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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:00
Hello friends, and welcome to episode 685 of the Juicebox Podcast

we're gonna do something today that we haven't done in a little bit. It's an ask Scott and Jenny episode. This episode is full of questions from you the listeners that Jenny and I sat around and mused about. Please remember, while you're listening 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. The T one D exchange is looking for US residents who are caregivers of someone with type one, or have type one diabetes themselves to fill out a short survey. It's AT T one D exchange.org. Forward slash juicebox. Your simple answers to simple questions will go a long way towards helping people living with type one diabetes, T one D exchange.org. Forward slash juicebox. I just looked and we haven't done an ask Scott and Jenny since 2020. But this one will be the 15th installment. I hope you enjoy it.

Today's episode of The Juicebox Podcast is sponsored by us med. US med is a supplier of diabetes supplies. And all you have to do to get a free benefits check from them is go to us med.com forward slash juicebox. Or call my number 888-721-1514. The podcast is also sponsored today by Ian Penn, from Medtronic diabetes. Do you wish you had some of the functionality of an insulin pump, but you like injecting, if that sounds like where you're at, you really might enjoy the in pen. Learn more and get started today at in pen today.com

Jennifer Smith, CDE 2:18
really wasn't what we talked about before we

Scott Benner 2:20
really get talking people are like what's happening? Well, they don't, you know, so we just chatted before we started recording. And I think that's important for people to kind of relax and get into a flow, which I think if you look at the episodes where I'm interviewing people, it's why the first 10 minutes are sort of like the way they are just trying to get calm and relaxed. And I know there's a world where you can edit all that out. But I think it's interesting to learn about people that way. So anyway, when I think

Jennifer Smith, CDE 2:47
when you're talking to somebody for the first time, honestly, right, you might have emailed with them or whatever to kind of get things set up. But you've probably never really talked to them before. And it's you have this sort of get to know somebody, you can't just really just start talking about a topic.

Scott Benner 3:05
The top I do not talk to people before I interview them, they fill out this very short form. It says What's your connection to type one? Have you been on another podcast in the last six months? What would you like to talk about? I understand that this is for entertainment purposes only. That's it and then they jump on and I meet them right in that moment. And we start talking so I love it like that. I wouldn't. I mean, I've interviewed people that I've known about, I interviewed Robin ORS on the other day, and the peloton, girl that has type one. And yeah, I mean, everybody loves her. I 100% That's what I tried to tell her. She didn't seem to know. But I, I had notes and you know, she had notes about me. And we had we had in I'd interviewed her for print years before she of course, with no reason to didn't remember me, but her people filled her in about it. And like I don't know, like I would have much rather us just felt like we were like grabbing a drink together, you know? So anyway, it still was a really nice conversation. But Alright, so here's what I did, Jennifer. Last night, I was up editing the show rather late. And about two o'clock in the morning as I was going to bed. I thought I don't want to do a defining diabetes tomorrow and Jenny calls. Oh, so I never know what we're going to talk to Scott brings to the table today. Let's see, I don't treat you much different than anybody else. So. So I put this little post in the Facebook group. And I'll tell you, it just shows how things have grown because you and I've done this before where I'll say Hey, Jenny, I got questions from people. We have eight 510 questions. So I put up a post eight hours ago in the middle of the night. That said, I'm thinking about recording and ask Scott and Jenny episode tomorrow, but it all depends on if there's questions here when I wake up in the morning. There are 100

Jennifer Smith, CDE 4:52
That's like putting something out into the universe, like expecting nothing to ever come back.

Scott Benner 4:57
I'm like, oh, we'll see what happens. Right? It's overnight. But anyway, there are 116 questions in this. It's I don't think we're gonna get to all of them. But now we have something to do for the next couple of times that we talked for sure. Because there's great question. So you want to just kick back and do this together? All right? Do you ever sleep? That's for me? I'll answer that later. Is a simple question. Someone said they'd like to know where you put your pods?

Jennifer Smith, CDE 5:23
Me personally, yeah. Oh, I get asked that an awful lot. So that's actually easy. My, I guess I don't really have favored locations, although they're the locations that I've rotate through, I'd say favored in terms of like one versus another that is better in terms of absorption, because I know some people do notice that. I use the backs and kind of the sides of my arms, and never use the tops of my arms or like the bicep area. I note that people do, I don't I use the front of my abdomen, either above or below my beltline. I use my lower back. Those are my go to places. I do not have luck on my legs. I don't love it on my upper but they just, it's almost like I'm not taking enough insulin there. It's an absorption thing. And I just prefer to not go to those places. So

Scott Benner 6:29
yeah, it's that's a lot of moving around, which makes me think what I wanted to say was Jenny takes her own advice. Like that's, you know, you know how some people give advice, but don't live it. You know, I rotate. Yeah, you really are rotating your sides. I don't know if you're doing it because you think it's right, or because you tell people to rotate. You don't want to be a hypocrite.

Jennifer Smith, CDE 6:49
I think it's probably both I and I've said before, I think it's really important to be a good example. And if you're not going to do the majority of what you're telling people to do, then why are you talking about right?

Scott Benner 7:03
No one asked, but Arden wears hers either side of her belly button, kind of in line with her belly button off to the side a little bit. She prefers the cannula face towards the belly button. But we will also turn it 180 degrees to face away. She uses her thighs, tops not so much more to the outside, she used to she overused the tops of her thighs. So she moved it sort of to the the the outside of the outer part of her legs. And I recently in the last year finally had luck getting her to put it back on her arms. So we now have the way I think of it as the legs are kind of there are a ton of spots because one spot on your thigh an inch over an inch higher an inch lower like becomes a lot of different spots, but her thighs, her abdomen and our her sides of her upper arms. She doesn't like it on the back. Okay, so I think it wiggles too much back there for

Jennifer Smith, CDE 8:02
like she's my I actually have a good friend years ago when I started wearing Omnipod. And it was probably a couple years after that, that I met somebody through like the diabetes community, who I've gotten to be good friends with now but she out of like swimsuit material, she actually made bands that I can put over almost as like a three inch sleeve kind of like a free arm, like a headband for my arm and like I've got my pump my pad on my arm now. And when I run longer, like longer than a 30 minute run, I will typically use one of those because kind of like Arden it it does it wiggles I mean, not enough that it's irritating in terms of the actual site. But just it's something you pay attention to. And it's like change jingling in your pocket, right? Just can't stand it after some time. So

Scott Benner 9:03
for Arden this goes all the way back to when she was young and she played softball, and she couldn't put it on her right arm because when she threw the pod would really kind of like torque around. And sure after that it was just, you know, the I think the funniest thing that happens with people, kids, maybe adults as well is they get rules in their head, like so after a while. She just thought, Oh, it doesn't go on my arms because we don't put it on my arms. And there was a reason that we stopped doing that. And then I had to show her one day I was like you're not throwing a softball anymore. So please,

Jennifer Smith, CDE 9:30
let's try the arm again. Yeah, I will say though, from a site rotation, those sites that I don't use for my pods or infusion from any pump, honestly, not just my pods, or when I when I've used a tube pump to but my upper thigh and my my upper but also they work really well for my sensors. So it's not that those sites don't get used. It's just that they don't use them for insulin. Okay, and Artem

Scott Benner 9:57
Arden puts her CGM on her hips, kind of on the side. So I was gonna say longitudinally and let but I don't, I'm not sure which is which anyway, sort of like, the top of her butt crack and you kind of draw a line around to the her sides and there's sort of like a flat spot in her sides and you can put it there. She just goes left, right, left, right. She's been doing it for years like that. So yeah. Okay. All right, next question. Thank you for that question. Blue. Next question is from Christine. And she said At what age do teenage years and and having fluctuating blood sugars due to hormones get better.

Jennifer Smith, CDE 10:38
So, this isn't like hormones relative to either male versus female. It sounds like it's just in general. I can say though, from female hormone standpoint, is that the cat is the cat that would like to be let out of my office. I'm gonna let the cat or the cat doesn't keep banging on the door

Scott Benner 11:13
you know what arrived at my house just the other day, the Omni pod five. It came to us directly from us men. Here's what I did. I contacted on the pod and I said I would like to get on the pod five. I did it just the same way you guys are gonna do it didn't get any special treatment. On the pod contacted us Med and said I have a customer here that would like to get there on the pod five supplies from you. Okay, not so tough. I think on the pod then contacted my doctor had a script sent and Bada bing bada boom, a box showed up at my house with the Omni pod five starter kit. And we're already set up for future deliveries of the pods that will need to continue with Omni pod five. It was in fact exactly that easy. They can do that for you as well. Maybe you're looking for libre to wear the Dexcom G six. How about the Omni pod dash? US med has it and so much more. At this point, you're thinking Scott, I'm in how do I try it? Well, you're in luck. You can either use the internet us med.com forward slash juice box to get your free benefits check. Or you can use this phone number that US Matt has provided just for Juicebox Podcast listeners. It is 888-721-1514 us met accepts Medicare nationwide and over 800 private insurers they always provide 90 days worth of supplies and they have fast and free shipping. I will now make a seamless transition to the in pen from Medtronic diabetes, are you using an insulin pen but wish it did more? The M pen is probably what you're looking for. Because the M pen is a reusable smart insulin pen that uses Bluetooth technology to send dose information to a mobile app. This offers us support with those calculations and tracking in pen helps take some of the mental math out of your diabetes management. You can get started with in pen today at See what I did there what you don't know yet, but you'll see the second you can get started within pen today at in pen today.com. Take the guesswork out of your dosing. Your in pen app will show you your current glucose levels, your dosing calculator, active insulin remaining meal history, dose history, glucose history, and an activity log. And other reports. The pen itself, it's just what you expect. It's a pen with a cap, an insulin needle, a dosing knob, a dosing window, and a button to do your injections with the implant is also surprisingly affordable. I hope you check it out in Penn today.com. All you have to do head over there right now. There are links in the show notes of the podcast player you're listening in right now to in Penn us Med and all of the sponsors. You can also find them at juicebox podcast.com. When you click on the links, you're supporting the show us med.com forward slash juicebox in pen today.com I'm now going to get you back to Jenny who by the way works at integrated diabetes.com If you'd like to hire her

Jennifer Smith, CDE 14:39
That's too funny. I totally thought that she was out of my office.

Scott Benner 14:42
I heard that noise and I thought hopefully that's Jenny's cat where she's she's abducted a neighborhood child and they're locked in the basement.

Jennifer Smith, CDE 14:51
Oh no, no, no. She thinks on my closet doors not the actual door to get out. She Bangs on the closet doors when she wants I don't know if she's

Scott Benner 14:58
good sound. Me Pay attention anyway. Sorry. So no, I

Jennifer Smith, CDE 15:02
was, I can't remember my thought. Now I was on a pattern. Say

Scott Benner 15:07
you started talking about when I guess we're not talking about hormones for gender specific. Right?

Jennifer Smith, CDE 15:13
Right, right. So hormones from a female hormone perspective, with monthly cycles, I've found that it's when the cycles tend to get a lot more regular, that things tend to get more stable girl or females also tend to stop growing sooner than men do. So from that perspective, when a growth phase for girls like they're no longer getting taller, you can tell visit after visit at the doctor, they're just not growing in height any longer, they might have a very regular cycle, that's when things do tend to even out more, there's not as much of that flux. If the cycle isn't very regular, then it could very well be that you've got a lot more ups and downs still, because those hormones are still so much on a rise and fall. That's not sort of a pattern, right? Guys tend to grow longer than girls do. In terms of the male hormone effect, and growth patterns, so you could have fluctuations, you know, through and up to about the age of 18, sometimes beyond, obviously, but again, some of it also has to do with have they finished growing? Are they more into a pattern of life, all of those kinds of things, because I think a lot of the variability in those teen years is just life as well. I mean, most teens don't have a very rigid schedule outside of a school schedule where you know, the typical pattern other than that sports come in, in the afternoon, extracurricular activities, weekends are completely different. You might have sleeping in compared to getting up early I there's just a lot of stuff in the teen years that I think causes a lot of fluctuation. That because we talk so much about growth, a lot of people think it's just growth. And some of it may just be the variables of

Scott Benner 17:20
the unexpected left turns, you take in the middle of an afternoon, like I'm gonna go run, jump on the trampoline now. Or, you know, my friends came over and we're gonna go play baseball in the backyard. When you're 37. You don't randomly get up at 330 in the afternoon. And go not usually, no, no, if you have kids. If you are, you're an Instagram influencer, and you're living an amazing life, because I just sit here and make this podcast and Jenny sits where she's sitting talking to people about their diabetes. So yes. So let's see. Next question is from Denise, I would love to hear about how you handle times when there are Dexcom sensor issues. How many times would you calibrate before giving up on a sensor? Do you calibrate? And if so, when Jenny and I did an entire episode about calibration, which you should definitely check out? But good. Um, to answer the question. Arden doesn't have a lot of problems with Dexcom it jives with her body chemistry pretty well. I would say that with GE six. It's interesting. I don't know this for certain, but they must make improvements to that device as they go. Like with the algorithm they must. I don't know they must. Because it's never the same. The products always better at the end of its product life. Like as they're getting ready to launch the new one than it is at the beginning. I feel like you sent it to you ever see that? Like it? Maybe I just get better at using it over time? Is that pi d? Right? That could be Yeah. Because I'll tell you like, Arden puts a sensor on. I wish we planned better, but we don't it usually happens like this. someone hears the noise that which is like the out of you know, there's no, there's been no data. And then everybody's head drops and goes oh, how long has it been since we put on a sensor you started thinking and when you can't remember you like this must be it. And you know, like, as an example, we put a new sensor otter at 130 in the morning, Friday, I would have been nice to do it. Put it on came on was pretty accurate, was happy with it. I have had them come on and be wildly off, you know, 8090 100 points sometimes. When that happens. I do what I talked about on the calibration episode is I just kind of I slow calibrate it back to where it needs to be if it's if her blood sugar's really 100 and the things that she's 200 I tell it, she's 170 and then it agrees with that you let it go a little longer that I tell it she's 150 and I calibrated. I kind of move it on my own. I don't know if that's right or not, but it works and we have a lot of success. As far as sensors just going bad. I hate to say this Arden's last ride out 10 days. I mean, constantly, you know, yeah, so

Jennifer Smith, CDE 20:07
I know I, and that's where I really do think that there's more about body chemistry, then there's any information about I think people get the sense that a sensor just doesn't work very well. And they may come from a previous brand to another brand and say, well, it's better, certainly better. But it's still not quite perfect. You know, I also, thankfully don't have a lot of sensor issues, at least not, not recently, the previous two g, six g, five G four in the seven series, I didn't really have much issues with those at all. In fact, my G fives, I could restart for three, three weeks and get like 21 days out of a sensor, and then it was like falling off. So I finally had to change it, right. But the G six, initially, I would almost like clockwork, eight days, I would get the three hour sensor error warning, it would start back up and get it again, I would call that I was calling Dexcom. almost weekly, because it literally was dying on day eight. And, and I don't know what shifted kind of goes along with, maybe they've changed something algorithm or the the sensor coating on the outside of that filament, I don't know. But I've not had that problem. And I can't say that my body chemistry is just decided to do like, you know, a 180 and sort of be completely different. And now it just works better. For me, I don't know, I'm mostly now get 10 days, I typically if I'm going to have a bad sensor, it's usually only bad for about eight to 12 hours after starting it up. And my trend is that it's not high, inaccurate, it's low inaccurate. If my sensors are going to be off, they're going to be off and they're going to tell me that my blood sugar's like 42. Consistently, even though it's in the 80s 90s, low 100. It'll just keep telling me I'm low. And I avoid calibrating at that point, right? Because I've had enough issue with trying to do it in that first kind of startup time that, then I've had sensor fail. So I just I leave it alone, I just opened my algorithm. And don't let my pump adjust off of those funny values. And just go ahead.

Scott Benner 22:34
So it's funny when you're you, you said something that really made me think when Ardennes is off for an extended amount of time. It's lower, when it's high off, I can bang it back down again. And it works. When it's low off. She's 5355 56. It just thinks that's what she is. You text her she's 85 Doesn't matter what she is, right? It does just sort of come online. And just it's kind of magical. And then works great after that, if you're using an algorithm like Arden is and like Jenny was just saying that I just made for this, I opened the loop. And we test. We test like every 90 minutes or so. And then through the health app on the iPhone, just enter it you enter her blood sugar on the health app, and the loop app pulls the number from there, and it's usually enough to get by until it straightens out. That is that concern from people who are new. Or even sometimes I see older people, the idea of I can never go on an algorithm because what if the sensor is wrong? It's gonna kill me. You know? Like, it just doesn't go that way.

Jennifer Smith, CDE 23:42
Yeah, unless there comes to be a system that doesn't allow you to go back to manual use mode. Quite honestly, you came from manual pumping or manual engine. I mean, you have something to go back to. If you know enough that something is inaccurate. Don't use it while it's inaccurate. Right? Do what you know how to do. Even if it means you have to go back to a little bit more old school. Don't use a system that's gonna adjust off of a blood sugar that's 42 When you're not sitting at 42 I

Scott Benner 24:16
think sometimes that people get stubborn. Meaning they have this feeling like this thing that I paid for supposed to do this and it's not doing it so I'm gonna be mad at it. You're like, cool. Yeah, of course, absolutely. I see it. I'm just like, open the loop and test every once in a while this thing will work in a little bit. We'll be fine. It sucks. If it happens overnight, because it's telling you you're low, you're low and you'd like you're not but even that's a mindset thing. I have to say. When Arden was really young, I met this person in the community who had an older child already. And they would tell me, you know, it's great that you guys have the CGM and I think they're amazing, but you know, my daughter never had one. And there she is. Isn't she's fine? And what that made me think was, Oh, okay. Like, it's alright if once in a while, Arden goes to sleep and her blood sugar's 135. And it climbs to 150 overnight, and I fix it at four in the morning or when we wake up or something like that, like, that's not the end of her life. If that happens, you know, but yeah, don't like it back then. When she was

Jennifer Smith, CDE 25:23
young, because you were used to having so much information to utilize to keep her where you really know, is a safe value long term to be sitting. Right. Yeah, but I mean, I, you know, and that's a point that I bring up with people all the time, too. I mean, I had, I had nothing fancy in technology growing up, right. Heck, I made it through college without anything fancy.

Scott Benner 25:47
But you're still paying attention to your health, right? Oh, of course. I

Jennifer Smith, CDE 25:50
mean, I use probably more more test strips in my life prior to a CGM, then yeah, probably was necessary. But I was a little bit OCD. Must Know What My blood sugar.

Scott Benner 26:06
Let's get to. Let's see, the next question just says it's not really formed as a question, but that's okay. It says breastfeeding a type one baby or toddler. So is that do you Bolus?

Jennifer Smith, CDE 26:20
I guess that's, that's a hard one. So talking about not the mother has type one, but the baby or the toddler actually has type one. Yeah, it's a it's a difficult scenario, honestly. Because unless you have a very rigid schedule of nursing, or even formula feeding, I mean, this kind of goes along. Because that age, that's a child's mean nutrition intake, it's either breast milk or formula, right. So unless you really have an idea of how much the child is eating, there's not really a way to carb count that per se. If you have a little bit more regularity, a lot of people tend to sort of coat with a Basal insulin. Knowing that nursing, especially an infant, typically is going to be nursing every three ish hours, until they get a little bit further out into post newborn stage, right. So sometimes there is a coding with a basil knowing that you have a regularity, to nursing or formula feeding. If you have a known amount more like formula, and you can gauge how many ounces the child is going to take at a time. You could base that on a dosing strategy then with rapid acting insulin. The big thing with that is we would usually, as much as we talk about Pre-Bolus ng for something like that. You just you don't Pre-Bolus There's no way to know how much a child who usually drinks, you know, three ounces at a feeding time. Today, for whatever reason, they're fussy, and they're only taking one ounce, but you can't Bolus or do anything for that until you know

Scott Benner 28:08
we're talking them into it if they need more. Right. And there is no more food. What are you gonna do with gummy bear? Yeah, right. Yeah, well, yeah,

Jennifer Smith, CDE 28:15
I mean, it's not really until that child is and I've worked with a couple of people, you know, more recently, who have littles who have either just weaned off of nursing, in that case, their Basal needs actually have gone down. Because what we were doing were We were coding the overall nursed milk intake with basil knowing that it was very regular night and day. And until they were weaned, and we had a little bit more in terms of a breakfast, a snack or lunch or snack and how to kind of coax that with bolused Insulin it and I know it's a difficult time. So

Scott Benner 28:53
it sounds like to me that you adapted that. So there's that. There's that old timey endo idea for people who they think don't Bolus for their meals, right? They jack them up on basil. And then they know they're going to eat. So they're feeding the insulin, they're not really feeding the insulin, they're feeding the drop before the drop happens because they're eating on a schedule. So you keep the baby's Basal at a spot where it's impactful of those every three hour feeding schedules. Correct, right. Yeah. And are you shooting for? What blood sugar are you shooting for?

Jennifer Smith, CDE 29:25
Yeah, it's a good question. I mean, most doctors are happy as long as they're not dropping usually below like 120. Honestly, most most parents find that littles like that will often drop very rapidly. If they get under about one to 101 20 ish. It's a very rapid drop and depending on then what they're able to tolerate in food intake, where they are in their intake of, you know, this kind of food versus that. It becomes really important to know how much does it take to turn that around and Um, yeah, it's a, it's a hard thing a corrections. Correction insulin often is very, very, very tiny. In fact, we often end up dealing with diluting insulin, so that you can actually get a larger dose because again, pens and pens and even syringes, the littlest that you can dose is about a half a unit. I mean, if you're really good on a syringe, you might be able to get, you know, a quarter unit kind of in there. But it's a little bit easier to see volume doses, if you dilute the insulin in a larger volume, you get the same dose. You know,

Scott Benner 30:40
I, there's two things that makes me think of the One is I, at some point, when Arden was super small, I took insulin, and I put it in a dish, and I colored it with food coloring, so I could see it. And then I practiced pulling on the syringe enough to get a drop in. So I could ah, and so it wasn't by eye anymore. It was like feel. So I taught myself how to just pull on it enough to get a drop of insulin out of it. And then I would I would try to correct her with a drop of insulin. That was not fun. I don't know. I don't remember any of that fondly. Yeah, okay, that's a that's good information. And I'm assuming if you can afford it, or have insurance, a CGM with a baby is probably going to be like the best thing you could do, right?

Jennifer Smith, CDE 31:23
A CGM above. I mean, above even a pump. A CGM is by far the best technology that you could possibly get. And even at that age pumps are not necessarily the greatest thing for some kiddos. either. It's a wearability issue, or it's a pull it and target and pick at it. And it's not worthwhile putting it on when it gets picked off by the end of the day anyway. And there's only so much hiding that you can do with a child's gonna

Scott Benner 31:55
find it. Yeah, yeah. All right. Well, that that makes sense. Thank you. Let's see, what does Monica say here? Oh, Monica is going to ask a question. And I'm going to answer by saying, You should listen to the Pro Tip series. But we'll go How can I reduce post meal spikes, my six year old is on an MDI. Hold on a second. This is it. I can't some water, water, a frequent tea I'm drinking alone. My six years, my six year old is on MDI, we always make sure to Pre-Bolus before food, she dips into hypo, but we almost always still spiked over 180. I listen to the podcast, I believe the Basal levels are good. Anything else we can improve or work on to reduce spikes? Also, this is not a question. But I want to say thank you to you and Jenny for all that you do. So that's very nice. Thank you very much.

Jennifer Smith, CDE 32:47
Yes. All right. Yes, you're welcome. Absolutely.

Scott Benner 32:49
So she's Pre-Bolus thing on MDI, dipping down dropping up. Pre-Bolus is too long,

Jennifer Smith, CDE 32:57
I would say either Pre-Bolus is too long. Or to get rid of a potential spike, you could Pre-Bolus the length of time on MDI, you could always do a split Bolus plan, especially if this is for a child that you don't necessarily know if they're actually going to finish everything, right. So you can Pre-Bolus the amount that they that you know that they'll definitely finish up eating. And then you know, by the end of the meal Bolus, the rest of it so you don't you kind of take care of getting rid of that ultimate dip that you end up having to treat. And there in may also be if you're treating a low, and then having a rise later, the rise actually might be going up higher, because you're having to treat the dip first, along with the food being there, right. So it's kind of a double whammy of, well, I have to take care of the lowest something quick because the food isn't obviously all hitting yet. But then the food does catch up. So it could be a double Bolus strategy still with Pre-Bolus or first thing may just be to decrease the Pre-Bolus time. Yeah,

Scott Benner 34:00
I mean, I would either. I mean that's how it occurs to me like just from this small description. Shorter Pre-Bolus Maybe maybe even shorter. Pre-Bolus a little heavier on the carb ratio maybe depending on what happens you know what you see next? Or split it I put some in gets a treat it like a baby, right? Like, baby it's funny, I think of babies and or young people and gastroparesis is the same thing. Put it in enough to get the insulin on your side. And if it starts happening the way you expect them putting the rest. That way you kind of stay out of a spike. Okay. Helen asks, How do you and Jenny deal with fat and protein using the loop? I'll tell you what, as I said it out loud. I thought to myself, does Jenny eat fat by the way now, just now for my description. People believe that you 86 pounds and you're just one muscle wrapped around a bone but no, no I just mean, you're a healthier eater, but you think have french fries? Sometimes I imagine. Oh, of course. Okay. Yeah. Sometimes, sometimes,

Jennifer Smith, CDE 35:09
not often,

Scott Benner 35:11
at the fair, Jenny, is that when you do it, maybe?

Jennifer Smith, CDE 35:18
Yeah, I mean fat and protein. And, again, I think this is where an individual nature of evaluation first needs to be done. How does it seem to impact you or your child or whoever you're caretaking for? Right? There are some sort of starting rules of when to start adding in extras for fats and proteins. And how much of each you should add in, in general, in a looping situation, since that's what the question is really asking about. Forward stamp damping, a fat or protein amount into the future, from the actual meal time. So let's say you have, you know, a whole pizza for dinner like many of my college students may definitely, right, there is a large amount of fat there, there may even be a very large amount of protein depending on what was on that pizza as an example. bolusing for the carbs right now is an important thing that has to get going. The absorption time is also really important here. So you're not going to put in one or two hours for pizza. Because despite the crust being a lot of carb, you're going to have a lengthy digestion of that, because of the slowing factor of fats and proteins right. Now fat and protein then can start to hit later in the aftermath. So one to three hours after a meal protein starts this climb, if you've eaten enough of it, somewhere between two to four hours after a meal is where fat climb typically starts to hit. So determining first how much you might need to cover, most often protein somewhere between 30 to 50% of the total amount of protein might need to be put in as if it were a carb entry, right. And then determine where into the future to timestamp. Let's see it's you know, 5pm, and you're having your pizza, expect protein to probably start hitting somewhere around, let's say seven o'clock, two hours later, give or take, whereas fat, large amount probably is going to take about three to four hours to kind of come into play. So again, how much fat 1020 30% of the fat to maybe get going again, grams of fat are important grams of protein. So this becomes less carb centric counting and more overall macro neural, knowing how much is in the actual portion that you're eating, which most people have never been taught, we are taught how to look at grams of carbs. So it's something new to learn about if you're planning to start using this strategy, but time stamping it into the future. So then loop has an idea in terms of the system loop will see that you stamped this coming forward into the hours ahead. And especially if you save without bolusing then loop will see missing insulin for the carbs that you've already entered. That it's it's watching for because remember, it's predictive glucose line is going out hours into the future beyond this point. Yeah, so it's looking for the impact of that. And if you can give it information about what may be coming into the picture to hit you

Scott Benner 38:50
should aggressively Bolus. It could either aggressively

Jennifer Smith, CDE 38:53
Bolus if you're using auto Bolus or aggressively increase basil if you're using it the basil branch right?

Scott Benner 38:59
I so I know what you do. So there's two ways that you can set up I have in the past set up exactly the way you think way that you just said that the other way, I just sort of think of it as this, that they're just different impacts. So there's an impact from the carbs, there's an impact from the protein, and there's an impact from the fat. They're basically just three different Pre-Bolus and opportunities in my mind. So you Pre-Bolus The meal around 80 minutes later I know the first rise is going to come then you Pre-Bolus That rise and then it's a waiting game. I either do it so well that I see this like 85 blood sugar and I'm like I done it I won this is over like others enough insulin there and the fats hitting at the same time and it's having this fight and we're winning. Or I start seeing the drift up. And then I I'll reevaluate and Bolus for the fat impact as well and add more Yeah, and I'm in my mind I'm thinking of this one specific difficult foods situation. It's this barf Whew that Arden has a number of times a year, she's basically getting a bowl of nachos with cheese steak on top of it. And like guacamole and sour cream, right? Everything it's hard to Bolus for all put together. And then there's french fries. So, you know, so it's fat from the fries. And then it's the french fries are processed. And you know, they're not like, it's not like we cut up a russet potato at home, baked it. Yeah, some frozen thing that shows up in a bag in a bar. You know. That's the I'll tell you what if you can Bolus for that. I'll give away a little bit of where the country I'm in if you can eat. If you can Bolus for cheese steak nachos and crab fries at Chickies. I think you're a ninja, because it's hard to do. But that to me, that's it, I just think of it as impacts. It doesn't matter to me that it's fat or that it's protein. It's a it's a known quantity that is going to happen. I know it's going to happen. I just Pre-Bolus it. Right. So

Jennifer Smith, CDE 40:55
and how much how do you know how much is a try? Right? Because that's that's really the behind the scenes question here. As I said, we're really carb centric. With diabetes and education. We don't talk about fats and proteins, I would say that the majority of people that I talked to, don't even know what a portion of protein is supposed to look like. Some people don't even know outside of butter, don't realize where fat is in the food that they're eating. So then taking the step further to say, well, how to how to add quantity, like what am i How much of this isn't my my eating? How many grams, now you're telling me I have to go back to school to learn again, right?

Scott Benner 41:35
I develop those ideas after you and I, you know, talk through, I have a list in front of me here, actually. And at the end of this episode. If I don't die. At the end of this episode, I'm gonna list other episodes that I think will help people with these questions. Awesome. But here, I'm going to tell you that you and I did a pro tip back at 263 fat and protein, then we defined it again at 360. I had a really great conversation. And in Episode 264, with the person who Bolus is for their keto diet that actually helped. That helped me a lot with the protein. And then in 471, we had a long conversation about the Warsaw method. And about bolusing for fat. It's all of these. Like, I take this question, and I know that how important this is right? And I want to talk about it. But to the person that asked this specific question, Helen, I'm good at this, because I've had 1000 conversations with people about it. And I tried it over and over again. Like it's not because someone walked up to me and said, Hey, fat impacts and protein impacts, you got a Bolus for like, I wouldn't know what to do with that information. You know, right. So

Jennifer Smith, CDE 42:46
Right. Well, and that's where I think even the information in the the Warsaw method, which is really well done in what does it waltzing thing, the dragon, right? I was gonna say dancing the dragon. I was like, That's not.

Scott Benner 43:03
That's the person I did that episode with.

Jennifer Smith, CDE 43:05
Yeah, they have a very good descriptive because they go through all of the calculations and protein and fat. And then at the very end, they kind of give real life and they say, Well, we found that if we cover all of this, as this method suggests, we end up with these issues. So we've found that we have to cover only this certain percent of, of protein, and not very much fat, and it ends up working best for us. So again, there are some starting places some tools to begin with. And then you really have to evaluate, how does it work for you. I mean, I myself have found the meals that I make, like I said, before I make homemade pizza, right? And I typically make like an almond flour crossed or a cauliflower almond flour across, which is almond flour. In general. It's high fat, because it's made from nuts, right? So it's not like I'm pouring in loads of butter and oil. It's just that the nature of what I'm using is high fat. So I've found with that particular meal, a certain strategy that definitely works. My pizzas are not terribly high in protein. They're just a lot higher in fat because of what they're made from. So it's more the fat effect that I ended up covering. Yeah, I don't really even worry about protein there.

Scott Benner 44:21
Right, Jenny? If this was just a regular episode, I would title it fatty nuts. A great title or Jenny has fatty nuts. I don't know.

Jennifer Smith, CDE 44:34
Jenny eats chatty.

Scott Benner 44:37
That's it. Yeah, we workshop that one right to the right when Jenny eats fatty nuts would have definitely been the episode title. Oh, that's funny. Because I'm a child of my mind. Okay, so I think we have we can do one more or you will have time? Yeah, I've got a little time Christina says. This is about her college age type 112 and 12 and a half years live with type one my 18 year old son forgets to Bolus before he eats at least once a day. And she's very clear. She said, this isn't a refusal to use insulin. It's not bad behavior. He just right out forgets. She's not a type one, but she gets frustrated. It makes her angry. She said that she realized the disease sucks. And despite being manageable, it's still not easy. And this is all coming from a place of love. She's just trying to get him through college. Sure. This is tough.

Jennifer Smith, CDE 45:30
So this is a college student.

Scott Benner 45:32
Yeah. Who's had diabetes? A good part of his life

Jennifer Smith, CDE 45:36
a long time. Okay. Is so my first starting things would be since it's not, because this adult child wants to forget, it's just there are a lot of things being a student in general, as well as a college student. There are a lot of there's clutter that gets in the way, there just is. So one, if it's a regular time of day that the Bolus is often forgotten, it doesn't sound like it's what it's every day or it's a couple days a week sounds

Scott Benner 46:07
like it's everyday like like once a day, once a day, the kid flakes and just doesn't Bolus Yeah, okay.

Jennifer Smith, CDE 46:13
Because I was gonna say if it's a regular meal of the day, then perhaps setting a timer. Around that time of day, just as a suggestive even on the phone just. It's noon, I usually eat somewhere between noon and one o'clock. Sometimes it can jog the brain enough to just remind you. Yeah, that's one thing. I mean, the other one that's

Scott Benner 46:39
right on your top of your hand.

Jennifer Smith, CDE 46:42
Oh, it's for food.

Scott Benner 46:45
Yeah, I'll tell you what, this has nothing to do with diabetes, but I'm gonna share this here. My son is 22. He is a senior in college at this moment, he is about to graduate. Yay. We're very excited not to send that college money anymore. And, and oh, for all of his success, etc, but mostly about. Here's something I've noticed over his four years of college. It's fascinating. We don't see him constantly, obviously, right. I talked to him. Every once in a while I text with them sometimes. Go see him here and again. He will tell me the same stories over and over again. He is not that person. He's never been that person when he comes home for the summer. It does not happen. And so I used to think at first I was like, Oh, this kid's doing smack.

Jennifer Smith, CDE 47:38
He's losing brain cells. Something is not right. Yeah.

Scott Benner 47:41
I had a drug thought from the mid 70s. No, but I realized it's not that it's that he is so busy. And so tired. He doesn't even remember having told me the story the last time. And I think this is probably part of this, like 18 years old. This kid sounds like a freshman. Right? It's a lot of adjustment. I think you I think if you want to come from a loving place you say to him, Look, this is going to become it'll become commonplace for you at some point. But until it does. Maybe we got to make up a code word for Bolus and need to write it on the top of a book or I don't know what are your fingernails read so that when you look at it, you think why is my one fingered? Oh, it's because I don't always remind me I don't know something you don't I mean, but that's why I said the

Jennifer Smith, CDE 48:26
alarm. As a reminder, if it is a typical time of day for it to happen within sometimes just that cue in to the brain can, like you said wake them up, in a way as a reminder. College is hard. It's hard. There's sleep patterns are disrupted, you know, at home, if he had been living at home, mom and dad or other caregivers were likely there and or in high school, maybe he was one that had to go by protocol to the school nurse. And it was this pattern of consistency that helped the Bolus always be put where it needed to be right. In college. They have to remember do everything. You have to remember to get food for one thing, actually remember to put themselves to bed, right? Do homework, do their laundry, I mean, all these things,

Scott Benner 49:20
my son plays a sport on top of that. I don't even know how he's staying alive. I'll tell you if he ever hears this or somebody he knows ever hears this in the future. I am going to tell him about this after he graduates. I have never brought it up to him. I just let him tell me the story. And I'm just happy to be with him. And he's just like, he's got a lot going on. You know, right. So yeah, it's just a lot.

Jennifer Smith, CDE 49:41
Yeah. So yeah, reminders, I think are the best little nudge that you can probably do.

Scott Benner 49:49
So about the getting frustrated and angry part. I understand that too. But I think earlier in this episode, we talked about something where I said I realized Is that a 140 blood sugar for a couple of hours isn't going to be the end of Arden. I think that's how you almost have to think of this too. Like, this is not a kid slipping off a slope. This is to me, and don't get me wrong. I've interviewed people. And there are people that are going to ask questions later, where they did fall off that, that edge, they just stopped paying attention and it got easier to ignore and stuff. But in this specific situation, I don't think this sounds like what's happening here. So no,

Jennifer Smith, CDE 50:27
it was she kind of states you know, he's, he takes care of himself. Typically, it's just and that's why I was wondering if it was a time of day because if it was an especially busy time of day, or the first thing in the morning, he's forgetting to Bolus for breakfast pretty regularly. It could very well be he's just like, like getting up. Oh, my goodness, I'm five minutes late. I have to get out the door and I'm going to grab you know, by Apple on the way out the door and Oh, I totally forgot to Bolus last

Scott Benner 50:55
time I went to my to see my son I drove with a bottle absorbtech with me, I took a bottle of Zyrtec 180 miles and a two and a half hour car drive. And I said to him, you know, there's a pharmacy up the street from your dorm, and you have a car, just drive there and by Desertec and he said to me, in all honesty, I would not know when to do that. And I was like, Okay, I got you, even when I take it, like I took them out to dinner the other day after a baseball game, like where do you want to go? Because I don't know this town. I was like, you've been here for four years. He goes, I play baseball. And I go to class, and I sit in my room and I do my homework and I pass out. He's like, I don't have time for any of this.

Jennifer Smith, CDE 51:32
I don't take Well, that's actually from a parental standpoint, you're like, great. All the local bars are local. Right?

Scott Benner 51:40
We walked into a little bar restaurant the other night, he goes, I've heard this is a good place. Let's try this for years. He'd never been there. I was a little happy. A little happier as a parent. Yeah. But can we roll through one more? Are you done? Absolutely. Are the card values you enter into loop usually close to the carbs listed on the nutrition labels? So it does, yeah,

Jennifer Smith, CDE 52:02
yes. Yeah. Yes, absolutely. Yes. And you also, obviously, I mean, we've talked about fiber before, you also have to take a peek at fiber amount, depending on the kind of food that you're eating. But again, all of that is nutrition information. That's it's yours for the picking. Right there. It's not an estimate, there is as much precision as there could possibly be in this carb count. Compared to just staring at the plate and wondering because you have no label. Yes, absolutely. So

Scott Benner 52:36
go into that fiber thing a little more you subtract for what do you do tracked

Jennifer Smith, CDE 52:41
for fiber? I do take it as a little step further, because there are there are added fibers to a lot of the foods in the grocery store today. Because companies kind of have latched on to that, well, gosh, if it's high in fiber, more people are gonna buy it, it's gonna be so much better for them, right? Well, those fibers oftentimes are very soluble added fibers that don't have the same slowing impact as unprocessed fibers, fiber in fruits and natural vegetables and lentils and beans, and some of your whole grains and oats and those types of things. sprouted grain breads, like, like the Ezekiel bread, I mean, the per slice has like five grams of fiber per slice, I think it is just an exorbitant amount. So in terms of subtraction, if you're going to subtract fiber, I recommend subtracting definitely from more of your unprocessed types of foods. Some of the ones that are more like your fiber one types of products or something like that, you'll likely find that if you subtract that fiber, you're going to end up with a higher blood sugar than you want. Because most of that fiber is more of a soluble type of fiber, it'll have a little slower impact. But it's very likely you're still going to need to cover it. There are some more of the like, keto, or those types of breads and grains that are out there that do have added fibres, they may be more like the word is going to escape me now. Like the unprocessed like corn starch, kind of where it has a slowing impact on blood sugar. And it doesn't really get digested if you will. So that's why they can consider it so low carb you know, they list the net carbs as like two grams per slice instead of eight or nine grams per slice. So because the fiber on those labels can definitely mean you would have to subtract it. The big thing is you kind of have to give it a try and see what it does for you.

Scott Benner 54:48
Actually you don't know this but Arden has been eating gluten free for five days now. And we all are doing it with her as a show of solidarity. It's one of the things that her Her doctor, actually Dr. BENITO asked her to try. So like we're debt, we've now like Arden's had a blood test for everything that exists on the planet for like joint pain and stuff like that. And it just, she just luckily keeps coming. You're, it's a happy day When someone says your kid does not appear to have RA, you know, you're like, that's great, but at the same time, you're like, could someone say something, find something helpful, please, you know, so we're giving this a whirl right now. And, and anyway, we'll see how that goes. Thank you for doing this. We there are a lot more here. I'm gonna, I'm gonna save them. And I'm going to tell you that I think the next number of times that we we do this, we're going to do this. So awesome. I like to thank in pen from Medtronic diabetes, for sponsoring this episode of The Juicebox Podcast and remind you to go to in pen today.com To get started. I'd also like to thank us med head to us med.com forward slash juice box or call 888-721-1514 To get your free benefits check. US med has served over 1 million diabetes customers since 1996. Check them out online or give them a call. Jenny works at integrated diabetes.com. And don't forget to please consider taking that survey AT T one D exchange.org. Forward slash juicebox.

If you enjoyed this and are looking for other ask Scott and Jenny episodes, I believe there are 14 previous ones. There's a great list in the private Facebook group. It's Juicebox Podcast type one diabetes, you go to the feature tab at the top, there's lists and lists of the different series within the podcast. Ask Scott and Jenny is one of them. You'll see the episode numbers there and then you'll be able to go back into your podcast player and find them. There's tons of topics. I think somewhere Isabel's made a list of them with what's actually inside of them. But that's beyond my paygrade so I'm not sure what else Oh, if you're enjoying the podcast, please subscribe and follow in the app. You're listening and say you're an Amazon music or audible. Apple podcasts. Spotify doesn't matter what app you're using. Hit subscribe or follow, please. And if you're listening online, I'm glad for you if it works that way, I'm not trying to change you. But the cool kids would listen to the podcast that I'm just saying. You might be falling behind the times. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.