#845 Ask Scott And Jenny: Chapter Eighteen

February 9, 2023Scott Benner

Scott and Jenny Smith, CDE answer your diabetes questions.

Is there an insulin that acts more like endogenous insulin meaning quicker acting than current options? Let’s talk about smart insulin.
If dehydrated and insulin is not working well, how much and how long does it take to get properly rehydrated?
What are the added risks of smoking to a person with diabetes?
School questions: How did Scott move from depending on a school nurse to directly communicating with Arden? How did she know when to pre bolus? Did she have alarms or did she only rely on her alerts? How did she handle texts in class? Did she wear a watch? What was your process if she missed a text? How old was Arden when she started to treat her own lows? What was your field trip protocol? Did she carry an extra pod on her?
Does a blood transfusion impact your blood sugar?
What are the settings that most often need changing when starting to Loop?

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Music - Google Play/Android - iHeart Radio - Radio Public, Amazon Alexa or wherever they get audio.

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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 845 of the Juicebox Podcast.

It's been a minute since Jenny and I have done an ask Scott and Jenny episode. But here we are back answering your questions. That's right questions from the listeners, right the Jedi and just got answered for you to the best of our ability. Today we'll speak about smart insulin hydration has Jenny ever smoked, and much more? Check it out. Stay with us enjoy. While you're listening, staying with us and enjoying. Please don't forget that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please Always consult a physician before making any changes to your health care plan or becoming bold with insulin. Now if you have type one diabetes, or are the caregiver of someone with type one, you know what I'm going to say? Go to T one D exchange.org. Forward slash juice box and fill out the survey. It takes fewer than 10 minutes. It's completely HIPAA compliant. Absolutely anonymous, easy to do. And once you finish you've helped with diabetes research. You may have even helped yourself, like the T one D exchange might come back to you and be like, Hey, are you interested in doing this? Right. And then if you are sometimes they offer gift cards. Just go check it out T one D exchange.org. Forward slash juice box. This episode of The Juicebox Podcast is sponsored today. By the Contour Next One blood glucose meter. You guys are always so generous about clicking on the Contour Next One link, I can only assume that you love it as much as I do contour next one.com forward slash juicebox. You owe it to yourself to have an accurate and easy to use meter. The Contour Next One is just that. today's podcast is also sponsored by touched by type one and guess what I did yesterday. I asked her to save the date from touched by type one. See if I can find it here. It's February now. But I could find it. Save the date it says, Hey, Scott, I hope this finds you. Well, we have begun planning our next touch by type on annual conference. And we'd love to have you join us again in 2023. Our conference will be held on Saturday, September 16. Well, that's a little something you can plan for. Check it out at touched by type one.org touched by type one does way more than this event. You can check it all out at the website. But um, I'm just saying if you can plan to come out, I'll be there making all kinds of talky talk. We'll have a great time.

Jennifer Smith, CDE 2:46
Yeah, I'm up for whatever.

Scott Benner 2:50
Since the end of the year, almost almost well, for in my mind it is because I'm making the podcasts like way out in the future. And I just edited your how Jaime eats episode, which came out really well.

Jennifer Smith, CDE 3:03
I thought of so many additional, like, additional things that I would have really added to that like, like I you know, they're just everything that you think in excess, like, I eat this. And sometimes they eat this and sometimes I gave you like this general idea.

Scott Benner 3:21
Don't be in a hurry, we can do another one. I make a lot of episodes, so don't worry. Yeah, we can come back and do a part two. Fabulous. It's like getting all that stuff together and everything and

Jennifer Smith, CDE 3:35
I'm glad it turned out well for what it was there. No, it

Scott Benner 3:38
no it definitely did in the end. I feel like they're less of a, like a checklist and more of a vibe. And I thought you did that really well. Like I think the way you think about food came across and what you eat in general comes comes across, you know what I mean? And yeah, it made an impact on me the other day i i was in between something and I walked through the kitchen and there were cookies from Thanksgiving and I grabbed a Clementine. I was like oh, I think this was what Jenny would do. So good. Very good. Yay. And by the way, very good. This is the time of year for clementines. I don't know if people know that or not. But

Jennifer Smith, CDE 4:19
it is absolutely actually growing up. My mom always had like more tangerines or oranges or something and I asked her when I got old enough. I was like here we have them more often this time of the year and she's like when we were little and my mom grew up on a farm right so they didn't have a heck of a lot. But this time of the year her dad would always go into town. Right? And like get some tangerines and they were like the best treat my mom said at this time of the year

Scott Benner 4:53
yeah, they're just for some reason. Ended November December January I must be where they where they're grown in the world. It must be the right timing for it, which is what I assumed. But yeah, they're definitely better because in the middle of the year you get them and you're like these are

Jennifer Smith, CDE 5:09
my mom always called them punky is how she said the rest of the year, they're not as juicy. The flavor is not what it's supposed to be. And you get the ones like half of your bag might be really like, dry, rather than that really big, like burst of juice that you should get your like, dry.

Scott Benner 5:29
You know, I was I know, we're not talking about where we're supposed to, but, but it's okay. Listen to people listening will decide if it's okay, if I see them clicking off, I'll know this wasn't okay. But I was in the in the vegetable aisle the other day. And there's this sign that's been there forever that I've, I mean, I don't know how I haven't seen it before. But it's tattered. That's how I know how long it's been there. All of these, all of these vegetables have been sprayed with a wax coating to extend freshness or something like that. And I was like, Oh, I didn't know that happened. I did. Did you know that happen?

Jennifer Smith, CDE 6:12
Well, you can tell though, I mean, even even like oranges and that kind of stuff. You can tell when you peel it sometimes the ones that have been coated, you can tell because it comes off on your hand. Apples as well are a common one that have that like, like, you can feel it you can almost rub it off. Because of the amount of time it goes between picking and actually getting to the supermarket, and then getting home with you. They have to do something to keep it

Scott Benner 6:44
Yeah, that's what occurred to me is that none of these things are grown here in New Jersey. I imagined. Oh, no, yeah, I'm sure. At some point they were

Jennifer Smith, CDE 6:52
right. Do you have tangerine trees in New Jersey? No,

Scott Benner 6:55
no? Well, you know, like, when I grew up, it was it was the stuff that you could grow here was grown here. In the winter, there was less of it. And we got it shipped in from the south. And anything sweet and round and yellow or orange came from an island somewhere or Florida. And that's just how it was. So now I'm realizing that they might be shipping in bell peppers from Uruguay and covering them with wax that they don't go ahead. I did not know that before. I also don't know where your way is. For clarity, just the name of the country. I mean, I pulled out of my butt, right. Anyway, Jenny, I'm going to go to our ask Scott and Jenny list. Cool of which is It's oddly extensive. Yes. And, and just scroll through a little bit, ask you a couple of questions that have been sent in by people. And we will answer them, hopefully, and move on to the good. So hopefully, if it's possible, we'll be like, I don't know the answer to this. I

Unknown Speaker 8:01
can't help you there.

Scott Benner 8:05
Do Okay, who knows? This is from Lisa. Do you know if an insulin that acts like endogenous insulin, meaning is it quicker acting than current options? is in the works. So that's a good question. Our pharma companies I mean, fiasco is here and loom Jove and a Frezza and a threat? Yeah. But are there more? I don't know the answer to that question at all.

Jennifer Smith, CDE 8:30
I know, I can tell you that there are things in in that are being researched? Yes. Where they are, I don't know. I know years ago, I attended JDRF used to have like these scientific sessions, sessions where you could come as like people with diabetes. And you could see what was in the works, right. And this Gosh, this was like 12 years ago, there was a company on the East Coast that was working on something called smart insulin, smart insulin from what I remember to the degree that this insulin would be taken once a day. And it would have almost a almost like a thermostat if you will, but but not relative to temperature relative to the glucose levels in your body. So it would see when your glucose was going up and going to rise sort of above this sort of setpoint and it would turn itself on. And then once your glucose was dropping and coming down into that setpoint it would essentially turn itself off and it worked on and off sort of all day long like that. From what I remember, it was in like the, the animal based studies, but since that time, I have literally heard nothing about it. So that's like It's like research. It's like we hear all these things. means and then there's no more news about it like where did it go? Did it get like shuffled off to Mars or?

Scott Benner 10:09
Exactly, there's the the most recent article I found online is from diatribe and it's from June of 2022.

Jennifer Smith, CDE 10:20
Okay, so not too long ago.

Scott Benner 10:23
Oral it's an overview of a smart insulin. The development of smart insulin options means designing an insulin that responds to glucose levels. Okay. We got it all that. Dr. Weiss distinguished professor at Indiana University School of Medicine explained to potential ways that glucose responsive insulin could work. Though we are still years away from smart insulins making their way to clinical trials, Oh, okay. We are years away from clinical trials. Right. Which means, what, 15 years?

Jennifer Smith, CDE 10:55
We're at work. We're nowhere near getting it into the human body to Yeah, yeah. So I think the answer to the question is, what we have right now is called Rapid insulin. It's much more rapid than it used to be years ago, and it was just regular insulin. But we're nowhere near smarter insulin that's more instantaneous, right?

Scott Benner 11:18
Like, reacts. Right? Yeah,

Jennifer Smith, CDE 11:22
it's just not.

Scott Benner 11:23
Okay. Well, sorry, Lisa.

Jennifer Smith, CDE 11:26
I know I'm sorry, to everybody. I that's just not an uncommon question. I've, I've gotten that a number of times, you know, when are we going to have insulin that just works now? And I don't have to wait and it does it faster. And it finishes when it says it's going to be done working? We I don't know.

Scott Benner 11:43
Yeah, sorry. Well, way to start off with a bummer. April wants to know, about hydration. She says she she hears people talk about it, you know, like they see a bad pump site or something or you know, blood sugar, excuse me, that's not moving. And people always come in and say, Hey, are you hydrated? Because hydration is super important. We've talked about in the podcast for a long time. What she wants to know is, how long does that take to work? Like she's saying, you know, say I am actually dehydrated. And that's the reason why insulins not working well. Is it a glass of water and I'm on my way is it I have to rehydrate my body and it's ours, I guess it would depend on how I would expect

Jennifer Smith, CDE 12:26
it's a min an average of about an hour to rehydrate. I mean, a good way to determine hydration is really the color of your your urine or your pee, right. So should be very, very mild, like a light lemonade color, if you will, right. It should not be dark. Now there are also some supplements, B vitamins and whatnot. If you take them, they can also sort of discolor the color of your urine. So that's not necessarily a good time to check. But, you know, hydration is where 60% of our body is made up of water, right. So if that's the case, hydration also means that all of the nutrients in your system that flow through your blood and need to get into the cells, they need, consistently moving bloodstream. If you are dehydrated, your body tries to pull water from other parts of your body to rehydrate and keep things moving. And so if you're not adding water back in, and you're more prone to drinking things that are more of a like a diuretic that are making you pee it out, but you're not putting it back in, you're more likely to be dehydrated, so with less fluid in the body, especially from a standpoint of a CGM. CGM is work off of monitoring the glucose in your interstitial fluid.

Scott Benner 13:55
Here's something interesting. This is NIH. Just a simple sentence. 75% of Americans are chronically dehydrated. That's it. Wow. That's a statement from October of 2022. Why is the dehydration so common? This is from Mayo Clinic. Sometimes dehydration occurs for simple reasons, like you don't drink enough because you're sick or busy or because you lack access to safe drinking water. So is this really just people just don't drink enough water? That's it?

Jennifer Smith, CDE 14:25
No. In fact, many people you know, a good strategy we talk about even in just general weight management is if you feel like you're hungry. Drink a glass of water first. Okay, most often, you your body is giving you a signal that you're misinterpreting right? You're actually not hungry. You're thirsty. So if you drink a big glass of water wait another 1520 minutes. Many people find that they're actually not hungry.

Scott Benner 14:53
Some early warning signs of dehydration include feeling thirsty and lightheaded, a dry mouth tiredness having dark colored strong smelling urine or passing urine less frequently than usual. What's now I want to know how often I'm supposed to pay.

Jennifer Smith, CDE 15:09
How often do you get to look up? How often should I go to the bathroom? Well, I mean, in general, six to eight glasses of water intake a day. And if you're hydrated enough, you should be probably going to the bathroom, every couple of hours, at least every two hours,

Scott Benner 15:32
bladder and bowel.org. Which I don't, oh, just the first one that came up. Not a number of normal urination is per day, between six and seven and a 24 hour period between four and 10 times a day can also be normal if that person is healthy and happy with the number of times they visit. So if you're not paying a lot, so then back to the person in question, I would think that rehydrating would have a lot to do with how dehydrated you are to begin with. True, right,

Jennifer Smith, CDE 16:03
right. Absolutely. You know, if you're just mildly thirsty, drink a glass of water, that probably takes care of it. But knowing as well that mild, even moderate levels of dehydration can also increase your blood sugar levels by a certain amount. And I know you've said it before, when we've talked about things like just higher blood sugars, like you force art and drink some water, drink some water and you can almost at some point, even without additional insulin, sometimes you can see a curve. Yeah, right. As you get things moving hydration that helps your body pass the sugar out of your bloodstream and you can actually pee some of it out if your blood sugar is high enough to need to do that. So yeah, hydration.

Scott Benner 16:53
Alright, I'm gonna add a little more here. How much fluid does the average healthy adult living in a temperate climate need? The US National Academies of Science, Engineering and medicine determine that an adequate daily fluid intake is about 15 and a half cups are 3.7 liters of fluid a day for men, about 11 and a half or 2.7 for women.

Jennifer Smith, CDE 17:17
Which means it goes right along with the recommendation of 60 glasses. Most people's glasses are about 12 to 16 ounces. So that goes it fits right in there.

Scott Benner 17:28
Is it the same not for children who on how much water should

Unknown Speaker 17:33
a child

Scott Benner 17:38
stay well hydrated children ages one to three need approximately four cups a day. Older kids five cups four to eight years old seven to eight cups for older children. Okay.

Jennifer Smith, CDE 17:50
And, you know, I think an important piece to bring into that too is that may be a baseline. This is just you in your normal day, right? If you are active at all, or you live someplace that is very hot, very humid, and you are active, it's very likely you need more than just the base of six to eight glasses a day.

Scott Benner 18:14
My so my daughter's home from college right now. Which means all of our girlfriends are starting to flood back in the house. Lynn, one of the girls is playing God. I hope she never hears this. Because I'm not which which is the one with the little stick. And field hockey, right? The little stick with a little curve at the end. Jenny's that field hockey field hockey, yeah. Okay, she played field hockey at college. And she's walking around with a jug of water all the time. And she's just constantly drinking and I think back to when my son was in college playing baseball, and the boys would all carry around like a one gallon jug of they were constantly drinking. Right? And these are the healthiest people I know college athletes so I don't mean I'm not I don't think I'm gonna grab a milk jug and fill it with water. But I am motivated from this conversation to do better, even though I better yes. Because I'm thinking about like, how much do I drink a day and does and by the way, let me ask you this. Does it count if it's not water, like

Jennifer Smith, CDE 19:18
you don't ensure you get some water from again it goes along with healthy eating right so you get some amount of fluid by eating fruits and vegetables because a good portion of them is made up of water. You know if you have soup that's not terribly salty. Sure that's made in a broth that is part water right? You can get it by drinking non caloric and like sparkling waters, right something like that. You're getting hydration that way. If you like herbal tea is or you know, decaffeinated tea or something like that. You're getting hydration that way so it doesn't have to be that you're drinking it eight glasses of plain old, no flavor water,

Scott Benner 20:04
right? But this doesn't count if I'm having a Diet Coke or a Gatorade or

Jennifer Smith, CDE 20:09
like the Gatorade would be hydration or it wouldn't be an electrolyte drink that they you know, Gatorade. What's the other one? Powerade. They give them to athletes, obviously. I mean, Gatorade was developed in Florida, if I remember correctly for the Florida Gators.

Scott Benner 20:25
That makes sense. I don't know that that's true. But I believe you. And but like, what about soda drinkers? Like I, I? I don't drink a lot of soda. Meaning that it's possible that a half a dozen times every two weeks, I have a small glass of some diet soda. Like you don't need me like I'm just not a soda drinker. But it's not I mean, I think we all are aware that soda is not good for us one way or the other. But am I hydrating when I'm drinking it?

Jennifer Smith, CDE 20:54
Yeah, you certainly are. I mean, there's a portion. I mean, it's not just like I hesitate to say this, because most soft drinks that are sugar in are like drinking liquid water, but are liquid sugar. But why is it liquid? It's liquid, because there's, there's water, there's fluid in it, which does provide you with some hydration, despite the fact that the other stuff that's in it isn't good for

Scott Benner 21:22
it a little like I come up on my home is burning. And I find a bucket and it's half water and half gas. And I'm like, Well, I wonder what will happen here if I just throw this off. So you're getting you're getting hydrated, but you're also getting a lot of stuff you don't need don't need and don't want. And correct

Jennifer Smith, CDE 21:41
and some of some of these beverages, too. could certainly be more of it what's called a diuretic, right? Which just encourages you to actually go to the bathroom even more than you would normally go to the bathroom. Which means that you have put back in what you

Scott Benner 21:55
sow coffee. Do you drink coffee? Yeah.

Jennifer Smith, CDE 21:57
Um, yeah, I like coffee.

Scott Benner 22:01
I've never had a cup of coffee in my entire life. So I'm outside of my

Jennifer Smith, CDE 22:05
you've never had a cup of coffee. Never. I don't think I've well other than kids. I don't think I've ever met another adult.

Scott Benner 22:14
No, I just my parents drank so much of it. And I can smell it still. It was terrible. And I associated with cigarettes too. Because it's always like a coffee and a cigarette for my father and like I just not interested. But my point is, is don't something's dehydrate you even though they're liquid, like alcohol dehydrates you. Right.

Jennifer Smith, CDE 22:34
Yeah, I mean, in many cases, it's really the caffeinated effect, right? That is more of a diuretic, which is the reason that if you really want the complete hydration, you're going to do things that are not full of caffeine. So you know, the typical dark cola based sodas, regular coffee, again, have a tendency to have more of a sort of a mild diuretic effect. Okay,

Scott Benner 23:01
because I had I recorded today before you, which I feel like I'm cheating on you. No, no. I had a cup of tea, and a glass of water with me. And I couldn't drink the tea because the tea was driving my mouth out. And I was like,

Jennifer Smith, CDE 23:20
oh, black tea. So it was a caffeinated

Scott Benner 23:22
tea. Yeah, it was and so I had to get away from it while I was drinking. Anyway. I just Googled Why does coffee make you poop so we can round out this conversation? Because because this is a integral part of some people's lives, right? So coffee sends a signal to your stomach to release gastrin this kicks off a wave of cause of contractions in your gut called PERS WHAT THE HELL peristalsis Thank you. It moves that that thing Jenny said moves food and liquid through the intestines. For some people. This leads to a trip to the bathroom in just a few minutes. Get me here seriously? Now when you go I mean next time I have to go maybe I'm gonna. I don't know. Then you need some coffee. I don't think I'm doing that. I really don't think I can. This one. Make sure it's good coffee. Well, what's good? Some people tell me Dunkin Donuts is amazing.

Jennifer Smith, CDE 24:19
How do I if I've heard the same thing? I mean, I can say that Dunkin Donuts is to me, it's okay coffee. I have grown very accustomed. After having lived in DC. I've grown very accustomed to like coffee houses that do their own roasting like in house. Okay, like I consider that good coffee.

Scott Benner 24:43
Is coffee and cigars kind of in the same vein. Like I don't know. Maybe. Have you ever smoked a cigar?

Jennifer Smith, CDE 24:49
I've never smoked anything in my life.

Scott Benner 24:52
Anything through it. Cigarettes. No cigar. No crack. Okay. Nope.

Jennifer Smith, CDE 25:00
Marijuana No, nothing I have never has anything passed my lips. Now I've probably and I'm sure I've inhaled quite an amount of secondhand smoke. In fact, I'm quite certain in my freshman year in college, my roommate who would smoke out the window, not cigarettes. I inhaled a fair portion of marijuana. Yeah.

Scott Benner 25:30
But as I get older, I just keep waiting for it to come get me the secondhand smoke. Because my dad, my son and I were talking about the other day. And he said, your dad smoked a lot. I said my father would smoke three packs of cigarettes a day, three packs of unfiltered cigarettes every day. And I mean, he would open his eyes in the morning, and light a cigarette. He'd have it in the bathroom with him. If he took a shower. He had it right till he got into the shower. If he was driving, if you if you got to a if you got to a restaurant, and they didn't allow smoking, he sometimes couldn't make it to the meal. He'd have to go outside. Like it was, like really bad. That's yeah, yeah. And he still I know him seven days, by the way. So

Jennifer Smith, CDE 26:18
I know it takes I know, it takes a certain number of years to recoup. I mean, the body is a self healing machine, right? As long as you don't continue to batter it up, was only

Scott Benner 26:33
around me till I was 13. So okay, maybe.

Jennifer Smith, CDE 26:36
So maybe you've got a lot of healing that's taken place and your lungs are back to a base.

Scott Benner 26:42
I also had a crappy job when I was a teenager. So I don't know what I buried there. But anyway, I just think about it all the time. I'm like, This is what's going to happen. I'm not going to even drink a cup of coffee. I'm gonna end up with lung cancer one day. You don't I mean, this is my Yeah, I know what'll happen. Alright, we've gotten way off the hydration path anyway. Drink water. Drink water. Yeah, it'll make. It'll make your insulin work better, and it will make your CGM more accurate.

Jennifer Smith, CDE 27:07
Well, and I think you brought up a good point, if I'm going to plug for not doing something the not smoking thing. Yeah, there you go.

Scott Benner 27:16
How much? How much more dangerous is smoking to a person with diabetes? Like what are the added risks?

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Jennifer Smith, CDE 29:53
well, many of the things have relative relevance to what smoking does to the blood vessels which we know that So we already are at risk with increased potential for damage to our vessels and to our nerves and to how our body reacts to stress. Smoking creates inflammation in the body. And those are all the things that we're trying to bring down by having optimized blood sugar levels. So it's like, You're doing all these wonderful things to manage your diabetes. But if you're also smoking, that's kind of putting some of those. It's counterproductive. Thank you.

Scott Benner 30:31
Also, you have an autoimmune disease. So inflammation is already coming for you. So yes, no reason to give me a helping hand. I don't think this one is aimed towards me, but doesn't mean we can't talk about it together. PIPA asks. Oh, oh, that's nice. I'd love to hear more about how we moved art in from relying on a school nurse to directly communicating to me, How does she know when to Pre-Bolus? Does she have alarms on does she rely on her alerts? How does she handle texts in class? Does she wear a watch? What's your process? If she misses a text? How old was she when she was able to treat her own lows? What's your field trip? Protocol? Cheese? pipa. All right, hold on. Does she carry an extra pod with her? Let's go through it one at a time. Cool. Well, I can tell you that, you know, the story of you probably know if you've listened long enough is that I realized in the summer between art in second and third grade year that I could manage Arden remotely, which had everything to do with me and nothing really to do with her. She was capable of like receiving a text and carrying out a thing in a way that I could trust. So I don't think the age is important Arden's age, I think it's Arden's ability, because if you're translating it to your kid, you know, kids are gonna be analyzed what your kid can do. 100% So, one day, I just was lazy. I didn't feel like walking upstairs. She was upstairs. And I texted her to Bolus and she did it. And I was like, oh, like, why? Like, I can imagine diabetes in my head. Now, if you don't I mean, like, you know, I don't know, like, one of those movies like beautiful mind or something. I have no idea which ones I'm thinking. I can see her blood sugar in my head. I know how much insulin is happening. If I know what she ate, I can reasonably manage her without being with her.

Jennifer Smith, CDE 32:25
And you have the benefit of looking at a CGM, as well, you're not guessing. Well, her blood sugar was at 615 minutes ago, and she was down here. I don't know if it was going up or down. You've got to CGM to be able to see where is she? I can easily text her and tell her because you also know the context that's going into the trend.

Scott Benner 32:43
Yes, but back then no. Like back then, oh, she didn't have a CGM when she was that night. Yeah, it was just coming at where it couldn't share by then. We might have a follow, we might still have it in the G four. Is that the the egg receiver? So?

Jennifer Smith, CDE 33:00
No, the Ag receiver was? Seven. That was the seven. Yeah, the seven system and then it went to the G four. And then it went to the G five and then it went to the G six.

Scott Benner 33:12
What a naming system Dexcom way to go. And so fancy back then they were probably just like, here it is. But But anyway, I realized I could do it without being with her. And that the only tripping point for me was my own fear. Because I kept thinking like, why would I do this. So we just started practicing in the house. I would just text her diabetes. Even if she was just in the other room. I was really practicing for myself. And then she went back to school in third grade and stopped going to the nurse because of that. So she could test she could send me her blood sugar's she could look at a CGM. Once it was available telling me the number that was on it. I just kind of bounced it all in my head. Did that make dependent? No.

Jennifer Smith, CDE 33:58
I think another question within that, which is sort of implied in a way here as well might be, how did you navigate that with the school nurse and the system? Right? How did you navigate saying, We've got this? These are the hit points that you have to know being the school nurse. And if needed, you would step in, but otherwise, please hands off because we have this Yeah,

Scott Benner 34:26
I might go to was usually just I just assumed they didn't really want to be doing it. And that they didn't really want to be responsible. Right? Like if you gave a school the choice between being responsible for somebody's blood sugar and not I figured they would rather not. So what I told them was, it's on me, like if something goes wrong, I did it. You're not at fault. And they were like, cool, and that was the end of it. So we did re kind of massage what what my expectations were from them. And from there, and we adjusted her 504 plan for it. But really, I have to, it sounds cynical, but the idea that they weren't on the hook anymore, I think was attractive to them. It's just always kind of how it felt to me.

Jennifer Smith, CDE 35:13
I wonder, you know, having worked with so many families, I have heard probably a good 50 different ways that school systems will or will not let things happen. I mean, whether or not they prefer to be doing it, some school systems really seem to have this, unless you don't tell them your child has diabetes at all. They have a plan that has to be followed, and much of it relies on the kid having to check in with somebody at some points in the day. So and it's hard because that many people probably want to do what you're doing.

Scott Benner 35:53
Yeah, I would, I would say that. I am not, I am not wildly different in my personal life than I am on this podcast. But I am more direct and ne than maybe some people are, and I don't be, I'm not pushing you. I'm direct. I'm like, This is what's going to happen. And then it's not open for conversation discussion. Yeah, and not in a mean way. But just, I don't leave. I think that it's, I kind of think of everything as a negotiation. And if you stop and think about how to negotiate anything, the last person who speaks wins. And so if you don't set the conversation up, where the person across from, you can respond, you sort of win by default. I don't know. That's a little. They, you know, I don't know, that might be outside of what people are comfortable with. But you have to be comfortable in the silence. You have to be comfortable saying this is what's going to happen. It's not open for discussion and be able to sit there without feeling because as soon as you feel the thing in your chest, it's when you give something up. You go okay, and then you get nervous and you give something away. And then it goes back and forth. And before you know it, you walk out you don't have anything. So anyway, going through her. How did Arden know when to Pre-Bolus? Well, that was easy. I set a lot of timers on my phone. And in the beginning, Arden had those timers on her phone as well. So her timer would go off and then we would text each other. And I'd say What's your blood sugar? If she had to test she test? If she had to tell me what was on her CGM? She would tell me and then I would just you know, say, Okay, what's Bolus this much right now Arden was using on the pod and you know, we didn't let Arden go to school on MTI. So she's been using Omni pod since she was like four, four and a half like right before she went. So that's how we did Pre-Bolus thing. It answers the question about weather alarms. How does she handle texts in class? Arden handles texts in class the same way you hear me say? Like, what I just said, basically, this is a necessity for her. We're not embarrassed by it. She wasn't, you know, she she didn't try to hide it. I mean, she doesn't love. Like she was still a kid, you know, like she wasn't looking to be texting with her dad and stuff like that. So we also kept it to a real bare minimum. Sure, yeah. That was that was that she just never want to watch. If she misses a if she missed the text, and it was, what's the process if she missed the text, depending on the context. So if it was important, or emergent, then I would go from texting to a phone call. And if the phone call didn't work, then I sent a find your iPhone signal, which is very difficult to ignore. If that would have cascaded through then I would have called the nurse's office. Sure that would have been the the last thing. How old was she when she was able to treat her own Lowe's, that was your husband, he just walked in, saw you were doing something and walked right back? He got this look on his face like oh, no, not now. And then. I don't know the answer to that question. How old was she when she was able to treat her own lows? I mean, I guess she was in third grade. Because

Jennifer Smith, CDE 39:16
I wonder if it's a little bit more depth of the question in terms of most kids can when told treat your low blood sugar by someone? They do it without question. Well, many times without question, right? They'll just eat or do what they need to do because they've been told but I think the question is really asking, would she treat her lows by acknowledging and alarm that went off on her CGM without you having to follow up and text or if you did texter, she said, I've already got it.

Scott Benner 39:52
Yeah. Oh, so if that's the question, when did I stop wondering if this is not happening? Like it's She's not handling this. Hey, I don't know, I still want her son.

Jennifer Smith, CDE 40:04
You still wonder? Right? That's

Scott Benner 40:05
a hard thing to shake, you know? Right. But I

Jennifer Smith, CDE 40:08
wonder, you know, well, if she was playing with a friend and you saw her blood sugar was where it shouldn't have been, or it was dropping fast or whatever. What age would she have already taken action on that? And said, Dad, I'm fine. I got this.

Scott Benner 40:25
Yeah, I think the answer is I don't think the answer is that clear. I, as far as timelines go, I think that I've always I mean, since we've had a CGM that shared, like Dexcom does now. I'm fairly aware of hardens blood sugar all the time. You know, like she's in college, and I'm still fairly aware of her blood sugar, you know?

Jennifer Smith, CDE 40:46
Well, you've got follow and you've got all the things to be able to watch. I mean, most parents do. So I have a

Scott Benner 40:51
lot of things on my computer. I don't even know what this is called. But I have a pulling it up. See if I can figure out what it's called. Oh, actually, it's just I have sugar me on my desk. I was gonna say sugar me. Yeah. So up on my I've a Mac computers, but up on the on the bar. Artists blood sugar is there along with

Jennifer Smith, CDE 41:14
the trend arrow? Yeah.

Scott Benner 41:15
Yeah, everything that it needs. So that's there when I'm working. But the question about when does she? So I think when she was 12, like 1011 1213. If she felt low, she would have done something. The alarms, I'll tell you, Arden and alarms. The you know, like, I don't know. I can't tell.

Jennifer Smith, CDE 41:38
Did she ignore them more?

Scott Benner 41:40
Well, how about the other night, her CGM just shuts off after she's home? And I'm like, What do you How did you? How did this happen? I'm like, it tells you all day, it's shutting off in six hours. It's shutting off. He says he'd never said that. I was like, You're out of your mind? Of course it did. No, it didn't. I'm like, Yes, it did. And so you know, like, I

Jennifer Smith, CDE 41:59
promise, that's how it's set up to do it.

Scott Benner 42:01
She swipes things away so quickly, she doesn't even know what they are. What I will tell you is that my confidence level is at an all time high, as she was learning to drive. So when she got her when she got her permit, we had a really serious conversation about that. And since then, so I guess 16 and a half right in there. I don't think about it as much anymore. Like, I know she's paying attention to it. Does she push her high blood sugar's down? As much as I wish she would if I don't bother her. Not always. So, you know, there's that. Let me just get this last little question on here. What was our field trip protocol? I went on the field trips. Does Arden carry an extra pod with her? No. The way we handle extra stuff is at school, there was supplies, but not a pump, but but not insulin. And then if she needed a pod change, I would go do it just didn't happen that often. And we didn't like leaving insulin at the school. But I guess we could have she easily could have changed it on her own. And

Jennifer Smith, CDE 43:15
now you also though it just for context, you also live pretty close to her school. So it was convenient, right?

Scott Benner 43:21
It's a couple of blocks from my house. So if if she if it was farther than I would have put insulin in the school, but I always was trying to give Arden the feeling that that that the nurse's office was not a place that she belonged. I don't know if that makes sense or not. But like I never wanted her to feel like oh, I have diabetes. So I'm one of these kids who's always in the nurse's office. Like I try not to give her that feeling. Sure, in regular life, there's like a distance in my head. If we go to the mall, it's 20 minutes away and doesn't carry supplies with her. If a pod blows up, we'll drive home. Once the drive becomes irritatingly long. You know, you go into somebody's house, it's 45 minutes away than we bring stuff with us. So

Jennifer Smith, CDE 44:05
that's well and in context there. You know, you're going to the mall, who cares if you have to drive 20 minutes back home, you're going over by a friend or something that's more of a lengthy social kind of setting. Bringing it along as in, in I guess your best interest because otherwise you're going to ruin that event. Right? Not not for the other people but for yourself and why? Right? I just have to go big just grab it when you walk out the door and just take it along.

Scott Benner 44:36
Now that she's getting older. And I'm not always with her college. Now there are times when she goes somewhere. She takes stuff with her because for that same reason because there's not a person who's just like, oh, well, I'll bring it to you right now. And that's been pretty important

Jennifer Smith, CDE 44:52
or it's a bus ride across town in order to get back to where she needs to get back to to get her stuff and then a class might be missed in the inch. You're on there. And that's not purposeful either.

Scott Benner 45:01
No, no, it definitely has a lot to do with her age and, and the amount of people who are around her to help her. Oh, cool. Cool. Let's see if we can find another one here. That doesn't make any sense. Molina I'm sorry. Does a blood transfusion impact your blood sugar?

Jennifer Smith, CDE 45:24
Oh, that's a really good question. I think we're gonna I know I can answer a question that often comes up outside of this one is, can people with type one donate blood? Yes, you can. Okay, so but blood transfusion? That is an interesting question. So what's your what answer do you find?

Scott Benner 45:47
I'm looking right now because my idea is it must. Right if my blood sugar was 200. And you infused me with some blood, that sugar was an ad? Wouldn't my blood sugar go down? But would it go down that much? Does a blood transfusion or this one? Or, or change I guess impact? I mean, my guess is it's not enough for that matter. You don't I mean?

Jennifer Smith, CDE 46:17
Yeah, there's a correlation between blood transfusion and blood glucose.

Scott Benner 46:23
Yeah, blood transfusions of bank blood products are blamed as one of the causes of hyperglycemia because they are stored in

Jennifer Smith, CDE 46:31
a glucose solution probably. Or they have glucose added to them within the other additives.

Scott Benner 46:38
I mean, I could try to say these words, anticoagulant citrate phosphate dextrose, then I mean, add it. Yeah. Good job. Good. I get through that a little bit. So here's the answer. It looks like yes, it could make your blood sugar lower. It looks like

Jennifer Smith, CDE 46:53
it could make it higher heart rate.

Scott Benner 46:55
Yeah. Conclusion we conclude the blood transfusions does not cause significant changes in blood glucose levels in the study. That's from NIH. And the question was, does sugar level increase after blood transfusion?

Jennifer Smith, CDE 47:13
But not a lot? Yeah.

Scott Benner 47:16
Does blood transfusion affect your agency? The effect of blood transfusion on a one C levels might be summarized as follows. And patients with pre transfusion a one C levels of over seven, a one C tends to fall at once, even when your agency is under seven, it rises minimally or not at all. I mean, it sounds like it has an impact, but not not a great one. And if it does, it might be on the lower side. I don't know that's a lot of information. That doesn't look like it's studied that often either. No, because here's another one, the dextrose and bank blood products does not seem to affect. So here's the answer. All the answers you can think of somebody says

Jennifer Smith, CDE 48:04
yes, it can. No, it can't Yes, by just a little bit. So in general, I would draw out of this, that it could have a minimal effect. But minimal is the important piece there that you're not going to have this exorbitant rise or drop in blood sugar because of a transfusion.

Scott Benner 48:24
Yeah, that would be okay. That was interesting. Here's one looping. Oh, God, we're up on time. Are you okay? I have five minutes. All right. One more looping. Helen asks, what are the settings that most often need changing when starting to loop? And more or less aggressive? Okay, so this is, I mean, I don't know about when you're starting? Like, I don't think there's an answer to that question. Right. You gotta get your settings, right. And then once they're right there, right, but I'm gonna go from the, from the perspective of once you have good settings, what do we touch most frequently? Because Arden's a girl, and she has fluctuations from hormones. I would say that most frequently we touch insulin sensitivity. And basil. Those are mine. What do you think?

Jennifer Smith, CDE 49:17
Yeah, I would agree. I think, as you said initially, starting with settings that are optimized before enabling any algorithm driven system, including loop gives a good base for the algorithm to then work for you. And then once you have been using your current settings, and you use loop or with loop, you probably need a good week or two to compare to the previous two weeks of CGM data and see what looks a little bit different, right? More Most common, I would say honestly most common is ISF or the sensitivity factor the correction factor, which honestly gets under adjusted in manual or conventional pumping, oftentimes the correction factor, it's like this poor little like, in the middle of nowhere, but I'm not going to consider it factor. And it doesn't get adjusted, we're probably needs to much more heavy we adjust the basil and oh, we might look at the insulin to carb ratio is but your correction factor it's not even talked about. I've even talked to many people who are like, I don't even know what this does. That's the purpose of this setting and my pump, right. But when you loo, yeah, it heavily relies on how sensitive your body is to the insulin that you have present, that it can readjust. Its predicted glucose and, and the outcome from everything that it knows about what it's given you so far.

Scott Benner 51:09
Yeah, I could make it. I don't know if I how right I'd be. But I can make an argument that your sensitivity might change meal to meal can be you know, if you're varying greatly on the kinds of foods you're eating, if you went from a salad today to, you know, chicken wings and fries tomorrow, I can see where a heavier or more aggressive sensitivity would help the french fries. And it's just, it's a weird,

Jennifer Smith, CDE 51:35
maybe too aggressive when you eat the salad, or eat the broccoli. Right? Yeah. And, and the more true image of physiologic sensitivity would really be eating clean, not terribly high fat, you know, eat a nice salad with, you know, maybe a little bit of like salad dressing on top of it or something and get an idea of how if you did get a high blood sugar? How was loop working to help you with that rise? Does it cost you back down to your target? Do you settle out there, right. And if not, then looking at another meal that did work out one time of day. And the next day, you had the chicken wings and the French fries, and doesn't look like it's working at all and you're beating it down with extra, like fake entries? That's probably not really relative to your setting being wrong. It's relative to loop working against something that's so resistant. Yeah,

Scott Benner 52:36
yeah, that's the that's the mind space, you have to put yourself in like your settings are great. If you're not, you know, for general days, if you're not over taxing, suddenly, when you over tax with a a tough meal, the settings aren't going to work for it. But we can't think about that way because people can't be changing their settings constantly. So that's when you have to start saying, Okay, I see that this food falls into a different glycemic load or index scenario, and it's just going to need more insulin than on a regular day when I'm not eating something so difficult. That's where the that's where the understanding comes in. You don't have to move settings. This person is talking about what settings move. I mean, around like I said around hormonal stuff. I like Arden's basil. I mean, I try to keep Arden's basil in a place where I don't see the algorithm having to constantly take it away or constantly add more right, you know, right where the basil seems to be working. And in the moments when it doesn't work. The adjustments that the loop has available to it are such that it can stop spikes and lows. Makes sense. Yeah. Okay. All right, Jenny, I appreciate you doing this with me today.

Jennifer Smith, CDE 53:46
Always. Absolutely. Thank you. Okay, have a good day.

Scott Benner 53:57
A huge thanks to all of you for sending in these questions. And of course to Jenny. You can find Jenny at integrated diabetes.com If you would like to hire her, she does this for a living. I also want to thank I'd also like to thank the Contour Next One blood glucose meter and remind you to go learn more about it at contour next one.com forward slash juicebox. And of course, touch by type one.org find their website and check them out on Facebook and Instagram. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast don't forget to go find the private Facebook group Juicebox Podcast type one diabetes, always free 34,000 members and counting. If you're enjoying the Juicebox Podcast, please share it with someone else who you think might also enjoy it.