. I just hold on. Air travel with a pump. Alright, that one I got figured out our kids easier when they get older. Maybe that's what that means. My writing is terrible. Is there a method to bazel increases Temp Basal increases? That might be what that is. Order. ordered. Cathy, that can't be right. Um, figure out bumps. I guess that's about how do you know how to bump and nudge. Bad. Turn COVID. Court Li issues Wait, what? Between Okay, not bad turn between old something issues. Health beegees that health? halt all halls.
Unknown Speaker 1:52
Okay.
Scott Benner 1:55
Um, anyway, it's gonna be a surprise. It's a great episode. I just edited it. I really loved it. I just edited it. The other day is edited a word or do I say it wrong? It's hard to know, I guess. All right, hold on a second. Let me tell you a little bit about Jenny Smith. You know, Jenny, of course, from the diabetes pro tip episodes from ask Scott and Jenny, and defining diabetes. Jenny has type one diabetes now for over 30 years. I wonder if I could do this off the top of my head. I'm gonna go to where I have the information. Give me a second. I'm gonna go to where I have the information about Jenny. But I'm going to try to say it off of the top of my head first. So I'm near Jenny's thing, but I'm not looking at it. Alright, ready? Off the top of my head. Jenny Smith has had Type One Diabetes for over 30 years. She's a certified diabetes educator. Something nutritionist, a certified trainer on most makes and models of pumps and continuous glucose monitors. She's a terrific person. Alright, hold on. Ready? Now let me go to the thing. Jenny Smith has lived with Type One Diabetes for 30 years. She holds a bachelor's degree in human nutrition and biology from the University of Wisconsin. She's 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. But of course, most importantly, she is the best Juicebox Podcast Guest ever unless you've been on the show. And then in that case, you're the best one and Jenny's the second best one. I wonder how well I got that from the first thing. We are four minutes into this now are you guys listening to this? I'm so sorry. This episode of The Juicebox Podcast is sponsored today by Dexcom. On the pod the Contour Next One blood glucose meter and touched by type one, there are no ads in the show today. I'm just here to remind you that these are the advertisers and that they're lovely. And if you're interested in them, using my links helps the podcast and I appreciate it. Usually I tell you dexcom.com forward slash juice box, my omnipod.com forward slash juice box touched by type one.org. And I usually say something about Contour Next One but I've got my own link now. So you got to remember this one now. Contour Next one.com forward slash juice box. And now I'm just gonna make sure that that's actually correct because that feels wrong. Nope, it's right. Contour Next one.com forward slash juice box. Check out the Contour Next One blood glucose meter and all of the meters that contour cells. Also do you know it's possible that you're paying more to your insurance than it would cost to buy test strips in cash. You should check that out at the link as well. Do you want a free no obligation demo of the Omni pod sent directly to your home? do that at my link to my omnipod.com forward slash juice box. Dexcom is Guess where all the great information about the G sexist, but that's a lot. So go check that out too. And when you're done, you're gonna need some energy because you've been on the internet now and you're getting sleepy. Touched by type one.org. It'll lift you're right back up again. Let's get to Jenny and the Ask Scott and Jenny questions. Thank you everyone for sending in the questions that you sent. I am sorry that at the moment, I don't remember what any of them were. But I do remember that they were wonderful. Jenny was fantastic. I of course, was delightful. Hey, now please remember, please remember 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. One last thing juice box. docs.com is an ever growing list of doctors and other helpful people in the medical industry that you found you the listeners have found and shared with me. We're making a beautiful list. You can add to it if you want or go take from it. It's like that Penny thing at the convenience store. Give a penny take a penny. Give a good doctor. Take a good doctor. When Jenny and I record we usually catch up for a few minutes first, and I don't record it normally. But this time I did. It's just us talking about weird stuff going on around Coronavirus in our lives and I left it in for you. You can eavesdrop on the silly things we say to each other when no one's listening.
Jennifer Smith, CDE 6:31
Because their haircut had been delayed twice. We had had haircuts set up right including my own. You got a friend who has her own shop. And so she was going to do the boys it's in with the boys watching a movie with their little girl who is just a little older than Oscar is. And she was going to do my hair all set up. Now we rescheduled it because things had been like postponed. Now we've rescheduled it again for like mid May. Who knows whether that my boys look like shaggy dogs. Like I was like, even my husband was like their hair needs to be cut like it was getting to the point of like they'd sleep. And that bed head was like just not culpable. How did you no matter how much I just I caught it. Have you ever cut anyone's hair before? Um, I've trimmed their hair before in a pinch like this, okay, but like this was really like it was a haircut. And I it's fine.
Scott Benner 7:27
Kelly, Kelly sent me the other day, time to go to the heavier hair product. And I was like, Yes, I'm gonna need something with a little more control. I had my hair kind of short recently. And so I was just using like a little paste or rod or whatever, just like just a little bit. And now I use it, my hair is just like weak back, we can overpower that. And you know that I'm gonna have to go to a baseball hat pretty soon. And I don't think I have the head to shave my head just to start over again. So I'm not doing that.
Jennifer Smith, CDE 7:57
It's kind of funny. I actually I refer to like those days with diabetes, where you're just like, I don't know what's going on today. And it's just weird and bizarre. I called them I call them bad diabetes hair days where there's no amount of like mousse or gel or whatever that you can throw at it. That makes it like flap down the right way. That's how I count for that.
Unknown Speaker 8:20
How long have you been in your house by now?
Scott Benner 8:23
This is in three days. I'm on to three solid weeks.
Jennifer Smith, CDE 8:29
Yeah, by the end of this week, it'll be three solid weeks. Yeah.
Scott Benner 8:32
Can I make them? admission? Yeah. I know a lot of people say this. But I haven't really noticed that much of a difference in my life, which I'm assuming is bad for me. But, but also, I find it incredibly relaxing
Jennifer Smith, CDE 8:50
that you don't actually have to physically go anywhere.
Scott Benner 8:53
what the expectations are gone now
Jennifer Smith, CDE 8:55
are gone. Right? Yeah. Like, you're not expected to attend the ball down the street or go to some fees like hoopla right?
Scott Benner 9:03
My kids keep my house clean. Talk to my wife the way we always do. There's nothing there that would change and put this podcast out in the schedule. Nothing else in the world matters right now.
Jennifer Smith, CDE 9:16
Yeah, that's the only the biggest things I mean, that are changes for us. Like I love. I love grocery shopping. I love grocery shopping. And at this point, my husband is the one that's actually going now to the grocery store, pick
Scott Benner 9:31
the person
Jennifer Smith, CDE 9:32
because we pick the person and I'm the person that doesn't have you know, so. So yeah, so he's the one going to the grocery store and doing all that I like, I feel kind of a sense of loss.
Scott Benner 9:45
Oh, wow. Now I hear you. I'm the one having to go to the store. So yeah, and I've been twice now. And I'm like a ninja. I just have a little schmutz in my pocket. You know, I'm sure there's a real word for it but the stuff that kills the germs. And I hadn't, you know, I don't touch anything, bang, bang, bang and grab my stuff. Get out of there gela hands, move to the car, get the stuff into the car gel the hands again, get back in the car. You know, get it home, I strip away the packaging and do all the things you're supposed to do then clean the place where I stripped away the packaging, clean my hands again, and I'm done. I'm just like, hmm, probably should be doing this all the time. Not this intensely. But.
Jennifer Smith, CDE 10:28
But something similar. Yeah, actually sounds very much like ginger. You know, she actually posted something the other day about this is, this is what I do my one trip out of the house like and we also in, we've been really trying to like, we get the load of what we need. And then we really like our refrigerator right now is on the minimum. I think the only fresh vegetable we have left in our fridge right now is celery. Like we got to get to the refrigerator or the grocery because I need more than celery and hummus.
Scott Benner 11:03
That's a Facebook post for us. Anyway, we're down to celery, it's time for the celery. It's time,
Jennifer Smith, CDE 11:07
right? But so ginger actually takes she has gloves. She wears them, she actually takes in paper bags to the grocery store so she can get her groceries into the paper bags. Rather than having to push a cart that somebody else pushed, she takes them to the self checkout. So nobody else has to touch her groceries. She puts them into her bags. And then she actually doesn't even take those bags into the house. She like, takes the stuff out, puts them in a new bag to go into the house. And she's like, and I wash and scrub and I sanitize and I she's like, that's what I do.
Scott Benner 11:40
So my friend washing a brand new bag of potatoes in their sink yesterday. And I had two simultaneous thoughts. I thought that's a great idea. And I laughed a little bit. So but I when I put the hand sanitizer on I hand sanitize me and the cart. But But again, I got lucky because when we moved my son out of college, he had a 40 ounce jug of hand sanitizer that he hadn't touched. Oh, it was like finding a gold brick and the top of his like I was up in the top of the shelf. I was like, Oh my god, I'm so glad you're coming home. You're saving all of our lives Look at this. And and and then it made me think like, why does he buy stuff like this and then not touch it and use it for anything? Because he we didn't give it to him. He needed it for something. He got into his head at some point, you know,
Jennifer Smith, CDE 12:28
yeah, he put it in the back of his closet.
Scott Benner 12:29
Yes. There's a 20 year old boy for you. He heard about what was going on. I do remember sending him a text. And I said, Look, I know I bug you sometimes at school about sanitizing your hands, please be a little more mindful about it. Like I was trying to get him moving before this all exploded without worrying him. And so I guess he went to the trouble of buying it, which was not using it away rather.
Jennifer Smith, CDE 12:51
I'll use it when it really gets. Alright.
Scott Benner 12:53
Now he did say he had a little one he been using. So I'm like, maybe he was using I mean,
Jennifer Smith, CDE 12:58
or maybe he was using the big one to refill his little one who wasn't open to me. So
Scott Benner 13:03
let's try not to be too full for
Jennifer Smith, CDE 13:05
giving him a little credit.
Scott Benner 13:06
He's two years into college. He just committed to his major he the other day. He's not exactly out in front kind of kid. Yeah. So anyway. Oh, I want to tell you something real quick. And then we'll start this recording. And All right. Let's get back to our Ask Scott and Jenny list. I say what's
Jennifer Smith, CDE 13:30
on the plan today? Well, I gotta tell you, oh, no, I never know. I appreciate
Scott Benner 13:34
that about you, by the way that you've never once been like, exactly what we're gonna talk about before we talk about, which is why it is a surprise. This time, I actually marked the ones we did with a little word done next to it, which trust me is a major, major consideration for me because I'm not normally even that smart.
Jennifer Smith, CDE 13:54
You're smart. You're just not that organized, right?
Scott Benner 13:56
Well, sure. I keep a lot of stuff in my head. I don't write stuff down. I'm not I don't check boxes and stuff like that. But sometimes like this is a necessary thing to me. All right, I'm gonna start with
Jennifer Smith, CDE 14:09
Well, our list here is also very long. So putting done next to them was Oh, yeah,
Scott Benner 14:14
it's a long list. I'm just telling you. I'm not normally that smart. Bethany asks, Is there a way to estimate how long an increased bazel will be necessary based on the amount of fat carbs or protein in a meal? So she's looking for if there's this many carbs then do it for that long, but I don't know if there is or not,
Jennifer Smith, CDE 14:35
not typically I and that's why we have the we have a standard of what we say start with right for fat end of the meal increase the bazel by 50% over the next six to eight hours. experience will show you whether or not that works well. I for one have found that an increase in bazel for a while That meal in the daytime, I don't need as much of an increase, and I don't need it for as long at night. So for example,
Scott Benner 15:09
if I think,
Jennifer Smith, CDE 15:10
I think it's because during the day I'm, I'm up, I'm moving after the meal time, like if I go and I have a higher fat type of lunch, let's call it pizza or whatever, right? That's the typical example. Usually in the evening, I would need that 50% increase, and I typically need it for about six hours, during the daytime lunch, I usually need maybe a 30% increase, and I only need it for about three or four hours. Okay. And I I have to save from just experimentation. I think it's truly because after lunch, I'm not going to lay down for a four hour nap. I'm up, I'm moving, I'm doing things. I've got things to do around the house or with my kids or whatever. I'm just busier were in the evening time after a dinner like that. Well, I might be doing some things like putting my kids to bed or doing the dishes or maybe in the laundry or something. But for the most part, a lot more like sedentary. I went to the evening.
Scott Benner 16:09
Yeah, that makes sense. I listen, obviously, I think about it in pictures. But in my mind the basals a, it's a heavy jacket. And you mean you put it on while you need it. And when you get too warm, you take it off. So it's easy to say if you have a CGM. But if you don't then just test at more at intervals, I also believe that after experience, you know, the answer will come to you. Let's say it ends up being four hours that you need this basal rate for, you know, the second and third time it ends up being four hours. Well, I mean, then I stopped testing and I assume it's four hours. Right? You know, but you have to try it to know,
Jennifer Smith, CDE 16:45
to know, and the same thing kind of goes for protein, you know, the, the bolusing strategy for the most part, not bazel increased. But the bolusing strategy for protein says try to start it at the end of the meal extend the whole bolus out over the course of a three hour time period. Well, on average, people probably needed somewhere between two and four hours, depending on the portion of the meat, you know, if you're only bolusing for 12 extra grams of protein versus the night that you go for your 16 ounce pound of steak and your bolusing for 40 grams of protein. Very likely, that's going to also define a time to extend it out over Hmm. Because of the portion, right, it's kind of like the load impact versus just, you know, yeah. So that that can help with that too. The other thing for protein is kind of the kind of protein, you may find that leaner proteins such as, like a lean chicken, or even most fish tend to have a lower impact on blood sugar over the hours after even if the quantity is large, you might still have to cover it but maybe not quite as much as something like red meat. Okay. Red meat has not only does it take longer to digest, but it also has a lingering impact. Yeah, so those are some things to consider. I wish people
Scott Benner 18:15
could see that out last night Arden had a an avocado salad and edamame a for dinner. Yeah. And I want to say that i bolused 40 or 50 carbs for that. Like, and that I think is stuff people look at and go there's, that's free, almost that's a vegetable. And then I looked at the fat and the avocado was a big part of it. Like I think the true carb count, if I was really paying attention was probably more like 30 carbs when she put the dressing on and stuff like that, which she didn't use a ton of. But I looked at the fat and I was like, all right, like we're gonna need more power here. This there's going to be more glycemic load here from the fat and not in the way you think of it normally not, not from carbs, but just from its ability to hold it up which I think yeah, I think that might lead us into Jamie's question here. Now Jamie bemused, Jamie says maybe this is a pro tip and you tell me if you think it needs its own miniature discussion? Because this is something I've I don't think we I don't think I put a ton of effort into understanding but I know that some people do. She's asking about eating food in a certain order. Her examples last saving fruit for last, when you aren't as low as you would be when you started the meal or like the other way around, like what do you do? You know? So the
Jennifer Smith, CDE 19:36
timing or the placement of the food intake?
Scott Benner 19:39
Yes.
Jennifer Smith, CDE 19:41
Is to a degree, there is some there is some strategy for what she's kind of talking about. You know, if you are starting on the higher end, blood sugar wise, and let's say you didn't have as much time to Pre-Bolus as you would have really liked to Sure. If you Start the meal with, like, Iceberg lettuce and the protein part of it right, you're gonna have that sitting in your stomach first getting worked on first before you maybe get to your baked potato or your rice peel off, or your fruit on the end or whatever it might be, starting with the lower glycemic or almost no carb kinds of foods first, yeah, puts that into the stomach to get going. We know that proteins and fats take longer time to process and digest to begin with. And well, I mean, I kind of always think of my stomach kind of like a cement mixer. Right? It's not just taking your chicken and digesting it, and then moving on to your berries and then digesting those. I mean, it does all get churned together and processed, you know, with stomach acids and whatnot. But for the most part, yes, if you can start the meal with the things that you know, are going to be slower, letting the insulin kind of get working and going, and then add in the carbs at the end. Absolutely. That's a strategy strategy to use. Yeah.
Scott Benner 21:01
And I mean, I've had I've sent Arden into a meal more times than, you know, I can count where she's, you know, 70, or 65. And the last thing in my text was like, start with, you know, whenever the simplest sugar is, right, is that
Jennifer Smith, CDE 21:15
what the right the apple or apple sauce or whatever,
Scott Benner 21:18
right? I've said before eat the banana first. And I know that's not exactly. I don't think she looks at it and thinks I should eat the banana first, although I don't know. Because yesterday, what did she say to me yesterday? That was she said, Can I have a snack? And I was like, yeah, sure she goes, so what do you want? And she said, Oh, no, wait, it was at the end of breakfast. And she's like, Can I have a little more food? And I said, Sure. What do you want? She said, can I send bacon and an orange? And I was like, yeah, you want a bacon with orange. And we had a little bacon left on a plate. And I had oranges. And I thought, all right, and she looks so happy. She's like, the orange and picking it the bake? And I was like, well, that's a weird mix. Definitely what she wanted. So, you know, I mean, I think that's, I think it's reasonable to be thoughtful about it. Now, I do know, there are some people who steadfastly eat their meals and orders to keep these incredibly stable blood sugars. I don't know, I can't speak to it. And I don't know that I would want to live my whole life that way, either.
Jennifer Smith, CDE 22:22
Right, you know, strategy wise that what you found works, and that makes you happiest, because then you're not dealing with the flux in blood sugar. Great, if that's your strategy, have at it, keep up with it, you know, everybody finds what works, or hopefully, they're learning to find what works, right. But I mean, even even in consideration it if you're looking at a dessert, like at the end of a really big meal, a good example is something like a Thanksgiving dinner, or a holiday meal, or you've had all of these like, heavier, more dense types of foods. And then at the end of the meal, you add like grandma's apple pie with like marshmallows baked on the top of it, or whatever it is, you know, you're thinking, Oh, my gosh, this is all sugar. Well, what else do you have to consider, you have to consider all that other food that's sitting in your stomach. So, so heavy, that might actually be a time that while normally you'd take Bolus and Pre-Bolus everything, not even choosing an extended Bolus. Yeah, at this point, you've got all this extra food sitting in your stomach. And while this is simpler sugar, its impact is going to be drawn out. So you may actually want to do an extended bolus for this dessert. Because otherwise you're going to go low,
Scott Benner 23:43
because it's flopping into your stomach and laying on top. It's not part of what's happening. Right? Correct. Yeah. See, that's the stuff that is it's smart to understand. And I just think I think of it is experiential, like I just might go I know from experience this doesn't need a Pre-Bolus the way it would normally we already and I think of it as like, we already have so much insulin in the processes or I guess what we're saying the same thing. The process is already happening. Now we're just throwing in, you know, like another teaspoon into a gallon of water. And yeah, okay. By the way, all of Jamie's questions are like I think this would be a good pro tip. I think she's trying to produce the podcast here which by the way, there's some really good questions here. I don't think this one needs its own episode. So I'm gonna ask one more of Jamie's questions because she asked specifically. I want to know Jenny's take on artificial sugar. So artificial sweeteners. I know they affect people differently. But in she said In your opinion, which ones seem to have the least impact. She said, I also feel like a lot of people don't realize you can see rise from zero carb drinks. I will tell you that Arden doesn't drink a lot of soda. But if I start seeing her blood sugar gets sticky. I look to see if she's gonna Diet Coke. And that sometimes that holds her up a little higher. It's not like don't get me wrong doesn't make her 300. But it could make an incredibly difficult 140. Right? It doesn't want to give up.
Jennifer Smith, CDE 25:12
So there are I mean, if you wanted, gosh, I'm trying to remember what the university was that did a study on. Like, how much of the on the market artificial sweeteners is considered safe, according to the type of artificial sweetener in the product. Right? So if you've got something like equal, you're talking about the artificial sweetener, aspartame, okay, right? If you're talking about Splenda, you're talking about sucralose. So and then, of course, there is sweet and low, which is this the saccharin kind of component right? Now, there are also what I call alternative sweeteners that I think sometimes get falsely right, that get falsely kind of categorized with artificial stevia, being one of those alternative sweeteners. It comes from a plant Yes, it is processed the the sweetening pieces that come out of the stevia plant get processed in order to make a product that you can like, you know, put into your, your drink tea, coffee, whatever sweetened beverage, you know, sweetened a baked product, with what with whatnot, but the studies around impact from stevia, comparative to those that are truly artificial, by artificial, I mean chemical in nature, they don't come from natural, outdoor plant life. Right, they are created in a lab. So those, there are acceptable limits to like how many packets a day technically you should have, or how many soft drinks you should have with how much or, you know, beverage or how much how much per packet or whatnot, and each of the different sweeteners does have a limit to it. I mean, it's, it's a lot. I mean, most of them, it's like 15 packets a day, you're 25 packets a day. I mean, maybe some people are having that much I,
Scott Benner 27:29
I hope to you,
Jennifer Smith, CDE 27:31
it seems like an awful lot to me. And I
Scott Benner 27:33
know, can I say something now that we've met in person? Yeah, not that this doesn't come across the video, you're in really good shape. Like you take really good care of yourself. And so like Jenny's fit, you know, she she's trying to embarrass us right now, only only I can see her and she's still embarrassed. But I mean, I thought you'd have a take on this, like, you know, I guess some people might be like, here's a glass of unsweetened tea, I'll put five packets of Splenda in it or something? I don't know,
Jennifer Smith, CDE 28:00
you know, right. And I mean, that it's a it's a question that she asks a good question, because it's something that whenever I'm talking nutrition with people in a visit, it often does come up, you know, what do you think about the artificial sweeteners, especially in the women that I work with through pregnancy? Right? It's a very common question, should I be you know, should I stop drinking my diet coke, blah, blah, blah, or whatever it is, you know, I, you know, we there are studies, I think that they're kind of like a 5050. There are studies that kind of err on the side of these are chemical in nature. They're, they're not natural. They're not like going out and pulling the broccoli off of your garden stock, right? It's something that some very smart lab chemistry person put together and hey, it's got a sweet taste. And hey, it doesn't. For many people, it doesn't raise blood sugar. I can't say that's 100% true for everybody. Like you said, Yes. Sometimes you'll see a rise and sometimes no sweetener sweetener.
Scott Benner 29:07
Yeah, I don't know if it's the I don't know if it's the artificial sweetener specifically, or if it's impacting or in a different way or I don't know what it's doing to her but her if she drinks too much Diet Coke, her blood sugar gets more difficult.
Jennifer Smith, CDE 29:20
Right? Right. Yeah. Right. And, and I've actually had some people I used to tea but teach a an in hospital type to class for people with type two diabetes. And even they, it was a very common question, and I can very much remember one older woman. She was like, in her upper 60s, the cutest little lady. And she was like, I can't drink those diet beverages. I just can't drink them. I'm like, Okay, well, why you know, the class is always like a discussion about you know, what works for you, blah, blah, blah. Just like every time I have them, my blood sugar goes right up and So and then obviously didn't have a continuous monitor or anything, she was really only doing it by finger stick analysis, you know, and whatnot. But I mean, she, her records actually showed I mean, she'd have nothing in the afternoon except her diet soda. And by dinnertime, her blood sugar was going up. If she didn't have it, it wasn't going up. It didn't happen. So, yeah.
Scott Benner 30:25
So aside from what you just said, which makes total sense that, you know, limiting the chemicals going into your body, probably a smart move. I don't eat that much sugar to begin with. So when I have a cup of tea, if I use two teaspoons of sugar, I mean, whatever, right? Like it, if Listen, if two teaspoons of sugar in a cup of tea is going to take me down Jenny, then I guess that's gonna take me down. You know, I mean, I, I just feel like that it wins. But
Jennifer Smith, CDE 30:50
I think eight grams of carb there.
Scott Benner 30:52
Yeah, I don't love I don't I don't need a lot of sugar at all. But, you know, at least it feels natural, to some degree, you know, so I didn't make it in a lab.
Jennifer Smith, CDE 31:05
You know, that's kind of what I say even about like the sugar free like the sugar free candies and whatnot that are out there. I mean, it kind of brings in along with artificial sweeteners. Of course, there's also then the alternative, like I said, the stevia. But then there's also another sort of bank of sweeteners, which are those sugar alcohols, right. And sugar alcohols, again, they come from, from plant based foods, most of them come from fermenting fruits and vegetable, carbs or sugars, so that what ends up happening in the body is the fermenting process allows a much slower impact on blood sugar than you would get from all out sugar. So most, you know of those sugar alcohols they provide only about half the amount of impact that true sugar does. And it's kervin action is very very slow. They also if you eat too many of them are not very nice digestive Lee on you. But I always feel like you know if you're going to eat three sugar free Hershey candy kisses, I would rather have the real thing. Yeah. And that's purchase personal at like you said you'd rather have the real sugar in your cup of tea than something that's artificial. And if you account for it in your day, total, you're keeping track of things. calorie wise, most of those sugar free products aren't lower calorie overall than the counterpart of regular things. Oftentimes, when they take sugar away, they have to add back something else that tastes a little bit better. And it's often fat. Yeah.
Scott Benner 32:46
Well, I listen, I will have chocolate once in a while. And there's a company that makes a chocolate chip that I find to be like a really quality chocolate chip. And instead of having like a Hershey Kiss, or something like that, not there's anything wrong with a Hershey Kiss, but there's a, you know, there's a quality issue there, like market chocolate versus, so I'll buy like a bag of chips. And if I want chocolate, I'll take like, I don't know, four or five chocolate chips. Yeah, by the way, the bag of chips is like $3 and it lasts forever. You know? So there's ways to, you know, substitute things and and correct and get more. I don't know, this isn't English, but more real food into your snacking. Even snacking like this, you know?
Jennifer Smith, CDE 33:32
Right, right. Okay. And I do know, I remember, if somebody wanted the actual information about how much artificial sweetener they can take in. It was a study done by the University of Alabama at Birmingham. You can actually go to their website and they give you information on how much saccharin aspartame and sucralose is appropriate. It's based on 150 pound person.
Scott Benner 34:00
So yeah, so be 150 pounds. You're taking this that into effect,
Unknown Speaker 34:03
FYI,
Scott Benner 34:04
restructuring your multiplications and your divisions in your business. Well, all right. Well, this question from Libby may not apply in our new world. But flying in an airplane and pumping with an insulin pump. So does air pressure deliver insulin? Is that why some people find themselves lower after a flight if they're wearing a pump? Jenny Jenny has read she just readjust her jaw six different times and a word. Yeah.
Jennifer Smith, CDE 34:36
Well, I want to I want to address it in terms of being true in also that there are no
Scott Benner 34:45
studies. There
Jennifer Smith, CDE 34:46
are no true studies that are approved by some fancy university or research laboratory that has actually done this. However, there is anecdotal let's call them evidence from people have diabetes where insulin pumps, and they've actually documented what happens when you fly with especially a tube insulin pump, okay? It's more, it's more of a known issue with a tube insulin pump, that in the ascent and descent with a tube pump pressurization can actually either withdraw insulin back into the reservoir, thus creating an air bubble in the tubing, and potentially then causing a lack in pumped insulin. Some people experience not only a high at some point, or a rise that they can't explain because they haven't had any food or anything else happening on a long flight. Or, in this example, a drop down often, and a lot of people refer to them as like the baggage claim lows, where they finally get to the baggage claim. And as long as their hike through the airport hasn't been like six miles, you know, they're huffing it. For the most part, people end up waiting for the bags and have a low blood sugar. And why it's because potentially on descent, there is a pump out of insulin from that piston from the pressure that pushes the insulin through the tubing and delivers almost a bolus of insulin, then that's it's not registered by the pump, you can't go into your insulin dose history and see oh two units was accidentally delivered. The pump doesn't give you that because it wasn't there were no button pushes get it.
Scott Benner 36:33
So it's like having a like a like a flatbed hose full of water and the water is just sitting in it, but you grab one side and give it a squeeze and it runs out the other side. So the air pressure increases and forces the insulin through an air to come out of your set. So that's where it goes
Jennifer Smith, CDE 36:48
correct. And our recommendation to kind of counter it is on ascent and descent, essentially, you disconnect. So for those with tube pumps, you would disconnect disconnect from your sight as soon as your rising or taking off. Once you get to cruising altitude, you go ahead, look at the tubing, if there are any air bubbles, prime the tubing, flush the air bubble out, reconnect cruise through, you know your three hour flight or whatever it is, as soon as you start your descent, go ahead and disconnect when you land. Go ahead again, take a peek at the tubing. If there are any air bubbles or anything, you essentially flush them out and reconnect. Yeah, that way you get rid of both potential problems makes sense.
Scott Benner 37:33
I happen to I'm googling while you're talking. And Medtronic has a little update on their site about just being more like attentive, which I think is any company's way of being like, you know, we don't really know what's gonna happen. So you pay better attention. And I'm not picking on Medtronic, I'm sure there's a version of this language is probably on everyone's site. But you're saying with Omni pod it might not exist?
Jennifer Smith, CDE 37:57
Yeah, there's I've only had, I've only had one person that I work with. Who has definitely she's noticed something happens. She always she never has highs. She has lows.
Scott Benner 38:12
But that's right. So
Jennifer Smith, CDE 38:13
but again, that's an N of one with one pump. And I you know, I've I've flown often enough I've worn Omni pod since 2006. I've flown a lot in that what? Almost 14 years ish, right? And I can't say that I've noticed anything. That's a trend when I fly. That would indicate Yeah, this is definitely happening three quarters of the time. We
Scott Benner 38:39
don't treat them differently during air travel at all. I mean, you know, maybe when you get out of the car at the airport, we're not I wouldn't bolus a 120 you know what I mean? Like I want to get through security and all that stuff with nothing going on. But as soon as we're back through, everything goes back to normal. We bolus normally on the plane and every other Yep. So yeah. Okay.
Jennifer Smith, CDE 39:01
The only thing that I guess it's not really in answer to this, like pressurization. But the one thing I do Do for travel and a lot of people notice is that many times when you're sedentary for more than about a two hour time period, you might actually need a temporary increase in your bazel just from the sedentary nature. You know, when I fly long distance, and I'm going to be sedentary for more than that two hours, I find that I need about a 15 to 20% bazel increase just
Scott Benner 39:28
to cover the fact that you're
Jennifer Smith, CDE 39:29
just not active anymore, just to do right.
Unknown Speaker 39:32
Okay. So, all right. What else?
Scott Benner 39:36
Well, Shannon has one here. Okay, that I don't know if we're gonna have the answer to or not. But let's take a look. It's a long one. So I'm going to synopsize she's curious about the health of older people with type one who have had what she's calling wild blood sugars in the first part of their life, but then learn tighter control later. Will they have you know, issues like that? or other health complications. And the last part is people who had to survive without CGM. Okay, so people who lived before all this technology, you know, like me? Yeah. Like
Jennifer Smith, CDE 40:15
I lived before all this
Scott Benner 40:16
fallacy. Oh, you know, I mean, I would I would say what we've said in the past is you can't bank health. Right. So you, but
Jennifer Smith, CDE 40:29
I don't know it also is not a like it, you know, the question really did really poor control leave lead into issues now that even with good control won't negate them all? we don't we don't know. Right, right. I mean, for the most part that earlier, less than optimal management wasn't good. I mean, it wasn't helpful, right. But does it mean that down the road with more optimized control, especially with the technology that we have, likely the control now is a huge benefit. And the fact that you were likely younger, and had the benefit of youth at that point, versus being older and now having really tight management, that's the benefit now that you're older. And as body systems age, things can break down faster? It is. It's just the life cycle. Right? It would
Scott Benner 41:34
make sense that while your body is older, and you know, by definition, more frail, that the better control, the better off it would be. I also do you remember back when they used to tell you like, Oh, you know, don't worry about blood sugar control in the first couple years when outlawed little kids even when Artem was first diagnosed. I was like, that doesn't make any sense to me, like a little bit it does. Now when I look back on it, like the idea of like, okay, she's young, and hopefully she's vital and healthy. And if you know, we scratch her arm, it's going to heal back over. And so if we scratch some veins on the inside of our body, they should heal. Okay. I don't know that that would be true for everybody. But I get the overall idea. But I think the danger of that idea back then, at least the way I saw it was that you were giving people the idea that blood sugar management didn't make a damn bit of difference. If you were young enough. You know, you've got five years to figure it out. Like I remember being told that when she was two, like, Don't worry, she's little. This won't hurt her right now. Like that does not make any rational sense to me.
Jennifer Smith, CDE 42:36
Yeah, my nephew was actually kind of the same thing. He was diagnosed when he was seven. And that was actually something that their pedes endo actually told them where I heard it. 100% it was, you know, don't worry right now he's not, he's not in his teen years. And you don't have to worry about anything? Well, from a, from a true standpoint, what I know is that we want to aim for more optimal, regardless of what age you are. Yeah, there are, there are some, like factual studies that have actually shown that once kids get to the teen years, with the hormones of growth within the teen years, that starts to make more impact on potential future complications. If glucose levels are poorly controlled, in that timeframe of life, comparative to earlier on, when the hormones are different, there's still growth going on. Obviously, you can see it in your kids as they grow when even when they're little, and they're not a teenager. But the difference being more of those like sex hormones really into the teen years have more of an impact. For whatever reason, I'm in the standpoint of glucose control being better or worse, and then what happens down the road? So
Scott Benner 44:02
trying to imagine like, you know, changing the sentence slightly, like, how about this one? Your four year old can smoke cigarettes, they're young enough, their body will fight it off. Would you say that? No.
Jennifer Smith, CDE 44:13
How about No,
Unknown Speaker 44:14
no, no, just a little crack cocaine. She's only six. Yeah, like, she'll bounce back from that
Jennifer Smith, CDE 44:18
wants to have the beer for dinner every night. Let her have
Scott Benner 44:22
a little she's only eight. It's never gonna impact her long term. Like, none of those things make sense to me. Don't right. And so when I was told that I was like, Listen, I am not buying into this mess. You know, uh, but at the same time, it didn't go well for you in the beginning. I think it is a lot akin to smoking cigarettes. The sooner you quit, the better off the rest of your time is gonna be.
Jennifer Smith, CDE 44:47
That's right. That's I mean, that's the reason that you know, parents are told not to smoke at home with their kids.
Unknown Speaker 44:54
Right, everybody.
Jennifer Smith, CDE 44:57
I mean, it's actually something for my nephew. I told him parents when they said, well, the doctor says it's okay, if you sit at you know, 200 all night, it's pretty safe. And as long as you staying under 250 That's okay. And I'm like that that's not okay. I mean, I really had to, like, emphasize to them that that that's not okay. He might only be seven, eight years old. But these numbers are not where you want him to be.
Scott Benner 45:21
Right? Well, um, here's what it reminds me of. And I probably said this once before, but it fits right here very well. I once helped a person in their late 30s make a pretty drastic transformation to their management pretty quickly. And when it when it kind of, you know, our time together came to an end, this person was really grateful that their blood sugar's were now, like in range and controllable, and, you know, not so variable, but angry and sad that someone hadn't told them about this sooner because they had had diabetes for you know, the better part of 25 years. Right. And and we're really concerned about exactly this question, like, What's going to happen to me in the future? Based on what happened to me, you know, in the beginning, and why would nobody have explained to me that, you know, Pre-Bolus things important, or any of the other little things that we talked about together? And the best I could say, in that moment, because I was out of my depth, you know, what I mean? Like, I don't have diabetes, no one's ever lied to me about my health care for dozens of years. And so I just said, Listen, you know, now, just do a good job, move forward. You can't change the past, you know, any other birthday card euphemisms you can think of, there's no sense in hanging on to anger about this, like you have a real chance. Like, let's see what happens. You know, I keep doing it. And and let's hope for the best and right. I mean, do you really have any other options than hoping for the best?
Jennifer Smith, CDE 46:53
No, there's not. And even, you know, if you knew what wasn't working in the past, it was likely because technology wasn't where it was today, right? I mean, my my mom definitely says, as I've said before, if she had the technology, now, she would have felt a lot more comfortable sending me off to a sleep over that the parents weren't given like a two page sheet of instructions of what to do, you know, she would have been able to follow things from home and felt a lot safer when she sent me to sleepaway camp. And, you know, all of those pieces of management that were there, we did the best that we could, but I'm quite sure that in between the finger sticks, I had a date, I'm sure it looked like a roller coaster, because we didn't know what was going on.
Scott Benner 47:40
I think that at some point in the very beginning, the statement 200 safe overnight, don't let it go over 250 I think that was probably reasonable at some point, you know what I mean, because of the lack of technology. And when they say safe, they didn't mean safe to your health, they meant safe, that you won't drop too far and get really low. Like that was the that was just try to understand that at some point, because of where the technology was, in the past, the entire focus of type one diabetes management was don't have a seizure, right? And don't go into DK, it was literally these two opposites. They didn't care about anything else, because they didn't know to care about anything else, because they didn't have the ability to care about anything else.
Jennifer Smith, CDE 48:25
And for little kids who don't often have symptom awareness.
Scott Benner 48:29
Even more important, even more important back then. Right? They can't tell you the problem ends up being is that as we leapt forward and leaped forward and leapt forward with technology,
Jennifer Smith, CDE 48:39
the education didn't
Scott Benner 48:41
Yeah, and and, and these, you know, tried and true methods of well, 200 safe and don't go over 250 they got passed down generation to generation. So what you're really seeing is that there's one group of people, health care providers, right, who have an origin story. And that origin story builds on how they talk. But a different group of people over here, device manufacturers, right? They're trying for something different. These two people do not intersect in their day to day business and the way they talk with other people. So while this guy's telling you to hundred safe, this company is over here telling you Hey, I think our gear can keep your blood sugar at 85. Which one sounds scarier? When the doctors telling you just to hundreds, okay, you don't want to get low and then the next person is like, Hey, 85 is possible. That sounds scary. Right? And so you're never going to reach the masses. Until healthcare professionals have the ability to believe that the technology does what it does, and are willing to say it out loud. And you know, I don't know. Good luck with that. Good luck getting a bunch of people to say what they think you know, instead of what they think is safe to say. Luck. That's gonna be very interesting. You know, if the FDA would let not let but I guess if if device manufacturers could get into the business of teaching their devices beyond, this is how it turns on and the sound turns off, then they might have the, the onus might be on them to show you how to use it correctly. Right? And because then they could really market their their devices as living healthier, not just easier, because that's how that's how they're stuck. That's how they're stuck marketing right now. It'll make your life easier. It'll be a smaller part of your life flexibility. Yeah, yeah. You don't want to have to disconnect to do this right on the pod. And like, like, and that's the stuff there. I don't want to say stock saying cuz that's a lot of valuable information in there. Yeah. But they don't get to say the rest of it. Like, why don't you try the Basal increase when you have pizza? Like, they can't say it, they can say the pump does a Temp Basal increase? They can't tell you why in the heck you might want to try. Try it. And therefore it's a tool you don't really it's a screwdriver, and you don't know how to use it. You don't know what it's for, you know, just know you have it. Anyway. Alright, that went down a weird road. Um, let's see. Sarah says, Sarah has three names. And her middle name is fun. Sarah says, I'm not sure if this is big enough. There's nothing too small to Jenny and I won't talk about. But is it true that younger children are harder control to control compared with older ones in terms of their blood sugar? Does body size make a difference? I always look at people stable graphs with such envy, as we seem to go up and down so much. That sounds like their daughter's two years old. Is that more normal in younger children? Or is that more proof of my inexperience? Because we're only about a year and a half into this? Well, I think it's probably both an indication of your inexperience and normal. I always tell people, you know, figure out how to use the insulin so you can feed them so you can fatten them up because this is easier when they get bigger. But I don't know if that's just me, or if that's true.
Jennifer Smith, CDE 52:07
Ya know? And they're they're kind of a number of questions within the question, right? There's, there are a number of things to kind of bring about our younger kids harder to manage than older kids. I think it's, it's a different strategy of management. Because variables through the life cycles change whether you're two or 82, there's always going to be something that's a little different in young children, you know how fast growth happens. So growth, impact is always going to be more profound than when you get to, let's say, the teen years, especially for like a teen girl, let's say, who's not growing anymore. But now she's got hormones and a monthly cycle and things like that. So that's in the picture, despite growth not being in the picture, right? You know,
Scott Benner 53:00
we talked about it wrong, though. We always say diabetes is always changing. Diabetes is the same, their bodies are changing. That's right. Right, right. So you know, when your kids littler, and like Jenny's saying they're putting on a pound or two every couple of weeks, that's making your bazel not correct, as they get bigger and bigger, right? Or at the same time, they become more active, they start to walk or they start to do more things. That changes the impact. And, and so is it harder, it's the same, it just changes more frequently, or growing, right? And then right, when they get to that point, you're talking about where they're like a, you know, an adult woman who's getting their period. It's still happening, but it's happening cyclically by week, this week is different than that week, and that week is different than this week, and you have to know what week you're in.
Jennifer Smith, CDE 53:49
Correct? Yeah. And then, you know, with little kids too, you know, the other the other part of little kids that can increase the amount of variability which she brings in, you know, I feel like we're all over the place versus some of these graphs that I see it that are just nice and flat. Well, the variability with a small child, 235 years old or whatnot, you know, and I mean, I know myself with even the way that my three year old eat, he could love the same exact breakfast and eat it 100% for five days in a row, and I give it to him On the sixth day, and he eats three nibbles, and he's like, I'm all done, mom. Okay, well, great. Now, if I had to, like Bolus for that, and I work with so many kids that I see this as a consistent problem, right? I mean, that as variability. Now you've bolus for this amount of insulin, and there's not this amount of food there. So you have to offset it in some way. Well, that brings in a potential roller coaster. If you haven't quite yet figured out how to offset what you sort of front loaded with.
Scott Benner 54:54
Right. I I always say that I think the key to Pre-Bolus in kids is to choose what ever amount, you know, they're gonna eat. Like it might just be five carbs, but nope. But have you ever sat your kid down, they've just been like, I'm not eating this at all that they put something in their mouth, right or they switch to something. So if it's a 20 carb meal, and you have that feeling of like, I don't know is this the day the kid just doesn't eat their breakfast Pre-Bolus five, you know, carbs have it right and get some insulin on your side. And then when you see Oh, this foods going in, then put the rest of it in right away, or they throw up their hands or like not today, lady, then you've got some time to decide what else they could eat, you haven't personally insulin for the entire 20 carbs. Now you're sitting there, just staring through the wall going, Oh, my God eat food. Because there's, because there's reasons you don't want to do that. You know, because you don't want to cause a weird relationship with your type one diabetic and food, you don't want them to feel like food is the thing they have to do even when they don't want to. There's some really good psychological reasons not to do that. Ah, you also don't want to get into the roller coaster situation where their blood sugar goes to 300 and then comes crashing down and then they have to feed them and that becomes your day. So you have to Pre-Bolus something. You know, it's so funny that I was corresponding with a person who was gastroparesis one time. And they were saying I really want to Pre-Bolus but I don't know how because some days my body starts to digest my food. And some days it doesn't. Right. And after a long phone conversation, I said, you should do what people do with little kids, and just get a little bit started. And then as you see your blood sugar, wanting to go up getting the indication that your food is being digested, then throw the rest of it in, right, that ended up working for that person,
Jennifer Smith, CDE 56:42
or throw some in and extend the rest of it, or keep
Scott Benner 56:45
eating it out into the future. But get it
Jennifer Smith, CDE 56:46
moving. Get it moving.
Scott Benner 56:48
And when I said that she's like, That's brilliant. I was like, that's not brilliant. That's desperate. I did not know what else to say. Like, well, but you've
Jennifer Smith, CDE 56:56
had enough experience with other situations in which that that sounded like a good alternative.
Scott Benner 57:03
parallels to try it. Yeah, yeah,
Unknown Speaker 57:05
absolutely.
Scott Benner 57:06
Absolutely. I was gonna say that I think that a pit that we all fall in it's one point or another with diabetes. Or maybe life in general, is feeling like there are rules that we don't know. And that we have to find those rules so that we can follow them when obviously, that's not how life really works.
Jennifer Smith, CDE 57:28
There are guidelines, I always feel like it's like this is your guideline to like, the exploration of the woods behind your house, right? There's no rules to follow. It's just don't go near the growling bear in the bush over there best practices, maybe some best practices, you know, that kind of a thing. The other thing that I did want to say is, you know, it's really hard with today's online community with diabetes, which is phenomenal. It is great. I wish I had had it as a teenager and even an adult into college. It would have been fantastic. But I also think that we unfortunately, start to compare to what other postings show. Right? And I I don't think that's fair to do. So in this case, you know, this mom was like, why see these straight graphs all the time? You don't know what went into that straight graph. Yeah. You don't know the food intake, you don't at the activity level, you don't know where they are in diagnosis, or whatnot, there's, there's a lot more that goes into that flat or that curvy or that, you know, up down roller coaster or whatever kind of graph. And so it's easy to stay, it's hard to like, accept, but don't judge your own management off of what somebody else has posted.
Scott Benner 58:56
Yeah, the things that they say are the important parts of getting that so I'm going to show Jenny something that she doesn't see they're gonna see versus that where's my camera? Can you see that? Mm hmm. Okay, so that's three different people I'm tracking on Dexcom. Wait, what are their blood sugars?
Jennifer Smith, CDE 59:12
Ah, one is 98 with a horizontal, straight, steady, and other one is 93 with an angled arrow up, and another one is 130 with a steady straight horizontal arrow,
Scott Benner 59:25
okay. Do you know what those three people have in common? They all have diabetes. They're managing their diabetes. This is gonna sound horrible to somebody. But trust me, I'm not trying to be like that. I'm not being pompous. They're using my style. Sure, that's what they have in common. They're reacting to certain things, doing certain things, not letting some things happen. Like that kind of stuff. There's a it's a system, they have a system on their head. They're following that system. And so at the same time of day, those are three people blood sugars that are pretty much the same, you know, they're there. They're stable in a great spot. Yep. It's because it's, it's the style. It's your style of management. So when when Sarah asks, Is this my inexperience? Not my circle, it might be an experience, it also might be that you're very experienced that something that doesn't work, right, you know, and now you're just beating your head against that wall going out, understand, this is what I was told to do. Why isn't it working? So there's one of those kids on there, I was texting with their mother last night. And I was like, you know, you need to give her some insulin right here. And she's like, I don't want to her blood sugar is only 140. And I was like, I don't care. Like, if you don't stop this 140 and make it 90, then two hours from now, when she goes to bed, she's going to be 200. And then you're going to get into a different space. And so my concept is, if you don't get high, you won't be high, you will be high. Right? And and it turns out if you put those concepts into practice, I mean, the pro tip series you and I did is just it's that's it. Like that's the whole thing right there. If you do those things, that's it. If you if you gave me three more kids, their blood sugar's would be right around there right now, then there's anomalies that happen, like, you know, I don't sometimes, you know, people eat things. They don't say what they eat, or they miss count carbs or don't don't aren't intuitive enough about glycemic load and index and stuff like that. But for the most part, you take the steps. It usually works,
Unknown Speaker 1:01:31
right? I mean, I don't
Scott Benner 1:01:32
know another way to say it. Like, I'm not trying to say it's easy. It's not easy. But there there is a formula in there to leads to that. Mm hmm. So that's two kids in there that are, you know, one of them's probably still asleep, one of them they're in, they're in different time zones, but they all have the same experience
Jennifer Smith, CDE 1:01:49
strategy.
Scott Benner 1:01:50
Yeah. So Sarah, I think you figure out what works. And then stay flexible while your kid is growing. And keep applying the tools. Understanding that the game is changing, right? A little bit. So yeah, if that makes any sense or not.
Jennifer Smith, CDE 1:02:08
And certainly reach out, you know, for help. Remember to ask more. Remember to ask more questions, even at your doctor or endo visit or CDE visit or whatever it is. Remember to ask more in depth questions in order to get more in depth help. Oftentimes, I think people end up going in not really knowing what to ask because they haven't gotten help before. So they just leave it up to the doctor to kind of give information, and then they get nothing back. And they think Well, my bad, dark, dark doctor is not very helpful. But if you don't bring in more I see this happening around gymnastics every day. I see this happening every Tuesday, Wednesday, Friday. Can you help me? Great. Now the doctor has more to go into the data and pull and get a trend. Yeah. And offer better suggests you have to
Scott Benner 1:02:59
you have to step back and have a macro view of diabetes. But you have to have micro questions. Right? Like, right, so like, you can't just yell. I don't understand every night at midnight, her blood sugar's high. But that's your macro view of it. That's not helpful to the person trying to help you. What's your micro view of it? What's happening in the hours just prior to that? Those are the things you need to know. You know, it's this one kid's blood sugar's were not great. Three days ago. And if you looked at the tech, I did it through texting. If you look at the questions, I asked them, most doctors would not look and go, Oh, well, those are the questions that need to be answered to fix this kid's blood sugar. I ask really odd things that answer the questions I need answered. And so my point is, is that those are the questions to me, you ask? Those are the like the micro specific questions. Yep. And I don't know how you Sarah, I don't know how you figure that out other than experience time and don't give up. But I can tell Sarah and anyone listening this? My experience has been that people who are thoughtful and concerned and care and ask questions like the one Sarah's asking, those are the people who make out well, because they're there, they're interested.
Jennifer Smith, CDE 1:04:14
Right? And they're trying and they keep looking until they get an actual answer that helps.
Scott Benner 1:04:19
That's it. They're interested in, they're trying and they care. And to be honest, that's pretty much what you need. Right? As long as you don't give up. You'll find it at some point. You might not find it for me, you might find it somewhere else. But right you'll find something that somebody says that clicks with you and makes it all feel kind of easy at that. Right. Jenny are we at a time?
Jennifer Smith, CDE 1:04:37
You have about nine minutes left nine minutes, or something easy for nine minutes?
Scott Benner 1:04:45
Um Oh, there's no answer to that one at all was like, oh, half an hour conversation and a lot of people asked it to, uh,
Jennifer Smith, CDE 1:04:57
maybe it's a maybe it's a
Scott Benner 1:05:00
Well, let's find out what you think. How do you calculate your bump and nudge ratios? So when I say to somebody, hey, that blood sugar's 140, I'd like it to get back to 90, bump it back down. That's not a, it's not a measurable idea to people, I guess. Okay, so I usually say how much insulin Do you think moves it from there to there and just go with your gut.
Jennifer Smith, CDE 1:05:30
Right. And it kind of starts then with kind of brings you back to the pro tip series of figuring out things like bazel and sensitivity factor. And even, you know, that kind of stuff. Because really, anytime you're playing with the bump the nudge, you're playing with the assumption that you know, a certain amount of insulin, let's say one unit will move your blood sugar, a certain number of points, right. So if you know one unit changes your blood sugar by 60 points. And you know that your cup of coffee in the morning without bolusing. for it, you've noticed that it kind of raises your blood sugar by 65 points on average, well, you know what, then you need to start taking a unit of insulin to stop the 65 point rise, because one unit offsets you by 60 points to drop you from too high, right back to where you want to be. Right. So the bump and nudge is kind of if they're looking for a math, it goes along mostly with sensitivity factor or correction factor. It goes along with how much do I want to knock this down, and how sensitive I am I to insulin at this point in the day, because many people also have sensitivity factors that differ based on nighttime daytime, afternoon or whatnot. I myself have two sensitivity factors, one that lasts through the day time, one that's overnight for me. So you know, I'm more sensitive to insulin overnight. So I don't need a load of correction. If I choose to Bolus for a higher number that gets up there overnight. I don't need as much overnight as I do during the daytime. Yeah,
Scott Benner 1:07:11
I have to say I don't think I take it for granted because of the podcast. And but if I wasn't talking about diabetes as much, I probably would, that idea that I can look at Arden's blood sugar to 11 o'clock and say, that needs a half unit and look at that same blood sugar at 7pm and say, hey, that's a unit or at four o'clock in the morning. It's point two, it just, I don't know how to explain, other than to say, I look at the blood sugar, I look at the situation. And then I know how much to give her. But I don't know how to tell you what I saw. And how it led me to that answer decision. Yeah, other than to say have diabetes for a while. And all of a sudden, you'll just sort of know.
Jennifer Smith, CDE 1:07:54
Some of it is some of its experienced definitely like I you know, I can say that. Gosh, if I know that one unit again, changes my blood sugar by 60 points. But I've also got like a load of fat in the picture. Well, gosh, yeah, need a lot more of a nudge than you would if it was just because of miscounted carbs.
Scott Benner 1:08:12
And I'm not saying that I haven't adjusted a blood sugar at 1am at an hour and a half later been woken up by the same high blood sugar and then thought, oh my god, what we ate for dinner. Now I remember like that's gonna happen, you know. But the good news about that is, is that I was trying to stop at 140. And it's still 140 I didn't stare at the 140 hope for the best watch it turned into a 220 Bolus for it, forget about the pizza, get up again at three o'clock when it's 250. Like didn't even like eat right, don't let it get out of hand so that it's manageable, and then the bumping in the nudging becomes less, in my mind dangerous because you're using less a less a smaller amount of insulin to accomplish something. So I say if you ever seen me speak, which might never see again. But that jokes funny for a couple of reasons. And everyone listening is only gonna get one of them. But that's okay. Yeah, thank you, Jay. which you may never see again, if you know, I'll say look, I'd like to see a stop a 110 or 120 diagonal up because you might stop it with point two or point three or if you're an adult with a unit like a tiny bit of insulin, you come back to 90, and you sit stable again, the likelihood of you getting low after that is small because you've used such a small amount of insulin to begin with. So that's how you keep from overcorrecting. And that's how I think of bumping and nudging. But and
Jennifer Smith, CDE 1:09:34
that is that is really where our where our hybrid closed looping systems, like control IQ, you know, with tandem, that's really where those systems are going. The idea that the bump and nudge becomes less of your play and more of the pumps interaction because it's got CGM data to interact with and it can see a rise happening. It knows Okay, I've got this value, I don't want this person to get above. So it starts nudging it either with a temporary bazel change, or with these little micro, you know, boluses, the control IQ system is in a system so far in what it can do, but I think that's where, you know, further progress into the pump company. Is that where they're going with the technology? Yeah, because they don't want Well, they don't people with diabetes don't want, while you know how to pump and nudge now, you don't want to have to pay attention so much to have to do it all the time.
Scott Benner 1:10:33
I always tell people to bumping and nudging is a teaching towards some point, you should learn from the bumping that you should have done something different meal, you know, like it's not a it's not a long term idea. It's part of a bigger teaching idea. And having said that, when I watch an algorithm change basal rates and you know, put insulin in, I'm like, that's what I do. Wow, I'm not gonna have to do that. And exciting. And by the way, bumping in nudging is, you know, it's my idea, the words, and they're for sale. Like if a pump company wants to buy them for marketing materials, I'm open to having a conversation, you know, just let me know. Anyway, Jenny, I'm gonna say thank you. Hold on one second. Thank you. You can actually hire Jenny Smith, did you know that she works at integrated diabetes. And they have a website aptly named, integrated diabetes calm. So that's where you can find more about what Jenny does in the professional life. I don't know how often I mentioned this, but I like to bring it up once in a while Jenny is not a paid contributor to the podcast. She just really likes being here. So this is not an ad. She's just a friend who likes being on the show. But that doesn't mean you can't you know, there are a couple of bucks. Get some help with your blood sugars. That's what you need. Thank you so much for listening to the Juicebox Podcast. Thank you for supporting the sponsors sponsors like Dexcom that you can find out more about@dexcom.com Ford slash juice box. And how about tubeless insulin pumps? Well, there's only really one, but it's called Omni pod. And you can find out more about that. And get yourself a free no obligation demo sent right to your home by going to my Omni pod.com forward slash juice box. And to find out more about Arden's blood sugar meter, the Contour Next One, you go to Contour Next one.com forward slash juice box, you're seeing a theme here you get it. And of course touched by type one is that touched by type one.org great organization doing wonderful things for people living with type one diabetes, and all they want is for you to know they exist. So go check them out. Touched by type one.org you think we'd get a juice box slash in there, but it's not happening? Okay. I'm not hurt. Oh my god, that was exhausting. I'll see you guys later. Bye. It's hard to talk like that for a long time. Everything's real deep and you're trying to enunciate and to not over speak or understand like, Hello, this is the word of God. You know, all fields like that a little bit. It's been a long week, too. It's Friday. I need to get to the weekend. Actually. I'm turning 49 on Sunday. And I'm feeling every moment of it. I'm not I'm okay. Am I it's hard to tell. Who am I arguing with
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About Jenny Smith
Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com
The Juicebox Podcast is a free show, but if you'd like to support the podcast directly, you can make a gift here. Recent donations were used to pay for podcast hosting fees. Thank you to all who have sent 5, 10 and 20 dollars!
