#805 Bold Beginnings: Illness Ketone Management

December 9, 2022Scott Benner

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

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

Scott Benner 0:00
Hello friends, and welcome to episode 805 of the Juicebox Podcast.

Well, you would think that I would have learned after saying that the Pro Tip series was only going to be 10 episodes, and now it's like 25, you would think I would have learned not to say we're all done, like I did at the end of the bulk beginning series, because here we are back with something that fits in the bowl beginning series. Jenny Smith and I are going to talk today about how to treat illness ketones. 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 healthcare plan, or becoming bold with insulin. If you're a US resident who has type one diabetes, or is the caregiver of someone with type one, it would mean a lot to me. And it would mean a lot to people living with diabetes. If you took a short survey that's available at T one D exchange.org. Forward slash juicebox. This survey helps move type one diabetes research forward. And it's something that you can do from the comfort of your home. It's also something that may open up other possibilities to you if you want them. And if you don't, doesn't matter. T one D exchange.org forward slash juice box fill out that survey helped move research forward. This episode of The Juicebox Podcast is sponsored by touched by type one, a wonderful organization helping people with type one diabetes, that you can learn more about on Instagram, Facebook, or at touched by type one.org. The podcast is also sponsored today by Ian pen from Medtronic diabetes Learn more at in pen today.com. And last but not least today's show is being sponsored by U S med. Us bed.com forward slash juice box or call 888-721-1514 to get your diabetes supplies the way we do from us med. You may remember a time when I told you we were all done with the bulb beginning series. Yes, that was a lie. So here we are.

Jennifer Smith, CDE 2:24
Okay, what did we lie? Or what did we not complete? I should say we might not lie. It

Scott Benner 2:29
wasn't a purposeful it was a it was we didn't know. So for today, I'd like to do a bold beginnings episode about how to deal with ketones. Because as I'm standing here or sitting, and Arden has now had diabetes since she was four, and she's 18. I would admit, I don't 100% know what I'm doing, especially around illness. So I think we should probably try to help people out a little bit with that.

Jennifer Smith, CDE 2:59
Yes. And I think for clarity there, too, I think you've had you've always been very bold with insulin, right. And so I, I have a sense that despite art and having higher blood sugars, you've attacked it with the knowledge of even if there are ketones there and you haven't tested for them, you're adding insulin, that is probably what we would recommend adding in excess of correction. That's helping to clear the ketones. So I think you've gotten away with it, for lack of a better way to explain, because you're just like, I'm not going to deal with the high. I'm just going to bring the high down and this much didn't work. So let's add more. You don't really have a science to how you're doing the more.

Scott Benner 3:50
And I do want to talk about that a little bit so that people have here's my last recollection of it. Arden had the flu, but she was well we both had the flu when she was like my god, four years old, maybe, like really little. And she and I are in bed together just like I mean, we were a mess, you know? And we that's when I learned how to use a lollipop to keep her blood sugar up. Because I was I didn't know what to do. She wouldn't eat. I think sports drinks helped a little bit but it was a lollipop I kept I kept them around. I was like here suck on this. And that she could kind of get away with

Jennifer Smith, CDE 4:26
it probably helped if she was nauseous too. If she had like stomach piece of the flu. Oh sweetness. Probably yeah, often sucking on things if you're nauseous can really help to calm

Scott Benner 4:38
the nausea action of sucking the sucking. Yeah,

Jennifer Smith, CDE 4:41
in fact, I mean, they have you know, in pregnancy, they've got all these fancy products, the preggie pops that they're called like these. They're literally just soccer by it. I mean, I got through actually the early part of my pregnancy is sucking on. They're made by the ginger people. They're just like they look like little All cough drops but they're a gram and a half of carb apiece. They taste like ginger. Ginger is really good for calming the stomach. So stuff like that. It's probably the reason along with supplying the sugar to keep her blood sugar up. It helped to calm some of the nausea. Maybe she might not have told you what she was feeling like as a four year old but

Scott Benner 5:19
well, you just messed up my my internet searching now because I'm going to start getting ads for preggy pop because I didn't I almost believe you that they existed. There are preggie pops, which are lollipops are also preggy pop drops, I guess. That women how about that. All right. Well, there's my there's my the ads. I'm gonna get served now. Google thinks I'm pregnant. Alright, well, that got off the track pretty quick there. Yeah. So. So what I remember from that time was, is that back then Arden was peeing on a strip to to see if she had ketones we Yes. We saw that she had ketones called the the sick line for her for her endos office. And I mean, the rest of it. I can't remember. Was it one unit for like, if our ketones were two, we were supposed to like put in a unit to bring our ketones the one? And is that right? Or whatever?

Jennifer Smith, CDE 6:24
It depends? Yeah, I mean, so you did, you did learn an adjustment strategy, based on like adjustment for insulin strategy to help to clear the ketones and if your blood sugars are high, and not only are you using the corrective insulin that either you're calculating, or your pump is helping to correctly, you know, calculate for you. But you also have to add on top of that based on mild or moderate or even large ketones, an amount of extra insulin to clear the ketones, and that's dependent on how much some some places recommend basing it on total daily insulin. Other places recommend looking at your Basal dose that you take or that your pump provides. And then dependent on whether you have mild or moderate ketones. It's either a 510, or 15% of that total daily Basal that you calculate, and then you add that on to your corrective dose. So let's say you know, let's say your blood sugar is high and your pump recommends two units for correcting that high. With ketones present, that correction is not going to bring the blood sugar down as effectively, but your ketones are not going to get cleared well. So we need to add on to that. And if we're saying mild ketones, let's say you need five to 10%. Let's say your total daily dose is of basil is 10 units a day 10% One extra unit. So you're gonna add on to the two units of corrective insulin, the one unit to bring your ketones down along with address the hi

Scott Benner 8:09
a couple of things here. First of all, what I realize now is that all that time ago, I thought they were telling me one unit for this number, but it turns out they may have been looking at other things about Arden's insulin usage that I didn't even know about.

Jennifer Smith, CDE 8:22
They could have been exactly. Okay. And

Scott Benner 8:25
the other thing I remember from that time was the abject horror because Arden's blood sugar was lower. It was like 90, and, and she had ketones, and the woman is like, so give her insulin. I was like, listen, she can't eat. And her blood sugar's 90, and a unit bill like Crusher, because she was little. And she's like, No, it won't. And I'm like what she's like, it'll just clear the ketones. That's a leap of faith right there. Because yes, yeah, I was like, wait, what so so you just kind of

Jennifer Smith, CDE 8:57
I have to say that your your clinical team then was a little bit more on the aggressive side of adjustment. Many people will go home with directions, if they do get anything for ketone clearance, they'll go home with directions that unless the blood sugar is above this value, you have to get the blood sugar high in order to give the correct IV dose and to clear the ketones with the adjusted ketone dose. Many clinics will not tell you to just take a unit even though your blood sugar's 90, and you're not eating anything. So it's a pretty progressive thinking clinic.

Scott Benner 9:33
There's, listen, I, the the problem is the reason I don't have more information about this is even though Arden is sick at the moment, we don't generally get sick in our house, or neither. And we don't get the kinds of illnesses that come with, like nobody vomits in my house. Right? Like, you know, families are either vomit or they're not, you know, like we don't we don't throw up and so I'm putting that on my tombstone. You're alive, Scott. Never really act. But so we don't have the problem with what we can't keep something down. Like it's not fun to drink or eat when you're sick. But Arden can she can power through it, right? Sure. So I've never really been in that situation. And I do take a lot of, I do believe what you said that we're just very aggressive with insulin so that even if Arden has been in a situation where there are ketones, we might not even know about it, because we're, we'd be bringing them down. Correct. There's a connection in there that um, oh, I know what it is. You hear a lot of people online get told. It's a variation of what you just said. You just said like push the blood sugar up so that you can put in a bunch of insulin. And I've also heard people told like, you know, Bolus but then drink like sports drinks at the same time. Correct. And that's

Jennifer Smith, CDE 10:54
actually I think, if your blood sugar is low, and you can take something in especially kiddos, often Pedialyte will sit, okay, sometimes just sucking on a popsicle, or like you did a sucker can be okay. Sometimes if kids aren't willing to take anything, put some honey, you know, in their mouth, it can get absorbed through the mouth tissue, essentially. But why would you leave ketones where they are and drive your blood sugar up just to take some insulin. So another strategy is to use some carbs that can be taken in and not cover those, okay? And then allow the ketone coverage alone without a Bolus for any of the carbs that you've intake, or you've taken in?

Scott Benner 11:41
What's the reason for that?

Jennifer Smith, CDE 11:43
The reason for that would be if your blood sugar was lower already, and you're worried, you know, Arden's blood sugar was 90, and you're like, No, we we can't give her a unit of insulin. This makes no sense to me, right? So had she been able to take something you would have essentially let the carbs go in without covering those at a lower blood sugar value? Because with ketones present, you need insulin to clear that.

Scott Benner 12:08
So correct. The blood sugar with carbs Bolus? Are the ketones. Correct? Right. This is this whole dance here is why a lot of people who are people who vomit, people, I can't believe I've designated there are people who vomit and don't but anyway, you don't even more prone to it. They often have a prescription for like Zofran in the house, right? A lot of type ones do that. So yeah, when nausea comes, you can treat the blood sugars treat the ketones if they exist, and have the safety of knowing that you can keep something in your stomach and not that I guess. I mean, let's just go over it. If you Bolus for something, and you eat it, but then it comes back out before you've digested it, then you don't have the impact of the carbs. All you have is the act of insulin. And that is the quick way to seizure Vil. Yeah,

Jennifer Smith, CDE 13:00
correct? Absolutely. I mean, it's the big reason that with stomach bugs, specifically where you are throwing up or potentially the opposite of that, right? Whether it's coming out one way or another, you're really not also absorbing everything that you're even able to put in. And because your digestive system is irritated. And with that we you say take in the carbs that you can and wait until you know it's going to stay down before you Bolus for it. And then reduce the Bolus for the carbs you ate by about 50 Maybe 60%.

Scott Benner 13:38
So some insolence happening, but not super aggressive. Correct? Yeah. Okay. All right. So now we're talking about illness ketones? Yes, these do land people in the hospital all the time, because then they can put you on a drip to keep your blood sugar up and give you insulin at the same time. They can bypass your digestive system basically and get your ketones down. Right. Can you tell people a little bit about why you don't want your ketones to be high?

Jennifer Smith, CDE 14:06
Yeah, absolutely. I mean ketones, ketones that are specific to illness and high blood sugar or ketones that are relative to lack of intake because you have a stomach bugs, we're talking about illness based ketones. We're not talking about nutritional ketosis are those on a ketogenic diet. Right. So ketones in general in an in a state where you're sick, it's like having waste in your body, right? You know, the ash that's kind of in a fireplace once you've burned the logs, right? That's kind of what ends up happening when you have the not desired ketones in your body. It's like waste product from having your body break down. Pieces of your body, right? And so your body tries very hard to flush that out. And which is The reason that we use to test ketones using urine ketone test strips, because your body will try to flush as much as possible out. Hydration thus is very important if you have ketones whether they're mild or moderate or absolutely high. Need hydration, I want to talk about like a water bottle an hour of hydration with ketones like flush, flush, flush, drink, drink, drink. But you so that's essentially the reason that ketones are present, your body doesn't have enough insulin to clear the high blood sugar. And that often blood sugar's over about 240 or 250. If they're left lingering high for hours on end, you're more likely, especially with an illness to have ketones show up.

Scott Benner 15:46
Okay, and this is just from the CDC. But decay develops when your body doesn't have enough insulin to allow blood sugar into your cells for the use of for use as energy. Instead, your liver breaks down fat for fuel a process that produces acids called ketones, when too many ketones are produced too quickly, they can build up to dangerous levels in your body. And decay in an illness situation can come on fast. And it can be deadly like, Yeah, seriously. Yeah.

Jennifer Smith, CDE 16:15
And that's another big one with that, you know, another testing piece that they often look at, if you do go in, and especially DKA, or electrolytes. And so with illnesses that are the vomiting kind of illness, so to speak, you may have a difficult time keeping in enough hydration, and electrolytes then get very off, which does not help in this scenario with ketones present. So I

Scott Benner 16:45
believe that beyond her, her initial diagnosis, Arden's only been in decay one time, and I don't know if she was in it or not. All I can tell you is that there was this one time, we had a kinked cannula that we didn't know about in a changed pump in the evening. So she went to bed and didn't get insulin, and then woke up in the morning, and was like, she had a really high blood sugar. And as soon as I saw it, I was like, That's odd. It's a long time ago. And I tested it. Change the pump saw the kink. And I thought, Ooh, Oh, no, no, no, this is bad. And you know, so I said to her, she was old enough to have a decision. It turns off, I said, Listen, if you can drink a lot of water right now. Hold on a second place.

Jennifer Smith, CDE 17:35
Yes. Are you defining a lot? Oh, much water is a lot.

Scott Benner 17:42
Well, back then. I, I told her to bottles, that if you can get two bottles of water, and I think I can get your blood sugar down in the next couple of hours. And she did not feel well. I mean, she felt terrible. And she kind of was like, I can't do that. And I said, that's no problem. But if you can't, we have to go to the hospital. They're gonna give you an IV and everything. She just like, I wish you could have seen me the water bucket action movie, she like grabbed the water bottle. She was like, just pushed it in. And I remember saying to Kelly like I put a timer on it. I was like, Listen, if you know, in three hours from now, like I said, an hour from now we're not seeing movement. But if we see movement that will go to two hours. And then after we get under a number, but I was making it up on the fly. I didn't know what I was like, You know what I mean? So

Jennifer Smith, CDE 18:36
you're actually at what you did was right in the timeframe. I mean, you're talking about not illness space, but but a pump failure really insulin, right? She didn't have any insulin. So in that case, right? You did the right thing, we recommend checking or looking at blood sugar after testing for ketones. And if you don't have a way to test ketones, assume with a consistent high blood sugar, that it's probably a pump site failure. Change it out, take insulin to get it down. Hydrate, check again, you know, I mean, now with continuous monitors, you have the ability to see where things are obviously going but if you don't really checking blood sugar is about every hour to two hours checking ketones somewhere between you know that timeframe, every about every two to four ish hours. Check ketones again, if they're coming down, great, continue with the water correct as your pump recommends, you can correct and continue to check your ketones until they're you know, down.

Scott Benner 19:36
So one of the more interesting conversations that I see online every year is around this. Somebody pops up into the private Facebook group. They're like, hey, my kid is sick, and they have ketones. What do I do?

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To in pen to us med to touch by type one and all the sponsors that you click on. I just hit something while I was talking. I apologize. When I'm talking with my hands right now I don't usually do that. When you click on my links, you're supporting the production of the podcast and keeping it free for listeners. So if you want it in Penn, if you want to switch to us med do it, but use my links and if you don't want to, I don't really care. Do what you want to do. But if you're doing my stuff, use the links this all makes sense to you right? Don't forget there are also links to the other sponsors Dex comm on the pod. G vo Capo pen Contour Next One blood glucose meter. Wow, a lot of sponsors. Feel like I can't remember them all. If I haven't said your name yet don't get Don't Don't get mad at me. Now I set them. Yeah, I got it. I mean, you know, take the T one D exchange survey that links they're touched by type one we already talked about today. Just use my legs please. Thank you. Oh geez. I'm all over the place. I have to say in pen requires a prescription in settings from your healthcare provider. You must use proper settings and follow the instructions as directed. Or you could experience high or low blood glucose levels. For more safety information visit in Penn today.com. I almost forgot to do that. But then I remembered at the end and they have ketones. What do I do? Somebody who has had a bad experience with it or is afraid right away says good hospital. They don't even ask any questions. I go to the hospital to last but then other people come in and say Well listen, like are they able to keep food down? You know, can they drink a sports drink? You can give them insulin like how high are the ketones? Are they really large? Are they moderate? Are they small? Like you know you might be able to manage this on your own. It's a very it's a very interesting conversation to watch happen because there is fear from people who have either been in decay because of this or have been in a situation where they can't keep down food. And then there's the other people on the other side who are Like, I guess not yakkers. And they're like, you know, they're like, oh, no, you can manage this, as long as it's not too out of hand, if it's too big, you should go. And I always think, like, what a horrible situation to be in, you really don't know what the right answer is, you know, call the sick line for your thing. Some people call the sick line, nobody gets back to them for a while and correct,

Jennifer Smith, CDE 25:20
or they give them information that that's not specific to their individual need, because the sick line really isn't. I mean, if it's within your healthcare network, they could potentially look up your information and see what's there. But they really don't know the day to day, you know, nuances of your management and how sensitive you are and whatnot. It's really just a, an off the list of do this, then do this and then do this and adjust based on what your calculated insulin dose should be.

Scott Benner 25:53
It also gets messy are messy is the wrong word. It's gonna be funny in a second, because a lot of people have urine, Keystone, urine ketone strips still so they're like, why Amelia, get this, like, it's a baby or like, you know, a kid or like, I don't want to be it. That's why I don't know what you have in your house. But we've had a blood ketone meter for a very

Jennifer Smith, CDE 26:13
long time, we in fact, that's the only thing we recommend. Yeah,

Scott Benner 26:17
I use the precision extra. I've used it forever. They're not. They're not sponsors. I've just had it forever. It works great.

Jennifer Smith, CDE 26:24
And they're, they're nice, because the test strips come individually wrapped. So you don't have to open a whole bottle, which is only then good for 90 days after you've opened it. Unlike the ketone, the urine ketone strips, once that bottle is open, you might use 10 out of the bottle of 100 over a sick period of time or a day when you had a high blood sugar because of a pump sight issue or whatnot. But then, hopefully, you don't have to use the rest of them in the next 90 days. But really, then that that battle is like, done there. And you know, you're in ketones also. They're old information, right? It's a couple of hours old, comparative to real time being a blood value of ketones.

Scott Benner 27:09
Well, as soon as Arden got sick this week, like we got her set up in a room and the first thing I said to Kelly was like, Well, I'm gonna check her ketones, get the meter out, make sure we have it, you know, have a baseline like right now she doesn't have any that's good. But I guess I want to talk a little bit about what we're really talking about here is meet the need, right? Like you. Generally speaking, you have a need for insulin, you have a different need for insulin during an illness. And by the way, not all illnesses hit people the same. So right, you know, you could like Arden had ketones with the flu. But now more recently, she has a sinus infection. She doesn't have ketones with a sinus infection. You know, the Hoos and whys of that are not important just that sometimes this might happen. And sometimes it might not correct in general, in whether it's this ketone situation or not, you have a you have an increased need for insulin, and you're not meeting it. That's all. That's all it is. It's, it's scary. And it's different. And there's the piece about, oh, what if I can't keep food down, which I think ratchets up ratchets up the fear about 1,000,000%, because I can still remember being scared giving her that insulin when she was like four.

Jennifer Smith, CDE 28:20
Right? Absolutely. And I think there's a there's a definition, kind of to make between high blood sugar illness and ketones. And the main illness that really doesn't drive blood sugar up, in fact, you may run lower, and your insulin needs may look like they go down on the base level of what you need. But if you have a stomach bug, and you're running lower blood sugars, as we said before, you may check ketones and ketones may be present. And they may be more mild. They may even get up to moderate because what you're doing is you're now not taking in any food. Right? Your body has to derive energy from something so you get this low level of ketones more from a starvation base. This isn't driven because of high blood sugars, because your blood sugar's aren't high is driven because you're not really taking anything in and so then it's sort of like the question, well, I've had a lot lower Basal insulin needs, I'm not eating anything, but I have ketones, and now I'm supposed to take insulin.

Scott Benner 29:30
You know, and the other side of this too, is that like you mentioned it earlier, just there are starvation ketones, which you could also see if you were doing an ultra low carb diet, these do not put you into decay.

Jennifer Smith, CDE 29:43
So not not at all. In fact, many people if you've been tested just just so that you figured out how to use the machine, like in a baseline setting and you're not sick or anything. Check your ketones first thing in the morning. Many people actually have a really mild, low low level of ketones because overnight, your body's supposed to go into this sort of like fasting. It's not supposed to be digesting food until you eat at midnight, the steak and fries and cheese sauce and whatever it

Scott Benner 30:15
is. We you and I talked about this is episode 287. It's a pro tip called illness injury and surgery and actually in Episode 288 is the defining diabetes about ketones. Oh, I actually think it comes up also in how we eat episode with a person who was on the show, but you should go listen to you should understand the difference, but you know, keeping it to just illness. Okay, so let's kind of like, let's go back over what we've talked about. So sure, kids sick with two options, two sets two scenarios, kids sick and keep food down kids sick or your adult sick doesn't matter. Can't keep food down. So if you can keep food down, and you have ketones present, is there I mean, you know, me I'm like just thinking like, just use more insulin. But I mean, what did they do, like call the doctor.

Jennifer Smith, CDE 31:10
So obviously, calling your Health Care Protect practitioner is really it's an important first step. Based on what their recommendations I would even say, rather than a, you know, a PCP, you really should be calling your endocrine team, because they're the ones that could help to dictate well, how much more insulin to clear the ketones. The baseline is typically again, one of two formulas, if you want a more precise dosing rather than us take two extra units because you got you know, ketones present. And I know I need more, so this must be more, right. But you know, if you're using it, looking at your total daily dose of insulin, and then you may need about 10% more than what you average total daily, if you have mild ketones. If you have moderate ketones, then about 15% More of what your total daily dose is. Other Other practices go more based on just basil. And that then would say mild ketones, you would look at just what your Basal rate is, or what your Basal doses and you would take 5% of that and add it on to your corrective dose if you also need corrective insulin at that time. Okay. And again, how often I that's a question when we're, when I'm talking with the people I work with, you know about, well, how much and how often can I give it really it's about every two to four ish hours is the kind of watch point right, where you're checking ketones again, about two hours later, again, hydration, the extra insulin, you should be starting to see some difference. And this is where the benefit of using a blood ketone meter really does come in, because it gives you decimal values to ketones. So you're starting ketone levels, maybe it's moderate. And maybe it's come down by, you know, point four over the time period that you've been testing and adjusting. And every that's a difference. Absolutely. You're making a dent in your ketones. They look like they're falling. So continue to do hydration, watch your blood sugar's watch the ketone levels, with kind of a testing plan of about every two to four hours, you

Scott Benner 33:25
can't stop paying attention to it, because it comes on quickly. Are there physical signs to look for? When you should? Like, is there anything physical that would make you think we're not winning this battle? Maybe the hospital is the right way to go?

Jennifer Smith, CDE 33:39
Well, if blood sugars are high enough, in ketones are present, obviously, somebody's going to be more thirsty. Definitely there. Also, ketones often make people nauseous. Like that feeling that you said Arden had ketones feel horrible. Okay. So those symptoms now again, in kids that are old enough to tell you how they're feeling or teens or even you're the adult, you know, managing everything. There's a little bit more ability to tell how you're feeling. But little kids are, I think they're harder. And so they're the ones that a lot more watchful, honestly, I would say under the age of six, more testing more watching. Because they may be the ones that end up needing to go in,

Scott Benner 34:27
right. So and you're in, you're clearing these ketones with water, if you're lucky enough to be able to drink it. And with insulin, those are the two ways you can clear it out of yours.

Jennifer Smith, CDE 34:36
Yep. And I usually even say try to try to go off and on with water and then maybe an electrolyte beverage that does have carbs in it. Because remember getting in some carb and if your blood sugar is high and you're doing carbs, obviously you're doing correction insulin, you're doing the carb insulin base, electrolyte drink, and you're doing the ketone. So you're doing kind of a three level of insulin. there because just because your blood sugar is high, your body still needs some energy

Scott Benner 35:04
in an illness situations where people are still eating, but they seem insulin resistant. That's, that can be fairly common during an illness. Yeah, so our didn't had it this week with this, with this sinus infection every night after dinner until like two o'clock in the morning, I gave her I mean enough insulin to put down a pony, you know, like, and it was, we were barely holding her blood sugar 200. And, you know, it just it takes a lot of time and experience to be able to say, I'm going to use a significant amount of insulin more than I then what would normally be needed here. And right, you know, I don't even know how to tell you to get into that headspace. It just it takes time, you have to do it over and over again. But there was a moment when I came in. I said, I was like, I'm gonna go get a syringe. And we're going to just shoot like five or six units. And, you know, because this 200 is creeping, it's going to go to 40 and five seconds like we're not ahead of it. insolence not touching you. Right? And I need to my thought there was, it's interesting, I'm almost not as aggressive as I sound there. I just don't want it to skyrocket because I know I'm putting all this insulin into her. And at some point, it might start working and put her in the wrong direction to correct. So I'm being super aggressive. If I told you I thought I might have used twice as much insulin. But I had her I had her basil doubled. Or basil was like at two units an hour. And we were bolusing. It felt like every 90 minutes, just to hold it where it was like every time it tried to go up. I was like no, no, no, no, like more, you know, and we were up watching what do we watch? on Hulu? Does Oh, only murders in the building. And we sat. We sat up all Arden was sick watching that for a couple of nights. And we just kept pushing. But the problem was is that she she hadn't lost her appetite. And on top of everything else was going for comfort food while she was sick. Right? So it wasn't just it was the illness. We were trying to hydrate her. But God knows how well that was going. She was drinking a lot. But then she's eating food that's more comfort food. And I mean it was a journey like it.

Jennifer Smith, CDE 37:25
I think you bring actually, an important point here in a sense is that when you're talking about illness, most illnesses that are the chest cold, the sinus infection and ear infection, even like a bad like tooth infection or whatnot, those will drive your insulin needs up because of the stress of the illness. And if you're not staying on top of that need to add more and by how much more mild mild cold when you're still up and around just feel sniffy, you might need 10% More Basal insulin, whether it's injected insulin or in your pump, you may need to use Temp Basal increases or whatever, you know system you're using to accommodate more. Yeah, you've got a nasty bug that is driving your blood sugar's up, and you're not adjusting your Basal up 2030 and 50%. I remember my insulin needs I wasn't even on a pump in college, I had mono. And I, I could barely like drink like broth. And my blood sugars are high. And my endo was like you need to just increase the Basal amount. I was amazed at how much my insulin needs went up, just because I was so sick. So I think if you don't stay on top of that with an illness early on, you're more likely to get ketones. Because you because you haven't brought the blood sugars down based on the illness. Yes.

Scott Benner 38:50
Right. So you could almost have because of the situation as such high blood sugars, you might have ketones that are just from high blood sugars that aren't specifically from illness. Charities. Yeah, and you know, there's always I'll let you go in a minute, but that's okay. Inevitably, I see someone online who's sick. And they have a CGM, and everyone who has a CGM has ever seen this knows how frightening it looks like. There's a ceiling to the CGM, like it only goes to like 400 or something. It's flat and that it just runs this dotted line across the top flat. And somebody posted recently, I've been sick for days. And my blood sugar has been like this for days. And I'm like, oh, no, no, no, no, no, no. And you know, and people are saying, like, do this do that I just popped into their head, I was like, use more insulin, use more Basal insulin, inject it to like bring it down. Like even if you can get it to 200. Like better I would be much better because also high blood sugars impede wellness in general and healing.

Jennifer Smith, CDE 39:52
Absolutely. The longer you leave high blood sugars while you're sick, the more likely you're going to be sick longer, right? Yeah, really.

Scott Benner 40:00
All right, well, I appreciate you doing this with me, because it just seems like something that people struggle with constantly. And it doesn't matter if you're newly diagnosed, or if you've had diabetes for a while, but I thought that it would fit into the beginning series. So

Jennifer Smith, CDE 40:13
it does I think the only thing that I, I think, because we have those levels of mild, moderate, and large for ketones, I think the last question a lot of people end up having is, when do when do I go into the emergency department? Yeah, right. When should I go, I've done all this stuff, things aren't moving, things are getting worse. You know, if your ketone levels, I think, one. You're trying to drive blood sugar down, it's not working. Let's say you've even while you're sick, you've done a site change because you think, Well, besides being sick, maybe it's my pump, right? Your blood sugar's aren't really moving. Your ketones aren't moving or are going up, that's more of a time, you may be behind the curve in terms of hydration and other the electrolyte balance and all of that in your body, you may need to go to the emergency department, you may need their assistance. So I think, just to clear up like, when should you really go?

Scott Benner 41:14
Well, Jenny, to be completely candid, this is a hard episode to do. Because there's a lot of nuance, and everyone listening is not going to be in the same situation, right? And really, honestly, I mean, there'll be a disclaimer at the beginning that says like, this is not medical advice, because I don't know your situation. And you might need to go to the hospital and like bringing up those Facebook posts where people run into like, go to the hospital. Those are people were like, I don't know what's happening there. And it sounds like you don't know, either. So go find somebody who understands

Jennifer Smith, CDE 41:47
this. Go somewhere who else who has a medical degree and can at least maybe hook you up to an IV?

Scott Benner 41:53
Right? Yeah, I mean, I think the way I think about it is the way I described it when Arden had the bent cannula, right, which by the way, I just want to say, only Ben cannula the entire time, she said diabetes, just one, which I think is Wow, not bad, right? Oh, but in my mind, when I saw that, I thought, if I can start bringing this down right away, if she can hold water, and I'm moving quickly, at a reduction, okay. But I am not going to mess around with this like so, you know, I you have to use your own personal intuition. And you know, it's don't genuine aren't telling you what to do. But, you know, I just thought maybe this would help guide people through it a little bit. It is a really weird thing. Like, I seriously in this space, sometimes you'll think Why does no one ever talk about this? Or that? And the answer is, because I don't know. Like, I don't want to tell you absolutely something and it not be right. And I'll give you an example. What's an episode that we have on our list that we never get to? How low of a blood sugar causes damage to a person? Everyone wants an episode about that? They bug me constantly, I get notes about it. I say to Jenny, how do we do this? And we're both like, I don't know, like, like, right? Yeah, you could difficult.

Jennifer Smith, CDE 43:11
That's a difficult one, because it's kind of like it's like ketones. It's you've been given these tools, you've been given this guideline to utilize. And every person I mean, what is it? It's your diabetes may vary, right?

Scott Benner 43:29
Yeah, me, right. Yeah. And by the way, some people are dizzy at 70. And some people are dizzy at 50. And some people never get dizzy and etc. And right. But the question people have over and over again is when does damage happen? Like, where can I let and listen, I can tell you that last night hardens, blood sugar dipped down to 55 for a couple minutes. It went up to 61. I looked at it. I said if this keeps rising, I'm okay. But it went back down again. So I gave her some juice. I didn't want her to sit there. Do I think that she's three IQ points dumber today because of that? No, no. But you know, but I also am not comfortable saying that out loud. Like as a certainty, you know, correct. And

Jennifer Smith, CDE 44:08
Reese, I mean, references or research often focus a lot heavier on what are what are the problems that come from high blood sugars. There's minimal. There is information but there's minimal information about what value creates problems with long term like mental health, right? And most of the research identifies under 55. So if you're looking for value, I would even say, let's say under 60, just to be safe, right? But honestly, it's it's the duration of the low blood sugar. And that's a general that's a general statement, right? If you're having duration one day into the next into the next into the next, it's very likely that you're impacting your brain cells,

Scott Benner 44:57
but if you're 60 for a half an hour It's a different situation.

Jennifer Smith, CDE 45:01
It's a different situation. I think that's the, that's the best, simplest way to say too much is too much and will likely create issues. So let's aim for less lows and defining lows as under 60. Let's aim for less of those.

Scott Benner 45:20
One one day, maybe we'll try to tackle it and see how it goes. But I just wanted to make the point that this is not this ketones thing. It's there's no real certainty in it. Like I don't know when to tell you to go to the hospital. So good luck. And try not to get sick. I'll tell you right now, Jenny. I don't miss COVID. But I miss everybody staying away from me and nobody gets sick. I love that time. But he's been so secure for so long, I would go back to being locked down. I have to feel like this.

Jennifer Smith, CDE 45:50
Hopefully, you guys are all on the mend.

Scott Benner 45:53
I hope so too. All right, I really appreciate it. Thank you. So welcome, of course. First, I want to thank my sponsors in pen from Medtronic diabetes and remind you to go to in pen today.com Also want to thank us med us med.com forward slash juice box or call 888-721-1514. And of course touched by type one is touched by type one.org. They also have a bustling Facebook and Instagram presence. Go find them. If you're looking for more bold beginnings, episodes, head to juicebox podcast.com. Go up to the top to the menu and it says it right there bold beginnings. Actually, a lot of the series are up there. Ask Scott and Jenny after dark algorithm pumping defining diabetes, diabetes, pro tip the variable series, mental wellness to finding thyroid. It's all there where you can just search your podcast app if you just said juicebox one word. And then like bold beginnings, I think you would get a list of all the episodes right your podcast player. I hope you enjoyed this episode. Thank you so much for listening. Let me remind you that Jenny works at integrated diabetes.com Who wants to hire her head over there. And I appreciate you listening and sharing the show. As the year comes to an end, I find myself very reminiscent of the past year I think back that's not the word reminiscent. What am I don't remember the word. I'm feeling good. So another long year of making the podcast for me. And I'm just thrilled with how it went. I'm thrilled with how you guys enjoy the show your feedback and how you share it. It grew exponentially this year. Doubling downloads over last year, maybe more than doubling downloads over Yes, sir. Anything. Yes, more than doubling the downloads from last year. It's just taking off because you guys are great listeners who not only download and subscribe and follow but you tell other people about the show. And that's why it's growing. And that's why we get content like this and I just can't thank you enough. I'll be back very soon with another episode of The Juicebox Podcast.