#866 Best of Juicebox: Diabetes Pro Tip Newly Diagnosed or Starting Over

March 10, 2023Scott Benner

First published on Feb 25, 2019. Diabetes Pro Tip: Newly Diagnosed or Starting Over is the first in the now 25 episode Pro Tip Series. Find them all at Juiceboxpodcast.com

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Scott Benner 0:00
Hello friends and welcome to episode 866 of the Juicebox Podcast

Hey everybody, welcome back. Today is another episode in the best of Juicebox Podcast series, and today we're going to revisit episode 210 diabetes pro tip newly diagnosed are starting over it originally aired on February 25 2019. In this episode, Jenny Smith and I begin the Pro Tip series that you now all know so well. By the way, if you're looking for that Pro Tip series, you can find it at juicebox podcast.com, where diabetes pro tip.com And of course, right here in your podcast player. While you're listening today, please remember that nothing you hear that Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan or becoming bold with insulin. Are you a US resident who has type one or the caregiver of someone with type one, please go to T one D exchange.org. Forward slash juicebox. Join the registry complete the survey. When you complete that survey. You are helping type one diabetes research to move forward right from your sofa. You also might be helping out yourself and you're supporting the podcast T one D exchange.org. Forward slash juicebox. Today's episode doesn't have any sponsors. But I want to remind you that if you're looking for the Omni pod five or on the pod dash, you should go to Omni pod.com forward slash juicebox want to get that Dexcom G six or that brand new Dexcom G seven dexcom.com forward slash juice box. How about the brand new Contour next gen blood glucose meter contour next.com forward slash juice box. Start your day off the same way I do with a delicious scoop of ag one from athletic greens, athletic greens.com forward slash juice box. The T one D exchange is a fantastic organization that helps people with type one diabetes and I'm speaking at their next event. Check out their website T one D exchange.org. Forward slash juice box. You can get your diabetes supplies the same way my daughter does from us med us med.com forward slash juice box or call 888-721-1514 Would you like to use the same glucagon that my daughter carries? You can G vote glucagon.com forward slash juice box. Wow, there's a lot of advertisers. This is why I spread them out throughout the week cozy earth.com Sleeping on cozier sheets this sweatshirt is from cozy Earth super soft and comfortable. Everything at cozy earth.com is 35% off when you use the offer code juicebox at checkout and hold on. I can't tell you about that one. There's a new sponsor coming next week. But I'm not just talking about it yet. So you'll check back and find that. All right, thank you so much for listening to all that. Now let's jump into Episode 210 newly diagnosed or starting over from the Pro Tip series. This is Jenny Smith and I in 2019 Making the very first episode of the now very famous diabetes Pro Tip series from the Juicebox Podcast.

Welcome to the Juicebox Podcast I'm your host Scott Benner. I first interviewed Jenny Smith, the CDE from Integrated diabetes back in season one on episode 37. At that point, Jenny and I were just talking about different management ideas. But it was then that I realized how much we agreed about type one diabetes, and the management of the disease. I brought Jenny back on in Episode 105. And we really drilled down about a onesies what they were and what they weren't. After that second interview with Jenny, I decided that one day I would have her back on to discuss all of the diabetes management ideas that come up on the show. I wanted to break them down into small categories, something that was easily digestible, where we'd stay focused on just one idea. I wanted to create something that you could come back to hopefully learn from and if you found useful share with others simply and so with that in mind, I give you the first in this 10 part series, diabetes pro tip for the newly diagnosed Pro for those wanting to start over with Jenny Smith CDE

Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And Always consult a physician before becoming bold with insulin or making any changes to your medical plan. If you're a newly diagnosed person with type one diabetes, or the parent of someone who's been newly diagnosed, what do you think the first things to understand are?

Jennifer Smith, CDE 5:29
The first things to understand beyond the glucose values are, what does insulin do? How does it work? I think that's it's a huge one. That is it's under, it's under emphasized, I guess is the best way to put it. Many people, especially adults who are diagnosed are kind of given a this is your insulin, this is the dose to take and kind of go experiment at home. I feel like that's kind of the way that it is. And I think insulin is a first most important thing to really understand. How does it work? What's What's the purpose of it? How is it supposed to kind of finish working? And what is the effect for you?

Scott Benner 6:17
Okay, and so what are some, like bare bones ways to come up with those understanding. So I think, obviously, if you have a CGM, it becomes different, right? If you have a CGM, you can get yourself at a stable spot where you haven't had insulin or food for a while. And just give yourself an amount of insulin and see how it moves you. Let's talk for a second about like old school, do you still teach people that they need to do Basal testing?

Jennifer Smith, CDE 6:43
In a general way? Yes, I think especially for pumping is helpful in the beginning, because it does in that basil only time period, it does give you a general idea of how things are being kept with the rate that's at play. I do think that basil testing needs to be more explained, let's say when we are talking about pumping insulin, though, because there are as you know, a lot of variables that could be at play in that barrel basil testing time period, especially like from from a woman's standpoint, it could very much be that it's not the right time of the month to be Basal testing. Right. Right, right. So all of these various are a kid or a teen who is a kid or a teen who is really athletic. Right, and there is consistent effect of activity level. And it may be different on different days, but there could be overlap from a data goal that you had for our practice or a tournament. I so Basal testing. As a general idea, yeah, it can be a really good place to start, especially if you think things are really off in a certain place of the day. But is it the end all be all of knowing where your insulin should be? Not 100% of the time, right

Scott Benner 8:07
and so, so what I ended up telling people when I speak with them, is that you know, if you're having an issue and that issue could be anything like you're spiking at a meal, or you're you know, drifting high all the time, or you're incredibly high all the time, you know, any of those things. You have to first look at your Basal insulin. It's it's absolutely far and away the first thing I have to apologize to you Arden's texting me and I believe she's trying to tell me, it's lunch. Okay, so lunch question mark. So Arden has been sick the last couple of days and pro already kind of resistant like this to her insulin a little bit. But we are ahead of it now. So she's 106 and stable now. But to give you an idea, she woke up at 110. By the time she was getting dressed, she was 120. Then there was this diagonal up, I Bolus a unit and doubled her Basal for an hour. And 30 minutes later had to Bolus two more units to get her back to this 106. Now she never got over about 150. But she sees that rise every morning like that, that little bit of a rise. But this morning I used I'm going to save three units more than I would normally use. Yeah, it's just because she's not feeling quite well.

Jennifer Smith, CDE 9:20
Again, another reason that basil testing things like this is not it's not purposeful. In fact, I think, you know, a lot of people try to overcome that morning time rise with a Basal adjustment. But what happens then when you wake up at a different time of the day, right or you have a variable schedule, so a lot of times I actually tell people, you know what, let's look at what the rise is. Don't correct it. Let's let's watch the rise. Let's figure out how much of a rise Are you consistently having, you know what we can offset it with a with a dose of it of Bolus. Sometimes that actually hits the mark better than trying to incrementally adjust a basil behind the scene that could actually change day to day.

Scott Benner 10:06
Right right. Okay, so now this is um this is really interesting to the waiter like tell you what just happened. So this is kind of hilarious but my wife is here. I'm gonna have to walk away for a second yeah back. Arden's pump only has 10 units left at it and, and just added her lunchtime Bolus is going to be 12 units. So I just had to do a smaller Bolus as a Pre-Bolus still, and I'm going to send my wife over to like swap. Oh, no, let me go out of my way. The Dexcom G six CGM is now FDA permitted for zero finger sticks. That's right, the continuous glucose monitor that Arden has been using forever, does not require calibration from a blood glucose meter any longer. But do you know what it does do? It allows you to see your blood sugar, speed and direction. Are you rising at two points a minute falling at three points a minute, the Dexcom CGM will let you know with customizable alerts. And if you're the caregiver, or someone who loves someone with type one diabetes, and you'd like to be able to see their blood sugar when they're not with you, that's possible too. Because Dexcom has a share and follow feature that is available for Apple and Android. My daughter is at school right now. We just gave her insulin for her lunch, and I can see her blood sugar, her blood sugar started to creep up on us a little bit. So I got an alert. And we added some insulin stopping a rise. The Dexcom G six features an applicator that is virtually painless. My daughter says she can't feel it at all. And it's completely automatic. One button push and the sensor bed has been applied. You snap in the transmitter and you're on your way. You can see your blood sugar's on your Apple watch or other smartwatches on your iPhone on your Android phone. You can share it with anyone in the world anywhere. I can tell you without hesitation that the Dexcom continuous glucose monitor is without a doubt one of the main reasons why we've been able to keep my daughter's a one C between 5.2 and 6.2 for five continuous years. To find out more go to dexcom.com forward slash juice box or the links in your podcast player show notes or at juicebox podcast.com. It's going to be the best decision that you ever made. So all is okay. Yeah, my wife's it's across the street. Yeah, my wife's gonna run over. She's working from home today. And it really does just go to show. I guess the fluidity that you have to keep around diabetes because okay, I'm lucky my wife's here today. If she wasn't, I would have to tell you, Hey, I gotta go. But in the end, there's no panic here. Arden's blood sugar's 107. I wanted, I wanted to do a Temp Basal increase of 50% for an hour and a half. And an extended 12 unit Bolus for lunch. But she only has 10 units. So instead, I had her set the Temp Basal still and do an eight unit extended Bolus. So she's still going to have four units going when my wife gets there, they're going to swap that pump real quick. And then she's going to head off the launch and be okay. Right. We'll be fine to get early lunch. Yeah, on every other day. It's a 1030. And then on the 30, like,

Unknown Speaker 13:23
what does he get up at five o'clock? Do breakfast? Really that

Scott Benner 13:27
sheets 1030 Every other day and the opposite day sheets at 1130? And she's out of school by two? Oh, wow. Okay, it's all kind of very quick. I don't know if she's learning anything. But so so I Yeah. So anyway, what I wanted to say about Basal is that, I'm sure just like you, I meet people who are having trouble, right? They're either on the roller coaster and they're going to 400. And they're going to 60 and up and down, or, you know, somewhere in that problem. They're high constantly, they're always 180, you know, they can't really seem to do anything about it. And when they get to you, they have all of these theories about why their blood sugar is too high, right? And I tell them, your blood sugar's too high because you don't have enough insulin, and it's not timed correctly. Now we're gonna start with your basil. And they'll inevitably say, Well, what about my insulin to carb like, that doesn't matter. I'm like, you can have a perfect insulin to carb ratio. If your Basal insulin is not right. None of this matters, right?

Jennifer Smith, CDE 14:24
That's right. That's why we call Basal insulin, the foundation of your management, it really is we, we actually tell people, it's like the foundation of a house. If you have a sound structure that you're building on top of everything you put on top of it will work. Even if the insulin, the carbon, the correction factor, and things are a little bit off. If the basil is off, those are going to also look like they're not working well.

Scott Benner 14:51
And it becomes impossible to diagnose what's happening, right. And so what I ended up saying is that you Try to imagine we use round numbers for examples. But try to imagine your basil is a unit an hour. That's what that's what it should be. But you have it at point five. And then you have you look at some food and you say, Oh, well, that food is two units. So you and let's say you're right about that. Let's say you're 100%, right that the food takes two units, you put your two units in, all you've done is now replaced the basil that you needed, right? You're so you're resistant, you're high, now you're replacing your Basal it's possible those two units will only go towards impacting the problems your Basal insulin has. And then your blood sugar shoots up and you go, I don't understand, I put in the right amount of insulin, I counted my carbs, right, I counted my carbs. I looked at the label, and I did everything the doctor told me why didn't this work. And in the end, and you know, through this series that you and I are going to do together, I'm going to repeat a couple of things over and over that I've found to be incredibly helpful. But in the end, if your blood sugar is high or low, you've mis timed miscalculated, or a combination of those ideas. And that's pretty much it, you know that I find that to be the core of it, it's not the first step to me, not being afraid of insulin is the first step. But we're going to talk about that in a different episode. But I think that it's it's timing and amount. And I think there's a million other things that can impact your life with diabetes. But that's the seed of the tree, right? And you could throw away all the leaves and all the branches and everything that comes off of that seed, if you'd have that seed timing and amount, you're well ahead of the game. Right?

Jennifer Smith, CDE 16:34
Right. Absolutely. And I would say the that those two pieces actually go very well together, as far as not fearing insulin, you know, and not being afraid of using it because I certainly work with many people who that is a major problem it is I just want to eat 200 Because I'm afraid to give the amount my pump is telling me to give or the amount that the doctor told me to give, you know, and I think understanding Insulin is the base of that understanding it and understanding the timing, and the action of the insulin and how it also individually works for you, helps to dissipate that fear,

Scott Benner 17:18
right? I think that I think that if you can keep your blood sugar stable at 200, then you can keep it stable at 180. And if you can do it any you can do it at 140. And believe it or not, if you can do it at 120, then you can do it at 75. And you know and so because the the tools that you use to to achieve that stability aren't different depending on what level your blood sugar's at. It's all the same. It's all the same stuff. Okay, so that's that is that's excellent. So we'll talk about fear in an upcoming episode as well. I'm newly diagnosed, I go into my doctor's office, now you are uniquely qualified to tell me this. What do people get told a diagnosis? And why do they only get told what is shared with them?

Jennifer Smith, CDE 18:04
I think it there's a wide range of what people are told, I certainly think that the younger the diagnosis, especially for type one, the younger the diagnosis, the more education there is, the more information is provided. adults that are diagnosed I think, unfortunately, get the least amount of education again, and it differs system to system and provider to provider. But in the beginning, you know, they're taught how to use a glucometer. They're taught how to give an injection, they're taught that you're going to be taught essentially the basics of that insulin action. And you're going to be taught carb counting. I mean, that is pretty much the gist of what you're going to be taught.

Scott Benner 18:51
Anyone who's been listening to this podcast for any amount of time will know that I call that do not die advice. That's the that's the advice you get so that you don't die. It doesn't keep you healthy. It doesn't help you understand anything. It just keeps you from going home and falling over.

Jennifer Smith, CDE 19:05
Well, and I think another piece of that, too, is very, very soon in that beginning is how to avoid hypoglycemia. How to avoid a low blood sugar because insulin causes low blood sugar. And unfortunately, that's where the fear starts.

Scott Benner 19:24
Exactly. And so that's where it starts where the fear starts, but try to understand that from the clinicians point of view, you are frazzled. I say this all the time being diagnosed with a disease that you cannot cure. It feels like someone just walked up to you with a shovel and smacked you square in the face with it and then started yelling, Basal insulin Bolus glucometer. This is a test strip and you're like, wait, wait, what? And so the doctor sees that on your face and can't in I guess in their minds, they don't want to overload you. But the unintended problem is just what you said that you start with Fear, then everything starts with fear. It would be a simple sentence, it would be, it would be Listen, we're going to teach this to you slowly. I know that seems counterproductive, but it's not. But there's no reason to be afraid. And that's what we're going to learn. Now, the question is, do doctors not teach that? Because they don't have the time? Or they don't have the knowledge? Like what like, because there are everyone's gonna walk into a different endos office, you're gonna get an 80 year old guy who's been doing this, since people have been boiling their urine, right? And he's just gonna think that if you count your carbs, and inject and go to 300, and come back to 100, that's amazing. And that's that, right? Right. And then you're gonna get a guy who's in his 50s, who's just starting to hear about like, this CGM stuff, and you're gonna get different advice from them, you're gonna get different advice from, you know, a woman who's been out of medical school for three years and has diabetes. How do you as the patient know what advice you're getting? When you don't know anything about diabetes?

Jennifer Smith, CDE 21:03
That's a very good question. Absolutely. And I think, you know, with today's technology, honestly, I, personally, as people have come to, to work with me, or to work with us that integrated, you know, it's people come because very soon, they realize they're not getting what they need. That's not quite, they're not sure what they're missing. But they know from researching and looking and Googling it, that the information that they've gotten is so just literally the tip of the iceberg, that they're missing so much more beyond and that, you know, that their doctor is saying, Well, you have to be in good control for a year to be able to start on a pump. And most parents or even adults are saying, that's not the case. Right? Doesn't it? That's that's not doesn't make sense. I want to know what I should be doing. I want to know, what is the best for my child or for myself? I want to know, and I think those are some of the things that as a as a newly diagnosed, asking more questions of your provider, even though you may not know exactly what you're asking, when you've Googled it, and you've researched and done some of your own searching, and even asked, you know, some people I think more and more people are, they're kind of they have acquaintances or whatnot, who might have diabetes. And so they, they will ask them, they'll say, Well, they're doing this, you know, maybe I should ask about this. And I tell all the people that I work with, you know, what, if your provider is not able to meet you or can't answer, even those basic questions in the beginning, it's, it's time unfortunately, to find a new provider. It really is.

Scott Benner 22:46
And based off of that idea, I want to say I want to say the same thing to two different segments. So if you're a clinician, and you're listening to this, or if you're a person who has diabetes, or is trying to care for someone who does, there's a space that a lot of people get into, they're not given enough information up front. And they're, they're paying attention, right, they want to do well, they're paying attention, and they see inconsistencies with what's been taught to them in the doctor's office. But because you're the doctor, or because you're looking at a doctrine, you were raised to listen to a police officer, your teachers and a doctor, you're raised to believe that a person in a white coat is infinitely more intelligent than you are, there's no reason to question them. And so when they give you these concrete laws of diabetes, you go home, put these laws into practice, and they don't give you decent results. This is for the doctors, it puts people into such a psychological bad place. It just wrenches their gut, they feel like they're killing themselves or their children. And they don't understand why. And even when common sense things about their diabetes show up. They can't bring themselves to make the leap, because you've told them, we're not told them anything about that idea. And I will give you a great example. And it's a very simple example.

Jennifer Smith, CDE 24:03
Or kind of before your example. You know, it's kind of a cut and dry too. As you know, kind of going with what the doctor said, the doctor said to do this, the doctor said I should take my my insulin and eat right away. Well, if that's not working, and you don't, if you don't know that and clinically, clinicians, I think, really do need more information about what really is the real life of diabetes. What's the real life use of insulin and mastering it's action and all of that because clinical book does not mean it meets what happens at home. And when your clients come to you and your patients with or people with diabetes come to you and they say this isn't working and following all of your rules. It's not working. Instead of saying well, you must be doing something wrong because that that happens often whether as a clinician you want that expression to come out or not. It does you Make them feel like they're not doing something right. And you don't give him a weight to, to help you don't explore with them and say, Okay, I hear what you're saying, I hear that you've tried everything I've thought would, excuse me would work. And it's not let's, let's see why it's not working, maybe something is variable for you.

Scott Benner 25:23
And let's have more of a conversation and explain what's happening. So that so the doctor can glean more from what's going on. I'm at the point now, and I'm sure you're there, too. I can look at a 24 hour graph and make changes in five minutes that improve somebody's life. immeasurably in 24 hours. I don't know why a doctor can't do that. So I mean, I figured

Jennifer Smith, CDE 25:44
some can yes, some are. Some are awesome. But some are not know me

Scott Benner 25:48
well enough. Now to know that, you know, I'm not the wisest person in the world. And I can look at it and go, Okay, this is this like this. My example of, of how powerful the doctor's suggestion or non suggestion can be to people is that I was speaking with a woman in her 40s, who had had diabetes for 25 years. I looked at her graph, she was distraught. And I said, you just need more insulin? And she said, Well, no, no, because in the ocean, like I said, all these reasons why that wasn't the case. And I said, No, that doesn't make sense. And in a brief 32nd, Explanation, over a telephone call, I could literally hear the light bulb turn on in her head, and she went, Oh, my God, I just need more insulin. And I was like, right? That's it? I mean, can we go now or, you know, but but think about, think about that. A well intended, intelligent, educated person who goes to her doctor's visits, and in 20 years, can't figure out why their blood sugars are the way they are, and no one's ever helped her. So what I'm saying to people who are newly diagnosed, or people who have gotten to that point and want to start over, you have to sort of think different, you have to, you know, if you're, if you're in a situation where you're newly diagnosed, and you've gotten some real, like what I call like old timey information, you need to think differently. And if you've had diabetes for a long time, or been caring for someone forever, and it's not going the way you want, that's the first thing you have to do. You have to say to yourself, I must not be thinking like flip it upside down, look at it all the time, I have a friend who every decision they make is wrong. And I once said to them, How come when you have a reaction to something, you just don't wonder, what's the completely opposite of that, and then just do that. I was like, I was like, right, you're right, you're always wrong, you know, so like, and that's what happens every day, you get up and you do this thing with this insulin, and this pump and all this stuff. And it always goes wrong. But yet, there you are the next day,

Jennifer Smith, CDE 27:46
doing it over and over and over again, which is another reason that I you know, working especially with the women through pregnancy that I work with, that's a piece of the variability that I try to encourage them to sort of work on prior to pregnancy. You know, because if you can figure out it's why many people with diabetes, eat some of the same things over and over and over again, they have a standard breakfast, I know that it works. I know that I need this much insulin, I knew they need to use a temporary basil for this much or for you know, whatever extended Bolus, and it works for me, it's, that's the reason is once you figure it out, you're like, great, I like little magic because magic piece right here and I'm not gonna screw it up. Now.

Scott Benner 28:32
I'm gonna have this half a piece of wheat toast two eggs over easy and two tablespoons of avocado for the rest of my life. Right? Exactly. Every morning, if that's happening to you, if you're listening, and that's happening to you, I say this proudly, the there are some low carb people who will get upset and I want to tell them right now you can eat low carb your whole life. I don't care. I'm just saying that if you ended up there because you couldn't figure out insulin. You know, if you're if you're eating something you don't want to be eating there might be a way to manage this. But I tell people very proudly that at this point, my daughter is 14 years old when I'm recording this. She has had type one diabetes since she was two. And for the last five years her agency has been between five two and six two with absolutely no diet restrictions whatsoever. Anything you can think of Arden eats and eats frequently.

Jennifer Smith, CDE 29:25
And I bet her more important within that I think we talked about this in the E one Z discussion and podcasts but more important than even the a one C is her standard deviation the variability which I would estimate without even seeing her information, I would estimate that her standard deviation is very nice meaning she's got these juicy little gentle rolls through the course of the day rather than this major roller coaster because you could have anyone see a 5.4 Yes, but you can have a major you know, standard deviation

Scott Benner 29:56
and we will talk about that in coming episodes. You can't run around with your six a one C but be it 300 Half the day and 50 the other half of the day that you've just tricked the a one C test

Jennifer Smith, CDE 30:06
right? On the doctor. Yeah. Because, again that goes back to clinician. A onesie is certainly it's a starting place. It is not the end all be all there is more in depth that needs to be looked at with that a onesie. Yeah,

Scott Benner 30:19
we try very hard. Well, you know, as you go on and listen to these episodes, you'll realize I'm not trying that hard anymore. I figured it out to the point where it doesn't really take that much involvement from us. But Arden's low alarm on her Dexcom is set at 70. On my follow up, it's 120 for the high alarm on hers, it's 130. And so we'll talk about like bumping and nudging later on, but that's my concept is that smaller amounts of insulin as you try to leave a tight range, get you back into that range more quickly. And cause far fewer lows later. Yeah. Give me one second here, we'll take a pause. Okay. I'm gonna text Arden, she's now wearing a new pump. I need to know how much insulin delivered from the last Bolus. And then because it's a new pump, and she's literally gonna walk right into lunch. Excuse me, going to double her basil for I was only gonna do 50%. Now I'm just gonna double it for an hour and a half. And that way, if there's any slow start with that site absorbing and having action I'm just going to do, I'm going to do something that at some point during these you'll hear me talk about where I call it over Bolus Singh, like I just I imagined not just what her needs are now. But the momentum and higher number that I know is coming. In 2008, we made the decision to get my then four year old daughter and insulin pump, it's a decision that I wish we would have made years sooner. After seeing everything that was available, we easily settled on the on the pod that was back again in 2000 and ate. Today Arden is about to turn 15 years old, and she has been wearing it on the pod every day since then, every day. And as I mentioned in the other ad Ardens eight one C has been between 5.2 and 6.2 for five solid years. How do we do that? Well, we start by seeing an insulin pump is more than just a way to not have to take shots. The Omnipod gives you the ability to do temporary Basal rates, that's increases or decreases in your background insulin, extended boluses, which will help you spread out your insulin over the life of a meal. And so much more. The Omni pod has no tubing at all. The pod is self contained, you wear it on your body, and you control it with a wireless controller. So there's no tubes running through your clothing, and no pump that you have to jam in your bra or down your pants or wherever people have to put their pumps that just doesn't exist with the Omni pod but does exist is the ability to swim while you're getting your insulin bathe while you're getting your insulin and live life untethered. Beyond the party even features self insertion, just push a button. Now I want you to go to my Omni pod.com forward slash juice box. And when you get there, you'll get a free, no obligation demonstration pod sent directly to your house. Check it out and see what you think for yourself. I'm going to do something that at some point during these you'll hear me talk about what I call an over ball of saying like I imagined not just what her needs are now. But the momentum and higher number that I know is coming. Yep. So that's hard change

Jennifer Smith, CDE 33:49
was one thing that I was always in in. In the beginning, I was very thankful that I had noticed the difference with my animus pump change that I needed that site to just be like, just saturated with insulin to get absorption sooner. So and I was glad because when I started Omni pod in 2006, I started doing the same thing that I did with my other pump sites, you know, just Temp Basal ng up by almost 100%. For about it was usually about an hour to two hours depending on kind of where I was at that point. And if it was I was having to change that pod, especially if it was before a meal and I was going to need insulin for that meal with the new pod. I actually instead of doing it through the pod I gave an injection because I just found that a Bolus with that new pod site. It never went well. Whereas if I did a Temp Basal increase, I took a Bolus via injection for that food that I was going to eat and let the pot gets settled in. I didn't have any blood sugar issues.

Scott Benner 35:03
Okay. Yeah,

Jennifer Smith, CDE 35:04
yeah, it's everybody's strategy is different,

Scott Benner 35:06
right? But I'll tell you what it what it what that tells me is, again, this is going to be another sentence you hear over and over again, you have to trust that what you know is going to happen is going to happen. Yeah. So if you make a pod change and your blood sugar's 90, you still need to do that. Right? Right. It's okay, hold on. Yeah, good. 5.6 units. So I'm gonna do a Temp Basal increase 95% for an hour, and Bolus. seven units. All now go eat as soon as possible. So she's got 5.6 units in from 20 minutes ago or so she's still 102. And so I'm not scared of those seven units. She's going to be eating in five minutes. And look, the 5.6 units didn't do anything over the last 20 minutes. So I'm good. My goal here on this Bolus is 75. Diagonal down while she's about halfway through her meal. Anyway, that's again, stuff we'll talk about later. Yeah. Okay. So

Jennifer Smith, CDE 36:10
and comfort level with, you know, will happen?

Scott Benner 36:14
Yeah. Because, and by the way, and this, this, you have to, you have to have these experiences, like, I'm going to leave this in this episode, so that, you know, that things have to happen that you don't expect, because it's data, right? It's, it's, I did this and this happen next time, I'd like this to happen. So I'm gonna do sooner or later, more or less, whatever it is, I'm going to do, but you can't know that unless something goes wrong. Right, right. And so and so here's a great tip for somebody starting over or who is newly diagnosed. There are no mistakes. There are only experiences that build on for next time. That's it. Yep. see something happen. Instead, you can't get dramatic. You can't get upset. You can't cry. You can't go, Oh, my God, I'm killing her. You can't do it. Right. You say to yourself, Okay, bare bones, what just happened here, I put insulin in here. It went up to there. And then it came down and crashed. I bet you if I would have put that much insulin in sooner and spread it out a little bit like I could have created the resistance that that blood sugar needed. Right, right. But if you're busy running around, wringing your hands, and just you gave away an amazing opportunity, and, and I will use this as an example. This past weekend, I was helping a mother with a five year old four or five year old boy. And while I was talking to her, this kid's blood sugar went to 300 off of some Cheerios. And we talked for 20 years, that breakfast cereal. Oh my gosh, we're talking for 20 minutes or so. This poor kids blood sugar's at 300. It's not moving. And we're getting ready to get off the phone. She's like, he's hungry. I don't know what to do. And I was like, Are you? Would you like to do something that's going to sound insane? I'll help you. And she goes, I think I'm desperate enough to try something insane. I was like, great. How much insulin Do you think it'll take to bring a 300 to 90 and she says a unit? And I said How much do you think lunch is going to take and she said a unit and a half as a cool Bolus two and a half units right now. And she says she's like, what's going to happen? We're going to put his blood sugar into a freefall. And then we're going to add the lunch at exactly the right time. And then with a little bit of fast acting carbs if we need to, we'll bring it in for a landing. I said I'll never leave you will will text the whole time we'll talk again and we have to. So she does it. We get diagnosed down to 90 to 75 to 52 hours down to 50. She's texting. Oh my god. I'm like no, no perfect, like, a whole lot. I actually texted her a picture of the guys from Star Wars who are trying to blow up the Death Star. Right? Stay on target. Like just don't don't flinch. Like don't flinch to 52 down to 42 3200. I said, Okay, now's the time to start getting the lunch together. And she laughs She goes Oh, it's already it's just here on a plate. That was good. I said when we get the one at given the food. So 182 down kid gets the food 10 minutes later. Now isn't this interesting? We're dropping 10 points every five minutes on the CGM. Then he eats then all of a sudden the dropping stops the arrows are still there but now it takes longer to get the 170 took even longer to get the 160 and she gets the watch this happen 150 Still two down 140 Still two down. I said okay. It's not going to catch the arrows. Do me a favor, give him a few ounces of juice. She says we don't have juice in the house. And I thought to myself, Oh I just killed a kid over the phone. And goodbye, wrong number. She says we treat Lowe's with jelly beans because they hit him so hard. I said, that's great. But do you have any liquid in the house that has carbs in it? That's not soda. And she's like, Oh, we have lemonade. I said, that's great. I want you to give him four ounces. Eliminate. So she gives them I said, Don't go crazy measuring it. Just give him a little bit of lemonade, right? So she gives him the lemonade boom, goes to one arrow goes to diagonal down, the kid comes in, I swear to you 75 Nice and stable. It's foods been in for a half an hour. And when it was over, she's like, wow, that was nerve wracking. I said, Okay, I know that, clear your head, and then go back and look at the boluses. Look at the time you put the food in and look at the CGM and figure out how that insulin works in him. Because you just had a Master's class how insulin impacts blood sugar and how food impacts insulin.

Jennifer Smith, CDE 40:53
Absolutely, absolutely. And that's, that's the place that as you know, clinicians, they don't have the time to do that. And it's unfortunate is it's unfortunate in the stance that with somebody something like diabetes, type one diabetes, specifically, you need that hand holding, in an instance like that, you need the ability to be with somebody who can say, you're okay, write it out, you're okay, he's going to be fine. You've got jelly beans, you've got juice, you've got honey, you've got something in the house, you've got a mini glucagon that you could use if you need to, you're going to he's going to be okay, she's going to be you're going to be okay. It's, it'll be fine. But you do you have to use those learning pieces, I think it kind of goes along with a really good friend of mine. Who has had diabetes a bit longer than me, which is 30 plus years, hurt. Or her doctor actually gave her kind of a good little hint. For numbers, you know, we start to view numbers in diabetes as good and bad, right? And that comes with that feeling of frustration then, and oh my gosh, I'm like killing myself, I'm doing something bad or whatever. And he said, you know, the numbers are information to just like you said, it is okay, I'm here. Why am I here? You know, what can I learn from this? What can I do better next time. And maybe you analyze it, you know, three hours from now, maybe not in the instant. But it's information. And so he told her, you know, when the number is going to come up on the glucometer. You put this test strip in you put your blood on the strip, and you tell yourself, I am awesome. And here comes a number,

Scott Benner 42:38
right? Yeah, because I just didn't begin to tell me what to do next. And it can't be a judgment, you can't feel judged by it. You can't let you can't, you know, you can't look at it and say bad luck, you can say not what I wanted, not what I was shooting for. Right? What makes me what gets me to what I'm shooting for. And you know, it's funny as as you and I are pretty much wrapping up this first thought, right? I have so many people asked me when they're first diagnosed, what are the things I need to know? And I find around diabetes in general, everyone's looking for an amount or a number from you just once tell me how many minutes I should Pre-Bolus Please tell me how many units I should do if his budget is like this. And I tell them all the time, I don't know figure it out for yourself. And you will write like you have to but I can't give you no one can tell you that a 10 minute Pre-Bolus is going to be what's right for you. In any given situation, let alone all the time. I think it's insane that we think that just because we've set a Basal rate of you know, one and a half units at 2am that we think that that's what our body is going to need every day at 2am It's It's insanity to think that it's just the best we have with the technology we have at the moment. Exactly. And so if you listen to this thinking someone's going to tell me the rules about what I need to do when I'm starting with diabetes. We did we told you what to do it just isn't what you expected. Right? Right. And so I get that I understand that it's it's not a pill disease it's not take three of these a day and you have to have food with them like it's not that easy.

Jennifer Smith, CDE 44:12
And I think as a general to in the beginning of of learning that comfort level and learning you're learning what works for you by watching you also have to take into that the variables that can mean what you did figure out needs to change because of such an such variable right? So you know my breakfast in the morning if I don't get to go to the gym before or after my normal breakfast which I just I like it which is why I eat almost the same thing every single day and it works nicely blood sugar wise but I like it so and it's easy. So but I the variables that I had to figure out were pre eating it. Exercise, post eating it Exercise there, those are the variables, you know. And so what works in a morning, where I'm not exercising at all, is completely different than the mornings when I have exercise at such or such time,

Scott Benner 45:14
there's variables are forever changing, which is why you have to, interestingly, know what they are, and at the same time completely ignored them. And what I mean by that is that you're not a machine, right? So there's certain things that are going to make sense. Like you just said, I know if I exercise prior or post that this changes how this Bolus needs to be. But if you're walking around trying to decide constantly, am I anxious? Did I just banged my knee? Like, like, you know, like, am I going to get a client the thing I see people saying online all the time, like his blood sugar's gonna, he's gonna get sick three days from now I'm like, Oh, my God, just give him more insulin. Like, who cares if he gets sick three days from now, I so that's what I think of. When I say be fluid, I just that it's going to keep changing at such a rate that for you to try to apply static rules to it is insane.

Jennifer Smith, CDE 46:08
You've got that piece of, of life with diabetes that you can then bring into education, which is why people usually come to us because we understand it from the living it standpoint, not from the this is what the clinical book says should be happening. So do this.

Scott Benner 46:27
I'm incredibly proud to say that I've gotten to the point where if I can talk to somebody for about 45 minutes or an hour, they can have a major change in just a couple of days. That's that's communication. That's what that is. Right? Well, that's what I have in mind, Jenny for this series. Today we talked about being newly diagnosed or starting over. The next episode will be about multiple daily injections or MDI. We'll do an episode about insulin bolusing pumping CGM EMS, and on and on until you and I finished covering every aspect of the things that we talked about on the show. Please remember that the Juicebox Podcast wouldn't be possible without its sponsors for today's episode on the pod, and Dexcom Dexcom, the makers of the G six continuous glucose monitor, and of course on the pod is the tubeless insulin pump that Arden has been wearing for over a decade. You can go to my on the pod.com forward slash juice box get a free no obligation demo of the pump sent right to your house. We can go to dexcom.com Ford slash juice box to find out more about art and CGM hack you could do both.

Jennifer Smith has lived with type one diabetes since she was a child. And so she has first hand knowledge of day to day events that affect diabetes management. Jenny holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She's a registered and licensed dietitian, certified diabetes educator and a certified trainer of most makes and models of insulin pumps and glucose monitors. She's an active member of the American diabetes Association, the American Association of diabetes Educators, Jenny also co authored the book pregnancy with type one diabetes your month to month guide to blood sugar management. It's available on Amazon and there's a link in the show notes. All that aside, Jenny's just a nice person. And I like having her on the show. And I love the way she thinks about type one diabetes. I am incredibly lucky that she's doing this series with me. I initially shared my idea with Jenny about putting together a series of shorter podcast episodes that would help people transition from their starting point with type one diabetes, because there's just no good reason to struggle. All you need are the right tools and a knowledge of how to use them. And that's what we're hoping to bring you. So when you see the next episode, it's about multiple daily injections. Don't skip it because you're pumping. Listen, there's good information in each one. By the time you get to the end of my talks with Jenny, it's going to feel like you sat in a room with her and I and hashed out every possible angle that you're going to need to understand. Because of the nature of these podcasts, I want to mention again that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, to Always consult a physician before becoming bold with insulin or making any changes to your health care plan. If you found this podcast to be valuable, please go to iTunes and leave a rating and a review. And don't forget to tell a friend the podcast grows when you share it

I hope you enjoyed this episode of the Best of the Juicebox Podcast if you're interested in the rest of the diabetes Pro Tip series. Again, you can find it at juicebox podcast.com diabetes pro tip.com or by going in your podcast app and searching juicebox all one word and pro tip that's two words juicebox pro tip, they should all pop right up in front of you. There are 25 episodes in the Pro Tip series. This is episode 210 Of course, but episode 211 is all about MDI episode 212 all about insulin episode 217 pre Pre-Bolus Episode 218 Temp Basal to 19 Insulin pumping to 24 mastering a CGM to 25 Bump and nudge to 26. The perfect Bolus to 31 variables to 37 Setting your Basal insulin. Episode 256 is about exercise, Episode 263 fat and protein episode 287 illness injury and surgery 301 glucagon and low Beegees 307 Emergency Room protocols 311 long term health episode 350 Bump and nudge Part Two episode 364 pregnancy 371 explaining type one that's an episode that you can give to people and it will explain type one diabetes to them. Episode 391 glycemic index and load Don't skip that one 449 postpartum 470 weight loss 608 Honeymoon 612 female hormones and God knows they'll probably be more one day. Check them out. If you're enjoying the podcast please share it with someone who you think might also enjoy it. And don't forget to check out the private Facebook group Juicebox Podcast type one diabetes. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast