Scott Benner 9/24/23 Scott Benner 9/24/23

#1025 Diabetes Pro Tip: TRANSITIONING

Scott and Jenny Smith, CDE share insights on type 1 diabetes care

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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 0:04
Hello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right, you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CD and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisit double. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. While you're listening please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have an amazing offer for you. Right now at my link only contour next one.com forward slash juice box free meter you can get an absolutely free contour next gen starter kit that's contour next.com forward slash juice box free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries G voc hypo pen. Find out more at G voc glucagon.com. Forward slash juicebox. What I would like to talk about today is transition. Just a an overview concept for this one, but transition from just finger sticks to CGM transition from MDI, to pumping, transition from pumping to algorithm. Sure, can we do that? Yeah, I thought we could all thank Isabel here for having her finger on the pulse of the people in the Facebook group and knowing exactly what people ask about and what they seem most confused about. Why don't we start with MDI, because everybody starts there, right? After you're doing it for a while, like let's put ourselves in that place. We've been doing MDI for a while it's working pretty well, or at least at a baseline. We're shooting a Basal insulin once a day, and we are shooting a meal insulin to correct blood sugars and to cover our carbs. That's the basics of MDI. Okay, correct. So then we're in a doctor's office, but it make up yeah, I'm gonna make up some numbers. Let's, let's say our Basal it's like, I don't know, let's say our basil is 10 a day. And let's say we're, I don't know, one to 10 for carb ratio. Okay. All right. Let's say our correction is one to 100. Let's keep it all very like, like that, so that it's easier

Jennifer Smith, CDE 3:53
to talk about. Okay, round 10 numbers

Scott Benner 3:57
and numbers, we're gonna do that. So the math makes sense when people are listening. So we're in the doctor's office, and the doctor says, you know, you might like a pump. Is he gonna say it just like that? I mean, if it's a lady, she might be like, You made like a bump? I don't know, like, exact. or anywhere in between. There's some women have more masculine voices. Jenny, this isn't the point of what we're talking. Oh, yeah. So they see you might like a pump. You are. I'm guessing. Gonna have a couple of different reactions. I see a lot of people scared. Oh, no, don't change something. I see a lot of people are like, Yes, please. Because this isn't working. And maybe this will they don't know why they think that just right. They're hoping for a change. So the first thing that's going to happen is the doctor is going to translate your Basal insulin to this pump. So Jenny, you do that math for me? I get her I get 10 units a day. Injection. What are they going to do on the pump for me?

Jennifer Smith, CDE 4:56
Most often on a pump, because it's expected that your Basal insulin which, and this is kind of outside of it, but within your Basal insulin will now be given by the pump as rapid acting insulin. So that's the first thing to understand is that you're injected Basal insulin, which is a specific long acting kind of insulin will now sit in your refrigerator as a backup in case of pump failure, right. So you don't put Basal insulin into a pump. The only insulin that goes in the pump is your rapid acting insulin of any of the brands, right. Depending on the pump, company, they all have a little bit of different kind of recommendations for type of rapid insulin, but it's a rapid insulin and to translate your Basal dose of what we said 10 units into a pumped Basal delivery, you would essentially take 10 units into a 24 hour day. Right? And that translates into a a dripped amount, right? Because insulin pumps drip drip, drip drip consistently to deliver that total amount of basil that you want.

Scott Benner 6:15
Okay, so let's clean it up for people who get lost very easily. You may be injecting trust Siba love Amira, Lantis, what are the other ones, Basil Glar.

Unknown Speaker 6:27
These are all basil, JL,

Scott Benner 6:29
these are basil insulins, these are now gone. You don't use those anymore. Because as Jenny points out, you're going to take your mealtime or your fast acting correction insulin, put it in the pump, and it's going to split it up, those 10 units are going to get split up over, not just over hours. That's how the settings the pump work, right, you're going to come up with what is it going to be like point four, maybe an hour if you're 10. Today about like that, right? Right, depending

Jennifer Smith, CDE 6:53
on your pump, all of the pumps differ in their precision of a single drip of insulin. Some pumps can drip as little as point one, one, some can drip as little as point oh two, five, or point oh five. So it just depends. But if you broke this down 10 units a day into 24 hours a day would be a rate of about point four, two, if you do rounding, right, some pumps, you may have to round that 2.4, because they can't deliver the point oh two,

Scott Benner 7:24
and you're, you're gonna hear that if you're MDI and think, oh, at the top of every hour, it's gonna give me point 14 Its events on but it's not doing that it's going to break those correctly for Twos Up over the entire hour, over the

Jennifer Smith, CDE 7:36
course of the time. Exactly. Now, the other step to this calculation is that we expect that your Basal insulin you've been injecting I'm trying to think how to say it, so people don't think their insulin is not working. But when you inject Basal insulin as its type it, it will not be absorbed as efficiently I guess is the better way to say it as it would from a pump where it gets infused in those little tiny drips over a very precise amount of time, a very precise dose. So your rapid insulin in your pump gets infused out of sight. And so we usually take your base Basal dose down by about 10%. Some even some physicians even go down by 20%. But the general idea is taking your base dose down by 10%. So 10 units a day taken down by 10% is one unit less, so nine units instead of 10 units. So if you do the math there, nine into 24 gets your rate down instead of point, let's call it point for an hour, down 2.37 an hour, which again, we'd probably round down 2.35.

Scott Benner 8:48
And you're going to want to keep an eye on that because I've seen it go either way. I've seen that be right. And it's amazing. I've seen that beat Now. Not enough insulin and people are getting high blood sugars. And they immediately like you hear them say like the pump doesn't work like well, you gave yourself less insulin and turns out you need right. So pay close attention to that.

Jennifer Smith, CDE 9:10
It also translates into the next step. Once you've been making some notes on this 24 hour dose of let's call it point three, five units an hour. And you can say Well, it seems okay here. But then at this time of the day, I'm always high no matter what I can skip eating and I'm high I can eat and I go even higher. Well, that's when the next step is Basal testing. Right? We need to really look at it and say, where is that point three, five, sufficient and where is it not and where might it be too much.

Scott Benner 9:43
And you might notice, and this is this might sound a little heady if you're thinking of switching but you could put your pump on your belly and have a different reaction to the insulin that is if it's on your hip or your thigh. There's reasons like Arden's thigh doesn't work as well. As her stomach does,

Jennifer Smith, CDE 10:01
you know, neither does mind I don't use my thighs anymore. Yeah, back of your arm might

Scott Benner 10:05
be better than your, the back of your butt or who knows, like, right

Jennifer Smith, CDE 10:10
and with with this being new from coming from MDI, to going to using a pump, I would suggest initially utilizing and testing out within an area of the body, you know, we talk a lot about rotation, not only should you be rotating, if you're doing MDI, your injection should be going multiple different places, not just the same site over and over, the same goes along with pumping, those sites need to be rotated. If you're new to pumping, however, you really want to get an idea if your settings are fairly good. Stick with rotating around your abdomen, right? Get an idea. And then once you have that fairly well set, you can then move to upper body or the back of the arm or maybe your thigh or you know, your lower back and see if you notice any difference some people do and some people don't at all.

Scott Benner 11:02
Yeah, right. No, I mean, there's it's your body composition, hydration, how you know where it's actually going inside of you? Is it subcutaneous? Is it very close to a muscle? We don't want to overwhelm people, but the muscle can kind of, I don't know what the term is like, what a large muscle group can, it kind of lessens the impact of the insulin, but for the life of me, I can't think of why right now. Do you know what I mean?

Jennifer Smith, CDE 11:27
Like lessons? I know, I don't know what you know,

Scott Benner 11:28
I always thought that's why the thigh was in a good spot because it was a large muscle.

Jennifer Smith, CDE 11:34
Well, it might have more to do with how well the insulin at that site is getting absorbed. Like that's a big reason that I don't use my thighs is because whenever I tried using it, either I got a collusion alarms because the cannula was bumping into muscle or potentially that I had nicked, like a small vessel under and it had been clouded kind of near that site where it was trying to infuse. And so that backs up into the pump and the pump tells you hey, the delivery of insulin has stopped. It gives you nice alarms. Right? So I think in some cases that may be part of the issue is the proximity to muscle. Yes. But also I it was either painful or I got occlusions like it just never worked on my thighs.

Scott Benner 12:24
Okay, I'll see. Look, I'm learning from the podcast. Finally. Finally, I learned about this every day, you learn a lot. Yes. Okay. So now we've, I think here's a good place to insert that it is possible that there are some people in the MDI who are achieving reasonable lower blood sugar's some how do I say this? Sometimes your doctors over baseline you because they don't think you're covering your food correctly. And

Jennifer Smith, CDE 12:55
that, or they may not have looked at your records enough to know why they've you know what I mean? Like, it might just be easier to backup with enough Basil with what they're seeing in your data. Yeah. And it may as you're saying, it might be wrong, right,

Scott Benner 13:09
right. So like, imagine if you're a person who has been getting more basil than they really technically need, but you kind of forget meals, sometimes you don't cover all your food. But now all of a sudden, you have this pump, you're like, Oh, it's so easy. Now, I just push the buttons for my food. So now you're covering your meals well, and you're like, why am I low all the time? Right? It might be because you're using more insulin than you have been in the past. So those are things to look for that I see people struggle with the beginning with a pump. And I do want to say I think there's a I think there's a period of transition there. It's not going to be like if you're nervous. It's not unfounded, you know, like you are starting a whole new way of doing something. But it really is just another way of delivering insulin to you. It's not that complicated.

Jennifer Smith, CDE 13:59
And I can say personally, when I switched from MDI, having done MDI a long time before I started using a pump. By the time I started using a pump I was already doing. I was already doing somewhat of a Pre-Bolus. But it wasn't the same once I switched to a pump, there was a definite time difference between my Pre-Bolus with injections, and there still is, I can take an injection and my Pre-Bolus Time is not as long as it is on a pump, right? Again, and have one. But that's what I noticed. And so those are some things to pay attention to between MDI and what you're doing along with what you said about maybe the doses you were taking on MDI. We're covering a certain way for your rapid insulin for meals and corrections. And now that you're on a pump, your meals, the food hasn't changed, your strategy has stayed the same and things are looking weird,

Scott Benner 14:58
right right there in You'll have to step back a lot and try to see what's happening. One reasonable reason for that could be reasonable reason why it wasn't right. But anyway, you use an omni pod and delivers insulin a little slowly. Like it doesn't just like you take a needle and you go. Yeah, and the pump is pumping over time. And and I don't imagine you use very large bonuses, but larger bonuses take longer. Yeah, I've seen, I've sat at a restaurant with Arden. And, you know, you forget you've done it, and you kind of still here like that, like think like click clicking, it's still giving her insolence feels like it's been five minutes, you know, and yeah, so that's, that could be part of it. Anyway, these are things you're going to learn along the way. They're new lessons, but they're not a reason, not just try, because you're going to gain weight, you're gonna gain so much, right? Like if, to me a pump is, at its core, I've always thought of pumping as a way to be able to manipulate basil. Whereas on MDI, I shoot it in, it's in there, nothing left to do. If it's too much, if it's too little, it's what it is, you know, with MD with a with a pump, you know, you can go back and listen to the Pro Tip series, I think about like, wow, if we sit down to a meal, that's all of a sudden, much carb heavier than what I usually eat, I could do a Temp Basal increase, they tried to help me with this. You know, I was thinking a minute ago, when we were talking about breaking the 10 units down into point 4.35, that if you think about putting a sprinkler out on a dry, dry lawn, right, and you need to give your lawn 10 gallons of water, you could come along and dump it on all at once. It'll just be there, that'll be it, right, or it could break it up into little point three, five gallons every hour and go back and forth. And just a light covering, covering, covering, covering, you're never gonna soak it down, you're and it's just I think of basil like sort of like that. Sometimes you're just,

Jennifer Smith, CDE 17:03
and that's a good way to think about it too. Because if you consider that slow Basal drip that you are getting from a pump, when you inject your Basal insulin all in one clump, right? You can, depending on the kind of activity you like to do, you may have found that you have to pay attention to Gosh, I'm doing like a really heavy arm workout, I'm probably not going to inject my Basal insulin into my arm today, I might inject it someplace else, right? Because there's this whopping dose sitting underneath your skin. And any kind of insulin, whether it's rapid, or Basal can get enhanced in action, the more active you are, and especially if you're using that site. So, you know, those are the kinds of things that having those tinier doses that you can manipulate and adjust, especially with the variables that you know, are coming in the day.

Scott Benner 18:04
If somebody's listening and thinking like, well, they have spent the first 15 minutes talking about Basal insulin, it's because it's really important, and nobody tells you it's important in setting. So if you listen to this podcast, like Well, I do MDI, they're always talking about, like, their settings on their pump or anything. This is still settings, you know, if it's MDI, it's your settings, it's, you know, these Basal carb ratio, correction factor, they're all settings. So it's just very important to have them. If they're not accurate to your needs, then everything else is just going to be a mess. And especially Basil, basil is wrong. The whole day is confused. So okay, so we've translated our basil, our insulin to carb ratio, does the doctor keep it the same? Do they usually like what is common?

Jennifer Smith, CDE 18:49
They may keep it the same, especially if your records prove to show that it seems to be for the most part working fairly. Okay. Right? Could there be improvement somewhere, possibly, or whatever, maybe that's also part of the reason that they feel like a pump might actually be better. Maybe you're the kind of person that just eats really slow digesting food. And so you've had problems with taking your insulin and having these big drops in your blood sugar too fast, and then it ends up catching up with you. And then you end up high later, and you've treated low blood sugars, right? And there's not a timing thing that you can really get quite right with MDI. And maybe the doctor says, Well, why don't we try a pump, because, hey, you're eating these types of foods more frequently. We could actually use some of the smart features on our conventional pumps that allow you to take some insulin for food. We're calling these extended boluses. And you can just kind of like basil. It's almost like a secondary use of Basal but for a Bolus where you drip drip, drip drip drip a Bolus in over a certain amount of designated time. You

Scott Benner 19:55
know, there's just there's so much you're gonna get out of having a pump there. Yeah. There's also going to be some things you need to know, sites can, like they're going to tell you whatever pump you have, they're gonna say this pump you can wear for X amount of days or X amount of hours. But sometimes sites go bad. You know, sometimes new sites don't work as well in the beginning. Those are little things that you'll learn along the way. There's, if depending on Arden's blood sugar, she might put on a new pod, and we might just Bolus a little bit to get the site working. This morning, I woke up in the morning, I saw that artists blood sugar was trending up overnight. And listen, for those of you just switching like Arden is looping, but I can see how much insulin is left her pod remotely, which most of you aren't gonna be able to see. But I can see she was down to like 30 units. So this is the end of her sight, right. And I just spent the weekend with her. And doesn't matter. But we were in a lot of restaurants this weekend. So Arden got a lot of insulin this weekend. And in my heart, her blood sugar is drifting up, because this site is kind of done. So because you have experience, yes, I can just tell and you will be able to one day as well. So I sent her a text and I said I wouldn't go to class with this pump one. Because if she does, she's going to spend her whole day with blood sugar's around 150. And she's going to be fighting with them constantly, and bolusing. And they're not going to work and and by the way, if that happens, and then all of a sudden she gets crazy active out of nowhere, she might experience a low blood sugar from all this insulin kind of sitting in this right over use. Well, yeah, get in this pool, right? And so like, that's just the thing you'll learn along the way, you'll learn, you know what people worry about so much like, well, you know, do you travel with pumps? You know, if we go too far from our house, we do if it's a 15 minute turnaround, we don't like you know what, I'm gonna have to have insulin with me now. Like, yeah, I don't know, we don't travel with insulin that frequently, as long as we're near home base, you know. But if we go far, you know, half hour, 45 minutes, and it's not something we want to turn back from, we'll take insulin with us, you know, it's just you. My point is, is that it becomes all second nature at some point. Just like everything else about diabetes, you're gonna have experiences they're going to teach you you'll learn from them and move on. Speaking of moving on, you'll think I'm going to go from MDI, to pumping, to pumping to algorithm pumping, but I want to do CGM first. So okay, you have a meter. And that's how you check your blood sugar. And that's all you have. Hey, you're in the doctor's office. The doctor is like, you know what you want to do?

Jennifer Smith, CDE 22:42
It must be the same deck.

Scott Benner 22:43
I wanted to draw here. Take this a sample you try. You'll love it. They're gonna try to give you they're gonna say to you, hey, you might want to libre, you might want to Dexcom if you're on a Medtronic pump, they might ask you to do whatever the Medtronic CGM is called. And you're gonna say I don't need that or you're going to be newer. You're gonna Yes, please. That remastered diabetes Pro Tip series is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have a unique offer just for listeners have the Juicebox Podcast. If you're new to contour, you can get a free contour next gen starter kit by visiting this special link contour next.com forward slash juice box free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juice box free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen. It fits well on your hand and features Second Chance sampling which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash juice box free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips you can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now through your insurance. Contour next one.com forward slash juice box free meter go get yourself a free starter kit. while supplies last US residents only are touched by type one has the back of people living with type one diabetes. Take for instance, their D box program touched by type one knows firsthand the intricacies of living with type one diabetes. And so their team has created a D box which is a starter kit that provides important resources and supportive materials to individuals with diabetes, they want you to thrive. The D box is completely free and available to newly diagnosed people. All you have to do is go to touched by type one.org. Go to the Programs tab and click on D box. While you're there check out all the other resources and programs available at touched by type one.org. Speaking of support, touched by type one.org is available in English and Spanish. Don't forget to find them on Facebook and Instagram too. You do not want to miss what touched by type one is doing. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. G voc hypo pen is a ready to use glucagon option that can treat very low blood sugar in adults and kids with diabetes ages two and above. Find out more go to G vote glucagon.com forward slash juicebox G voc shouldn't be used in patients with pheochromocytoma or insulinoma. Visit G voc glucagon.com/risk. Wherever you fall on that you do want it if your insurance covers it, you want it? That's for sure. Right? Tell me why.

Jennifer Smith, CDE 26:38
And I think it applies in all realms of diabetes as well. Right? Not just in type one diabetes, but also type two diabetes and even worthwhile and gestational diabetes. I know there are some rules in terms of when it can be prescribed whatnot. But I think it's beneficial all around what you miss with finger sticks are all of the little dots in between. So where things were trending, right, so if it is something that your doctor does bring up? Absolutely say yes. Right. You may not know how to look at the information or what you're getting from it initially. But it's so worthwhile. You want

Scott Benner 27:21
to know what you don't know. And with finger sticks, especially if you're newer to diabetes, or if you just been doing them your whole life. And this is how you tend to think of it. You do the well i i test before I eat or I test before I go to bed or I test before I drive. And and I know you've asked yourself what's happening when I'm not looking. Right, like and if you haven't asked yourself that. I wonder how do I go from 250 to 50 in an hour, like how does that happen? And you'll learn you'll start seeing the impacts of activity and the lack of hydration and different foods that you eat, the age of your your insulin pump site, all these different things that have a huge impact on the way your blood sugar moves. And now suddenly, it's there. A CGM is going to show you minute by minute. I think it's every five minutes. Right.

Jennifer Smith, CDE 28:21
And I think there are there are some people who have been using it long enough that can say there can be some frustration around the amount of data that you get. And I wouldn't disagree with that. I but I do you think it's how you interact with the data, right? It's how you actually take a look at things and what you do with it and what you learn from it. And you have to you have to expect that in the first month. Let's call it of using a CGM, you're gonna see a lot of stuff. And so rather than being so very emotionally reactive, again, taking a step back and kind of looking at the data to be able to make better decisions about what you felt like was probably happening. And now you can actually see,

Scott Benner 29:10
well imagine you have your sprinkler out on the yard. And you have to keep the dirt moist because you've planted grass seeds, except every time you look out it's kind of dry. That's the CGM. You look at the CGM ago Oh from 3am till 6am. My blood sugar's 140. It's pretty stable, but it's 140. I wish it was lower or moister. I can turn up the sprinkler a little and put on a little more insulin and make it where I want it to be like push that number down a little.

Jennifer Smith, CDE 29:37
And the CGM can show you that if you're really looking at it. That way the CGM can show you where did it start to lose right effect? Where do I start to need to add more insulin? It's not once you get stuck higher or once you get stuck lower than you want. It's before that so any drifts up or drifts down. Now, you can see that very clearly on a CGM I, you have a really good example I think from when Arden first started using her CGM, it was like that overnight thing that you are constantly missing was at Lowe's when you had finger sticks. And I would put

Scott Benner 30:14
or you could see them. I thought it was a genius. I've said it before I would put Arden to bed at 180. And she'd wake up at 90. And I was like, Look how good I am at this. And what would happen. We put a CGM on her. She was 180, she'd go down to the 50s sit there for hours, I'm assuming her liver would be like, hey, here, try not to die. Here's some, you know, some, here's some, here's some glucagon, I'll give you a little bit. And then she drift up to 90 overnight was happening constantly. So the reasons for that are mind numbing in not for this conversation, but we were bad at bolusing for dinner, we were her basil wasn't like there were so many things that weren't right, you know,

Jennifer Smith, CDE 30:52
you didn't know it because you couldn't see what was happening unless you really did a finger stick even an hourly finger stick, it would have caught a drift, it still would apply it. But it would have still been confusing unless you sat down and you connected all those dots. And you could say, well look, look at this. And you probably I mean, not necessarily wanting to see your child sit at 50 for three hours before your body actually reacts and gets you the glucose that is needed to bring it up. But you'd have on a first finger stick probably under 70, you would have ended up treating, so you also wouldn't have had the information to show. Well, how much do we need to take away? And what do we need to do differently?

Scott Benner 31:34
I can't I can't say how valuable it is to be able to see a graph and to enter look at it every three hours or you know what's it look like over six hours, like Jenny's point is great is that you? You don't know why? What happened happened? It's um, if you're married here, it's nine o'clock at night. And you're now in an argument. Right? And you think I don't know what just happened. But mostly this is guys like they're like what? They searched the last five minutes in their brain. And I've not done anything wrong in the last five minutes, right. But if you could step back and see a whole graph of your day, you'd realize that at 630. At dinner, you said something really stupid. And now it's hit me at nine o'clock. So I think that that can be similar. You could have cheeseburger with french fries at dinner at eight o'clock at a restaurant and hit it with a great Bolus. And you're like, Oh, well, my blood sugar's still where I want it to be it's 140 After dinner, that's not bad. And two hours later, it starts to jump up. And that doesn't make any sense to you. Because you haven't listened to the Pro Tip series. You don't know about the fat and the French fries and the slow digestion and how you're going to go up afterwards. But at least if you see it on a graph, and then you go have those French fries and that burger again, you see it happen again, you can go Oh, I could get ahead of this. Right? Yeah, I could not say that stupid thing at dinner. And now we'd be watching television, and she wouldn't be yelling at me.

Jennifer Smith, CDE 32:56
Right. And if you have a pump, you can also address it a different way than waiting for it to finally start rising and getting too high. You can offset it ahead of time knowing what is coming because you've had the experience that, oh, it always hits around two hours. So I'm going to start doing something about an hour and a half before that. So that it actually doesn't happen. Right. So I mean, yeah,

Scott Benner 33:21
million ways to handle that if you're from Arden, an hour after she has french fries, we have to Bolus for the fat. And there's a calculation you can do. And there's that heads off that secondary rise and doesn't cause a low later. That's the other great thing is that everyone, when you don't have enough data, you think, Oh, if I just keep throwing in more insulin here and there, it's gonna be it's not true. Like you can match the need up with the impact of the insulin and never cause a low. Right. And that's something you're going to learn looking at a CGM that, that uh, that a stable line on a CGM is really, your insulin, your insulin is pulling down, and your food and your other impacts are pushing up. And neither of them are winning like so if you can kind of imagine that line going off into affinity nice and stable. There's invisible lines. cables attached to it. One's trying to pull it up. One's trying to pull the line down, and neither can win because you have a great balance between your insulin and your knee. Yeah, so that in the CGM, like, seriously, like I don't care like there's decks comms and advertiser. It's not like I'm saying that like get a CGM. It's of any,

Jennifer Smith, CDE 34:33
right? Absolutely. I mean, I've said before, many times if somebody was going to take my technology, I would fight for my CGM. Before I'd fight for my palm. Yeah, no, I would 100% would keep my CGM.

Scott Benner 34:47
I'll throw this here too. Even though it's about like, leaving quote unquote, finger sticks. You're never going to leave finger sticks by the way, you're going to need them. You're gonna pass when you're not sure about your CGM. You're gonna test when you're making big I listen to my daughter's blood sugar looks high on her CGM, and we're gonna make a big Bolus. I said, Look, you gotta test, we got to know this numbers, right? We can't just start throwing insulin in here. And you're actually 40 points lower than this or whatever.

Jennifer Smith, CDE 35:12
And I think it's also really important to acknowledge what you know about how you feel around certain blood sugars. Because, again, technology. It's wonderful. And it's so much better than it was years ago. But it may still not be accurate at certain points. So always those finger sticks are important to continue to use. Because if your symptoms or how you're feeling doesn't go with what your CGM is reading, I guarantee a finger stick isn't gonna lie to you not unless you still have like, apple juice on your fingers or something.

Scott Benner 35:47
I was gonna say, and I didn't get to it just an accurate meter, just the blood glucose meter. Yes, they're not all the same. They don't all work as well. Don't just take the one that doctor handed you from the drawer, do a tiny bit of research. He's the one that I that advertises here because that's the one we use and it's amazing and, you know, like or do what you can do your own research and find out I will throw out a little story here. Because I did spend the weekend with my college age daughter, which I haven't done in a while as a visitor at school. Second night she was with me. We replaced her CGM. Okay. So at five o'clock at night, I said, Hey, your Dexcom is going to expire one in the morning. You should switch it now. It's before we're gonna eat dinner. We'll get it back online. It will have it we can do some finger sticks through dinner. And then it'll be rolling and working well by the time we go to sleep, because it does take a little while for some people to look right. You know? She does. I don't want to do that right now. So then when do we change her CGM? 11 o'clock, you know, like, oh, so then it's done. So then it's wonky for the first couple hours. And for Arden, if her Dexcom is wonky, it's wonky low when she first puts it on, mine is too. Okay. So like I made it, it'll be like you're 42. And she's 100. Yeah. 10. Like that kind of thing. Yeah. So there's a lot of consternation in what you should do. I'm a fan of letting it be on for a little while and calibrating it to help it get along a little more. But now we're asleep. And it's like Beep, beep, beep. All I could think was like that tone. I know. I said this. Nobody listens to me. But that's fine. And I'm like, and I know she's not that low, like and but it's worrying. So now she's, she's asleep. And I get up and I'm checking her blood sugar and she wakes up. She's like, What are you doing? I'm like, your CGM is going off. She goes, I'm fine. It's like, okay, so I tested her. And she was 130. And I was like, okay, so she's right. And I did a calibration and it came together pretty quickly. And that was it. Having said that, we could have done that at five o'clock. There. So there is a way to time, your technology. Now the new g7 is going to have a shorter warmup period, which will help overlapping you'll be able to soak your sensor, which I'm not going to bother explaining here. But as the technology gets better, so should those things. But that is not to say it's not like hands down. The most valuable thing that's happened to people who have any kind of diabetes, since I've since I've been aware of diabetes, some absolutely. Okay. All right, Jenny. Now we got our CGM. We're using a pump. We're looking online. And we're like, see, this isn't that the doctor is not gonna go you know you ought to do. That's not gonna happen now. Because this stuff's also new. Maybe maybe a really in tuned doctor might say, once you get an algorithm, but for the most part, I don't think I think that's the thing you're going to figure out on your own a little bit. So all this stuff we're talking about about, you know, the Bayes will be incorrect. And you might need a Temp Basal here, you might need to extend a Bolus for fat, you might need all this. There are pumps that make those decisions autonomously. Yeah, you have to be wearing at this time, you have to be wearing a Dexcom. Because it works with that. Right, but

Jennifer Smith, CDE 39:08
or med tronics. CGM? Yes, because they're their system also works with their pump, right? Yeah, so

Scott Benner 39:15
there's a Medtronic version of this. There's a tandem version of this. There's an omni pod version of this. All their algorithms are proprietary, they work slightly differently, but long and the short of it is they're going to give you insulin when you need insulin, and they're going to take insulin away when you don't need it. They're going to endeavor to stop you from getting low and endeavor to stop you from getting too high. You

Jennifer Smith, CDE 39:37
still had how they do that it was with targets Yes, right. Right, specific targets in each of the different pump systems. Medtronic newest one was just approved, which is really nice. But they all have specific targets. So how that algorithm works is based on when and how to give you more or less be Send a target and based on what the system is projecting off of your current CGM trend. So it's a very interesting like the algorithms don't just willy nilly deliver or take.

Scott Benner 40:13
Like, I think maybe now more,

Jennifer Smith, CDE 40:14
right? Yeah, exactly. There's a math to the algorithm

Scott Benner 40:19
Gremlin inside of your pub flipping a coin going, Oh, my God heads. Let's do it. So but it's it's it's stunning. Now there's another version. There's a number of other versions there are Do It Yourself versions. There's Android APs. There's loop. I think, Jenny, you loop. Right. I do. I think you and

Jennifer Smith, CDE 40:37
I've been looping for five and a half years.

Scott Benner 40:41
And Arden has been doing it I think since 2019. Maybe? So okay, yeah. And your Arden's using loop three as a mic, and you just switched to it as well. So like, so they're all just different versions of an algorithm making decisions about insulin based on your CGM tread tread. That's it? Yep. They're astonishing. They work incredibly well. They are not magic. Again, all settings, all knowing how to Bolus for certain foods, understanding the impacts of things, your digestion, your hydration, like all the things that are important about MDI are the same things that are important about pumping are the same things that are important about using an algorithm.

Jennifer Smith, CDE 41:28
And you made I know, people can't see you, but you were very in a line going from MDI, to pumping to algorithm. And I think that's, it's a really important piece. For those who are listening to understand if you're kind of listening to this, because these are not pieces in your life already, right, and you want to get an idea. There is 100%, I'd say 1,000% value in learning on MDI. And then moving to a conventional pump, that does not do anything for you, meaning it does not use an algorithm. There's absolute value in that, you know, we talked about testing, and evaluating settings, and learning about all the variables, food and activity and everything, and how to adjust your pump, or your insulin doses to accommodate for those variables. I think, as you mentioned, when you said, you know, your pumps, like, hey, let's start on algorithms. I can't go as deep as you. So it's a totally different doctor. Right. But in that sense, there are I think, more doctors today who are thinking algorithm, but in my personal and professional opinion, I think some of them are thinking that too fast. Okay? They are they are moving somebody to, hey, you're MDI, let's move to this algorithm driven system, whatever the system is, whether it's Omnipod, five, or tandem or Medtronic there is, there's a missing piece in the middle there, that if for some reason, and we talked about CGM is potentially not being always accurate or technology failing. If your pump fails in its algorithmic dosing, and you have nothing to step back to, you're at a loss. And it's important to understand that, you know, so I can't emphasize.

Scott Benner 43:32
It's incredibly important. Jenny's been talking to me about this privately for years. Honestly, she's like, people can't just be put on the machine, the machine does the whole thing. And they don't understand why it's happening. Because, you know, the general argument is what if the machine stops working? I don't even think that's the need for that I think the need is that this is a thing you have to understand. Like it right, no matter what none of this machine stuff is at the point where you don't need to know how to how it works. It's not AI, it's not even a computer like you know, you used to have to know how to fix your computer because it would break all the time. Nowadays, you buy a Mac, it'll just do the thing you want it to do, you'll never have to touch it, and it'll die. At the end. You'll recall my math doesn't work anymore, you get another one. And you don't need to understand how a computer works. To use a computer. You need to understand how diabetes works. To have diabetes. I don't care what version of care you're using. I don't care what the next one is. Now, if someone magically comes up with something one day, where it just works, no matter what, like a, like a laptop from Apple, okay, then then okay, then God bless. If you want to skip it, then skip it. But I'm still gonna say that isn't happening anytime soon because of not just the things we've mentioned today. You know, your insulin pump site might not work on time, like your CGM might not be right right away like all the other things. It's just not happening anytime soon. So you don't want The worst thing I can imagine is that you put an algorithm on a nine year old who it works for. And then five years later, the kid hits like puberty hard or something, and you have no idea, like the algorithms doesn't know you just became a completely different person, you're gonna have to change your settings to make that work, right. And that takes experience. If you I think if you ever find yourself listening to Jenny and I talking and thinking, How come whenever something comes up, they just fill the next space with something valuable. It's because Jenny has been living with diabetes for over 30 years. And I've been staring at my daughter for 15 years watching her have diabetes, and I have a never ending supply of experiences and answers in my head because I live through them. Yes, that's why and that's why you absolutely yeah. Like you didn't go to like diabetes University where they told you something secret that they don't tell everybody else, right?

Jennifer Smith, CDE 46:03
No, no, not at all. I mean, I have valuable behind the scenes, like information about disease states and those types of things from a medical knowledge base. Absolutely. And understanding them helps me to understand some of the navigation of that with diabetes, but the lived experience and the work that I get to do with so many people, that's the valley that you can't teach that right? In a university, you you can't teach, there's no degree and diet.

Scott Benner 46:36
And for your situation, you've been helping people for so long. And professionally. I tell people all the time, like, it's, it's gonna sound self serving, but it's not like, it's that I was able to get advertisers for the show. So I could turn the show into a job so that I could put this much effort into it. Because I learned that every day I talked to people, like you'll hear me say, like, Oh, I was talking to a guy the other day, he said something about this, that's me. hearing something I'd never heard before and right and retaining it and being able to apply it to a situation go, oh, you know, where that'll help here. And then you get to keep expanding those conversations. I'm gonna get to something here. And you get to keep expanding those conversations till they help other things. We did fibroid episodes. Now we hear from people are like, Oh, my God, my life is different. Because I got my thyroid managed, well, I'm getting a lot of my I didn't realize about my iron and my ferritin, like, a lot of women especially are getting back to me, like they're feeling so much better, because it's something they heard on the podcast, they heard it on the podcast, because I was able to focus on this because this is what I think about. And now and now it's coming to digestion. And that because we had to figure out a problem with my daughter's digestion. And then we shared it on the podcast now I've seen that help other people. That goes for little things about diabetes, too. Yes, that's how this stuff spreads. This is a repository of information, but you're gonna build that in your own mind. Correct? Not if somebody slaps new algorithm on you and tells you don't worry about the thing will take care of it.

Jennifer Smith, CDE 48:07
Right? Because it one that's such a, that's such a big thing that I hear well, shouldn't it be helping me with this shouldn't be doing this shouldn't? The one word I hate is learned, I shouldn't have learned that I don't need this much insulin at two o'clock in the morning. Nope, your system isn't learning. I promise you. It's not learning. It doesn't keep track of two o'clock in the morning, gosh, I gotta give less insulin for this person. It's not that's it's not smart.

Scott Benner 48:33
And Jenny, you know, oddly enough, as we make this episode, I put up an episode today called Rise of the Machines, where a guy comes on to talk about his Android APS system and how it he does believe it's going to learn in the future, which is so exciting, but not now. Like, you know, what's one of his examples? He said, location services. So if you say I'm having pizza, and it realizes you're at Domino's, okay, and you have an experience with insulin, someday, it will remember that experience. Yeah, if you go to a different pizza place and have a different experience. It'll remember that if you go to a third pizza place, it'll remember that if you head back to Domino's, it's gonna go Oh, we're back at Domino's. This. That's not happening right now.

Jennifer Smith, CDE 49:22
No, in fact, there is there are some. There are some apps that actually you can track that way. Like you can take a photo of something and tap the location indicator and the next time you come back to that location, you'll be able to see what your dosing looked like what your CGM trend looked like so you can learn from Bob's pizzas, Friday night last week to this Friday night. Maybe I should change my strategy. It looked like this and I want to improve this right or do it differently, but those they need to be married right into the pump so that not only do you have Okay, now I'm at Bob's pizza. This is what I had. And hey, let's the pump then can acknowledge and I'm going to do something different for Jenny.

Scott Benner 50:06
But for that happening just automatically, that's not here yet. 2023 on the pod five doesn't do that. Tandem T slim doesn't do that the control IQ doesn't do that the Medtronic doesn't do that. They know it may have happened one day. Sure. But the other I think the other thing is, I know you want your days to be easy. And they can be they can be much easier than they are now they can be more your intuition can come into play as you grow. But this is a lifelong thing. And what you want is you want to get to the point where I saw Arden get into this weekend, where we sat down to this meal, there were 16 different things. And she just looked at it and picked up her phone and went and push the button. Yeah. And I was like, How much does she give? She was I don't know, I told her it was like 85 carbs. And I was like, and she and I was like, okay, and then she was okay. And it was okay, look at a table at a restaurant. And she's like, I think about this much. And that's boy, forget this podcast and everything else. It's that's where you want to get to where it just where you wake up at two in the morning, you see a high blood sugar and you go, Oh, I know what this is. And that does come it really does come. So anyway. But you're going to transition along, by the way, I think algorithms are amazing. And

Jennifer Smith, CDE 51:31
yes, they are absolutely i i love my algorithm. Absolutely. But I've also learned to work with it. And I've learned what it can do and what I still need to tell it to do. I think that's the big thing about algorithms is knowing that you still have a fair amount of action to put in to it so that the algorithm can work with you.

Scott Benner 51:53
Yeah, yeah, I wouldn't want anybody to think like, oh, you're using a do it yourself loop. It's magical over the other. There, it all is about the same. Like they all need your help. They all need your intuition. They all need your knowledge. There's nothing if you think you're going to just put a loop on or on the pod five, and it's just going to be perfect. Like, you don't have to do anything. Like that's not going to be the case. No, yeah. So but don't be afraid. Like I'll say something here on the spot myself Saturday, make them clean and make myself set up. Yesterday was my friend Mike would have been my friend Mike's birthday. And I don't want to bring all this down. But Mike had diabetes, type one when we were teenagers. He's not with us any longer. I believe that one of the reasons Mike's not with us any longer is because Jenny alluded earlier that I was stepping along with my hands while I was talking about things like Mike never came along. He just somebody gave him regular an MPH. And he used it long, long after he should have been and you know, didn't have updated meters and didn't you know, he didn't do the little things that you do to come along. I mean, I guess what I'm saying is you don't want to be managing your diabetes like it was 10 years ago.

Jennifer Smith, CDE 53:12
Right? I don't think he's tonight. I think you're also bringing something in here. That's really important to consider. Because you've you've talked about, you know, practitioners bringing up hey, why don't you try a CGM? Hey, why don't you try a pump? If, if you're the one always going to your doctor asking for what's new. I don't know. I you know, and your doctor is very willing and can talk about it then with you. Maybe they didn't bring it up. But they're very, they're knowledgeable about it. Once you do get on it fine. But if this is someone who's never really brought it up and kind of like, shrugs their shoulder and like, sure you could try it, whatever you may need kind of like your friend maybe didn't have a doctor who was keeping up with what could have been better for him. Yeah,

Scott Benner 53:59
yeah. Yeah, you don't you have to take this as a, I don't know if you want to call it a disease or like, some people don't like that word. But this is a way of living, that it begs you to be involved in it. Yes. Like it just it just really does. You have to be aware, you have to take some time to learn what is happening with technology, what's happening with insolence, you know, and you need to move along with it. Because if you look back 50 years, I still interview people who are like in their 70s and have had diabetes forever and they don't even understand why they're alive. Like Like you don't want your life to be a coin flip. You don't I mean, like there are things you can do to to to give yourself better health outcomes. And those health outcomes are not just health outcomes, their quality of life. They're your they're your psychological state of being like there's so much good that comes from just understanding. I know that sounds silly, but How to set your Basal rate and make sure your correction factors, right. And you know how to cover the foods you eat?

Jennifer Smith, CDE 55:05
Absolutely, I think and on a bigger scale, we're also we're all supposed to be a participant in our life, right? health in general, you may have been given good health to begin with, but you're the keeper of that health. Right? It's just like, you're the keeper of the car. If you continue to let the salt buildup on you never wash it off, you're gonna have a rusty car? Well, you're your body's the same way, right? You're the keeper of your health, you got to do things to maintain your health, diabetes, it stepped up a level it is

Scott Benner 55:39
absolutely and so prepare to transition by getting as much good information as you can. But then at some point, you just have to do it. You have to just dive in and do it and then learn a new thing. And then once then you'll be surprised at what else comes from that. And anyway, listen, it's also not to say that you couldn't get an algorithm pump right now and teach yourself backwards. I actually think you can. Sure. I think some people have a harder time with that than others. And I don't want you to be in a position where you're lost and something's happening. And you don't understand why because it won't be any different than a person that gets over Basal on MDI and thinks they're doing okay, but it's not really covering their meals well, right, you know, and then doesn't get hungry one day and it's up low all afternoon doesn't understand what happened, like crack diabetes. There's no reason that if, if you have an if you have enough information and understanding diabetes doesn't have to happen to you. And I think that's maybe the most important part like I would if it feels like it's happening to you, instead of you are doing something and then something's happening. I think you have to have to look and get a deeper understanding, because it shouldn't just be happening to you. That's all. Okay. Awesome. Thank you, Jerry. I want to thank assenza diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free contour next gen starter kit at contour next one.com forward slash juicebox free meter, while supplies last US residents only. If you're enjoying the remastered episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org. A huge thank you to one of today's sponsors, G voc glucagon, find out more about Chivo Capo pen at G voc glucagon.com. Ford slash juicebox. you spell that GVOKEGLUC AG o n.com. Forward slash juicebox. If you're living with diabetes, or the caregiver of someone who is and you're looking for an online community of supportive people who understand, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, there are over 41,000 active members and we add 300 new members every week. There is a conversation happening right now that would interest you, inform you or give you the opportunity to share something that you've learned Juicebox Podcast, type one diabetes on Facebook, and it's not just for type ones, any kind of diabetes, any way you're connected to it. You are invited to join this absolutely free and welcoming community. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer and most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com If you're interested in hiring Jenny, you can learn more about her at that link. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bumping nudge 1008 The perfect Bolus 1009 variables 1010 setting basil insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low Beegees. In Episode 1015, Jenny and I talked about emergency room protocols in 1016 longterm health 1017 Bumping nudge part two, in Episode 1008 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022, weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025, we talk about transitioning from MDI to pumping. Before I go, I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with this and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insolence so that is active as the carbs become active, took me already from a decent 6.5 A one C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.

#1024 Diabetes Pro Tip: Female Hormones

Scott and Jenny dive into the topic of hormones, specifically female hormones and how they affect those with diabetes. They discuss the challenges and changes that come with menstruation and provide insights on managing blood sugar levels throughout the month.

You can listen online to the entire series at DiabetesProTip.com or in your fav audio app.

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:03
Hello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right, you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CD and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisit double. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. While you're listening please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have an amazing offer for you. Right now at my link only contour next one.com forward slash juicebox free meter you can get an absolutely free contour next gen starter kit that's contour next.com forward slash juice box free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries G voc hypo Penn. Find out more at G voc glucagon.com. Forward slash juicebox. Okay, give me a testing. Hello. All right. You're there? I'm there. Okay. Yeah. All right. So I've spent, not my whole life, you know, but the last number of days and weeks looking into all of this, trying to get ready to make a pro tip episode about female hormones. And it's a very scary proposition. There's a lot going on. I'm not scared, scared, but I'm overwhelmed. And then the last kind of piece of it was that I went on to the Facebook page and said to people look, you know, throw out your questions for this episode. I want to be clear, I almost didn't think I needed their questions so that we could talk. I wanted to see if there was repetitive need, like you don't even like what are people like same questions over and over. And my goodness, I mean, it's kind of obvious, right? Like so. The questions ranged from like, just God, is there any rhyme or reason to this to? What about menopause? What about perimenopause, what about the time where my kid isn't getting their period yet, but it's starting to exhibit, you know, symptoms and having hormone fluctuations, talking about puberty and then pregnancy and then and then. Oh, is your head spinning post pregnancy? It's it's listen nature. God, I don't care what you think this is, there's gotta be a better way to do this. Someone, someone, this was an afterthought. Like, like someone at the end was like, oh, you know, here's what we'll do. We'll throw some eggs in here. And then you'll have to throw in some estrogen to get the eggs really roll and then one egg will come out. And if they don't get pregnant, the whole thing will just bleed out of their vagina. Perfect. Like, I don't know who what. Oh, my goodness. PCOS keeps coming up. Is that polycystic ovarian syndrome? PCOS? Yes. Now I know those words. So already, Jenny, I want you to tell me what you just said before we started recording about the inequities of diabetes management from men to men to women,

Jennifer Smith, CDE 4:48
or from an education standpoint to begin with. I mean, it was not something that was ever discussed in my presence, at least and I don't think my mom had outside of this Did conversations with my peds? No at all about hormones? Right. So I learned all of this as I was having this like, typical cycle, you know, that should happen after a certain point in the sort of teen years. And education today. It's focused as on diabetes, in general, right? Not on, if you're a woman with diabetes, versus if you're a man with diabetes, these are the differences that you will definitely see. So you're a woman with diabetes, you've got all the female hormones pumping in your body. Let's discuss diabetes from the angle of being a woman. Right? I mean, especially for my like, I wouldn't even say, when I start working with somebody, if they're from about the age 1011, all the way into, well, even the women they work with, into the perimenopause and menopause age, that's something in an initial visit, I always ask about, because it, even if it isn't yet visible, it will be at some point. And people need an idea that they need to like, see out into, if I see this, and this and this, I'm clearly not a crazy person. This is body function.

Scott Benner 6:21
Well, I guess, especially given that, you know, because we talk about things in general terms, like the cycles, 28 days, that's in general, it's not, it's not for everybody, and it might not be for you from month to month as well. So if you can imagine when you hear people talk about like diabetes, like just when I thought I had it, it changed or you know, those memes, there's meat is it memes? Oh, my God, I'm old, you know, where it's like Monday, two plus two is for Tuesday, two plus two is seven, you know, Wednesday, two plus two is zebra, like that kind of stuff. If that's already how diabetes feels to people in general, and then you put this on top. I mean, you really are kind of creating two different spinning layers of confusion that can impact each other, or show up on their own. And I don't know how you're supposed to make sense that I actually after going through all this, I have an idea I'll share at the end about how to get a handle on this. But I just don't know. Well, I guess to give people some context aren't in 17. So this is the depth of my understanding of this. My understanding of this is I'm married, and I've lived with a lady for a couple of decades. And, and my daughter has diabetes, and she's been getting her period for a while.

Jennifer Smith, CDE 7:43
And I bet you never paid as much attention as when it really was in reference to diabetes management.

Scott Benner 7:49
Only thing I used to pay attention to was, there's this what I call the nice day, there's like this. There's this literally one day a month, where my wife is a 1950s. Like, I'm making quotes perfect mom, wife, lover, like it's that day on that day, I feel taller and more handsome. Like, you know, like she is so incredibly

Jennifer Smith, CDE 8:18
kind of like Leave It to Beaver mom, sort of, at that age have an idea of what a Mom was

Scott Benner 8:23
right? Yeah. 100%. And I, I bask in that day, because the day that comes after it. I can't even look her in the eye. Because if I do something wrong, she's the different like, and then I know that the the event is coming in about five to seven days. Like that's how it works for

Jennifer Smith, CDE 8:44
us paid enough attention to actually like, I can tell you many, many spouses or partners are,

Scott Benner 8:51
I thought I was gonna die. I was defending my own life, you know. And so for years, that's the only way I ever thought about it. And then Arden starts to get her, you know, and then we're kind of rocking along and taking care of Arden's blood sugar. Like it ain't nothing some days, you know, it's just like, I do really have this all figured out. And then one day, she started getting her period. And it was all fine at first. It actually almost got more difficult at some junctures. But it was it was very structured. So I didn't have any trouble with it really. Right. And then all of a sudden, her periods got heavy. And you know, people listening will know that, you know, Arden went through a year or two of like us not understanding what was going on. She got anemic a number of times she had to have iron infusions. This was all ended up being because of her period. Right? Yeah. So Arden would get her period for like 11 days, like she'd have like 11 day long cycle, and then only a couple of day break before she started to bleed again. It was just really Nicholas, which led us to put her on birth control, hoping, like, you know that she wouldn't bleed to death, because she was, I mean, the impact on our life was insane. Sure, you know. And so first go round with the birth control they gave her it wasn't strong enough didn't really do anything. But they still asked you to be on it for 90 days before they consider changing it. So you, you struggled all this time you think you have an answer, and then 90 more days is struggling. And then they moved her up to another, I guess strength and that has, you know, straightened out her. Excuse me. Also, the first indication of that problem was nosebleeds. Oh, really bad out of nowhere nosebleeds. That only happened once a month. And it took us a while to figure it out. It was literally happening on a cycle. I never was able to connect it to her periods. But the minute she went on the birth control and the second round of birth control, and it straightened out her periods, the nosebleeds never happened again.

Jennifer Smith, CDE 11:11
That's really interesting. Well, and I mean, again, a symptom that if you're paying enough attention to your body, there are lots of things that your body is trying to tell you. Right, if we just pay attention to.

Scott Benner 11:24
And that's why I bring it up, honestly, because part of what I figured out, Jenny, part of what I figured out being a man who doesn't get a period, and a person who doesn't have diabetes, as I consider talking about this with you today was was that you kind of have to, you gotta kind of have to Jane Goodall it a little bit, right, like, you got to take notes and step back and see things and keep wondering what's happening until you can build some, some idea of like, I keep seeing this thing over and over again. And where does that fit on the calendar? And how does it work in relationship to, you know, bleeding or pain or insulin resistance, and then you sort of start making sense of it, you have to track your period. Yes, maybe for six months before you'll be able to wrap your head around it a little bit,

Jennifer Smith, CDE 12:14
especially if your cycle is not regular. I would say for women who, especially women who are considering maybe you're starting to track things and pay attention because you are planning a pregnancy, or maybe you're really trying to prevent a pregnancy. So then tracking things becomes just as important, right. But then along with the lines of even planning a pregnancy, the goal in diabetes is to have pretty optimized management prior to conception. So yes, I mean, you really should be tracking things for a fair amount of time, if you don't have them already nailed down because you've paid attention, right. And there are a number of really good period apps out there. I mean, there are some that are free that do just as well as some of the ones that have all the 1000s of bells and whistles for tracking everything else. But I think the ones that are the best actually have a place where you can keep notes. Because the tracking app that I like to use, I actually track month to month, how my insulin changes have looked this month. So I can go back last month, the month before and actually see, has it been consistent enough? Is it going along with what is normal for me. And that helps.

Scott Benner 13:29
Well, even very recently, in the last couple of months, Apple added a period tracker to their health app, which sounds interesting, robust, and it's free, and a lot of people use Apple phones. So I wanted to throw that out there.

Jennifer Smith, CDE 13:43
I didn't even know that was an option. So thanks.

Scott Benner 13:45
Yeah, so because Arden uses one that's third party, I don't even know what it's called now. But as I looked at people's questions, and I thought about Hold on a second. The gods are coming after me for talking about periods when I'm not a leader. That's right. As I thought about how I been figured, like, like step back and looked at what we had to go through to try to figure this out for Arden. And then I looked at people's questions. The real fear when you see fear is around the unknown portion of it. And all I could think over and over again, when I saw their questions like how do I know if it's going to fluctuate? When do I turn up my Basal insulin if I can't be sure when it's going to start? I kept thinking you're gonna have to track it, you're gonna have to pay attention you're gonna have to put like work in and I know that sucks because it feels like diabetes has already worked. But it really made me think about like, kind of what we talked about another pro tips, which is, you know, some upfront effort can save a lot of heartache, right over and over again,

Jennifer Smith, CDE 14:50
are a lot more micromanagement than you really should need to be doing.

Scott Benner 14:54
Yeah, yeah, you get stuck in that situation where you're constantly constantly constantly adjusting your blood sugar in the moment, which I'm a listen, I'm a fan of if your last to stay flexible, but in this situation where what was the number I saw the average woman's gonna have how many periods like 400. And something or it was like, oh, like

Jennifer Smith, CDE 15:17
hold on in a lifetime? Well, I guess if you expect an average age of a period starting at the age of 12, and there are 12 months in a year, right? So you would have, let's say, one cycle a year. And then the average time period of a cycle, completing would be about, let's say, age 12, all the way to maybe 55, let's say maybe even 60. And that's a good amount of time that you would be having cycle.

Scott Benner 15:52
I'm using your math 55 minus 12, is 43 times 12 months, is 516. So you go. So I'm saying, that's a lot of tracking. I'm saying put in put some, like real, like, it's gonna be honest effort, because you're gonna have to track you know, your insulin use every day. And, you know, just giving yourself I think, what helped me was just simple words. Difficult, easy. You know what I mean? Like, referring to my management, you know, meals were, what I expected, easier than I expected, harder than I expected. Yes, you know, my Basal seemed to work well, not Well, today, like just kind of keep it keep it like that, you make a little note for yourself. And I'll tell you to tracking your period is going to help you get better at taking care of your blood sugar, too, because you're gonna see all all around. Yeah, yes, you're gonna see all kinds of things that you didn't, didn't see before. To begin with,

Jennifer Smith, CDE 16:50
you're gonna learn a lot of things too, in that time of tracking for all of those other variables that we have to adjust around, right? Because I for one, know that my sensitivity, once I've gotten to about day three of my period, after that point, and until about ovulation is a really sensitive time. But it's more sensitive from day three to about like day seven ish. And in exercise, I have to be more aggressive and adjusting my insulin for exercise. Or I will go low. Despite my other tools and tweaks working outside of that, I will go low, if I don't adjust more than I normally would, is

Scott Benner 17:39
that a progesterone period in there.

Jennifer Smith, CDE 17:42
So you're essentially when you're looking at progesterone, that is typically like, peaking at certain points, right. And then there's also the luteinizing hormone, there's follicle stimulating hormone and there's estrogen, and you got a lot of hormones that are coming into play. So progesterone kind of starts to really kind of like, fall off. Essentially, once your period is started, it has really climbed in the time of you coming into potentially having a period. And part of the reason for that is in the anticipation that you in sort of that Avi LaTorre time period, have actually conceived, right? progesterone levels will stay high and continue to climb in pregnancy. One, you don't have conception happen, and you start to have your period, that level falls because there's no reason to have that elevated. I mean, again, other hormones at play here as well progesterone being one of them, but it doesn't need to remain where it was because you're not pregnant. Okay. So then it flexes right.

Scott Benner 18:58
And do do we let's try to think about this. Do we count the the beginning of the cycle is considered when the period starts right?

Jennifer Smith, CDE 19:09
Day one of your period is day one of your sites.

Scott Benner 19:14
In that moment, estrogen at that point is lower. Is that right? And then it starts to

Jennifer Smith, CDE 19:23
and then estrogen starts decline. Coming in to ovulation. And then in that next day is around ovulation and potential like conception. Again, progesterone is sort of like climbing into that time period, right? So, you know, again, all these fun hormones doing different things. I mean, if you even looked up a simple like just Google have a graph of like, what your hormones should look like. You can tell why. One Basal for 30 days in a row if you're a woman who has As a monthly cycle

Scott Benner 20:01
couldn't doesn't work yeah, it does. The remastered diabetes Pro Tip series is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have a unique offer just for listeners of the Juicebox Podcast. If you're new to contour, you can get a free contour next gen starter kit by visiting this special link contour next one.com forward slash juice box free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips 10 lancets, a lancing device control solution and to carry case but most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen. It fits well on your hand and features Second Chance sampling which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash juice box free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips, you can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now, through your insurance. Contour next one.com forward slash juice box for E meter go get yourself a free starter kit. Touched by type one has the back of people living with type one diabetes. Take for instance, their D box program touched by type one knows firsthand the intricacies of living with type one diabetes, and so their team has created a D box which is a starter kit that provides important resources and supportive materials to individuals with diabetes. They want you to thrive. The D box is completely free and available to newly diagnosed people. All you have to do is go to touched by type one.org. Go to the program's tab and click on the box. While you're there check out all the other resources and programs available at touched by type one.org. Speaking of support, touched by type one.org is available in English and Spanish. Don't forget to find them on Facebook and Instagram too. You do not want to miss what touched by type one is doing. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. G voc hypo pen is a ready to use glucagon option that can treat very low blood sugar in adults and kids with diabetes ages two and above. Find out more go to G voc glucagon.com forward slash juicebox G voc shouldn't be used in patients with pheochromocytoma or insulinoma visit G voc glucagon.com/risk. You know what else I learned by digging into all this? Is that not that I wouldn't expect this because it's a physiological thing. But it's incredibly complicated what's happening. It's not just like, you know your your eighth grade health understanding of it, which you know, in my mind was an egg gets released you use it or you don't use it if you don't use it, you know the uterine lining and the egg come out in a period which I know is high level what it is. But the idea of like the ramp up right like the gosh, like you start talking about like follicles and like there's this process that's happening in there where your body's trying to locate the strongest egg to be released. It's not just like the next one on the assembly line. It's like it literally anyway, it's mind boggling. Even the TED talks on it are confusing. Even when even when nice girl sit in front of cameras in front of YouTube and trying to talk to you right in your eyes. You're like, I don't understand there's so much happening. But I think for the case of but for type one for using insulin is it is it as easy as saying that there's a time when you're bleeding. There's a time when you're ovulating. And there's a time when your body is trying to make your body a hospitable place for sperm to live. So that the process of fertilization can happen well, is that basically like there's I mean, that's

Jennifer Smith, CDE 24:45
basically the simplified and I think sort of along the same line of what you're getting at is if you if you're having a cycle whether you're on birth control with a cycle or you're not on birth control with a cycle you can expect the times of your period to show similarities for you in insulin need, right? One person may experience during this phase of, you know, hormone release, or this phase of their cycle, that they always have higher blood sugars now that they've been tracking things, they can say, Yes, I'm always getting higher here, one of the first places that that commonly starts is the fasting blood sugar, or the overnight blood sugar. For whatever reason, in the hormone dance of the human body, that's the first place that commonly women see things are running higher. And if you start to pay attention to your calendar, it will most likely coincide with, that's going to be somewhere about like, three to maybe seven days prior to your period, starting. Some women experience really short lived higher insulin needs. And whether they may have missed a slight nudge up maybe a week sooner. Most of them notice cash, the first, you know, day and maybe the two days before my period, I'm just high, I can't take enough insulin, I dump it all in and I still sit high. Well, next month, you know, if that's the case, and you start seeing higher blood sugars, and you do and you are maybe somebody who doesn't have a regular enough cycle, I would probably expect that this is what's probably on its way, as long as your site isn't bad, you know, all the other variables that it could possibly be?

Scott Benner 26:34
Yeah, so it's going to be incredibly important for you not to throw your hands up to the diabetes ferry and go, Oh, it's just diabetes, it's happening to me again, like, after it happens a couple of times, you gotta say, like Jenny saying, like, this is what happens. Whether or not I can tell you that it absolutely happens on day, I don't know 13 of my cycle or not, it becomes unimportant, like you, you sort of see, you know, it's not any different than, like, as you're talking about all this and about when people see higher blood sugars, like Arden has this too. But because my mindset is like more insulin pushback, don't let it happen. I can't see it. Sometimes I can tell you that we're bolusing more or that I'm running a higher Basal like profile. But I'm so accustomed to just being in the fight and fighting the fight. I sometimes don't think about why it's happening. I just

Jennifer Smith, CDE 27:27
right, you just adjust to get it back to target. Yeah. And I think that's, that's okay, as long as you're okay, adjusting that way. And if that works for you, then great. I think that more women especially again, those who are planning a potential pregnancy, are really wanting to track well enough because they're also in ensuring that their blood sugar's are really optimally managed for possible conception, and that thereafter, you know, so if you really do want more consistency, rather than saying, Well, I know how to do more insulin, I do it all the time. I just, you know, adjusted here and take more, they're just back here or whatever. But if you have even those that have a regular enough cycle, it could take some of the like headache out of the salon. Hi again, I know I need more, I'll take more. But gosh, is this happening regularly enough that I could actually figure out how much more do I need on an average monthly change time? Well, yeah, well, that is less guesswork in the moment that

Scott Benner 28:30
and the reason I brought it up is because the process of getting ready to make this episode with you made me realize I'm going to set up three different profiles for art and because she's gonna go to college. Yeah, I know what I need to do. Her blood sugar is gonna go up and she's gonna be like, this never used to happen before. You know, and she's, you know, not going to realize the thing she's missing is me. Texting, texting, you're going yo Bolus, what are you doing? Cuz because for people who don't like really understand, I know, it sounds like micromanaging to some like newer people, but for people listening to podcasts, I don't imagine it does. Like, I don't like to see a blood sugar over 140. And I act like like, you know how some people might act when your blood sugar is 300 is about how I start feeling at 140. I'm like, yo, what are we doing here? Because in my mind, I'm targeting back to AD in my mind 140 60 points too high. Like get it get it, but the the amount of insulin that it takes to get it has climbed since Arden's been on a birth control pill. So while yes, the birth control pill has regulated artists period, and she's not bleeding to death anymore. Her diabetes has gotten more difficult. Yeah, because and now if you go look at graphs about how it's like, Listen, what I know about birth control is probably not enough. But you're getting you're getting a pretty regulated amount of these hormones. Every day, and that birth control is literally tricking your body into not releasing an egg. I didn't realize that, that the bleed

Jennifer Smith, CDE 30:09
is keeping you on a one cycle of hormone akin to not needing

Scott Benner 30:14
ovulation. Yeah. Right. And so you're not nothing's happening. And obviously like the whole process isn't happening actually, I think what confuses people? Is that the bleeding that happens when you're off the hormones and you're on the the placebo placebos is not your period. It's got it's actually got a name. It's, uh, hold on a second. I have so many browser windows open. It's called withdrawal bleeding. Yeah, it's not your it's not the same thing.

Jennifer Smith, CDE 30:44
Never heard. I've never heard it called that before. Okay. Well,

Scott Benner 30:47
I was schooled, I recorded an episode about this with a different podcast. I'm going to be on a vagina podcast pretty soon. And that's funny. Oh, it was hilarious. And as I was being asked, I was like, why is this happening to me? But but but people who really take birth control? I don't mean, seriously is the wrong word. But but see it as stuff that maybe, you know, there are people who think you shouldn't do it. There are people who think you shouldn't tell people how to live their lives, there's a lot of consternation around birth control in some circles. And it's important for those people for you to know you're not actually getting your period when you're on birth control. So and I have to be honest, I don't want Arden to be on birth control, not because it's birth control, but because I don't want her to take anything she doesn't have to take right when she was going down. You know what I mean? Like, we were looking at her like, I guess this is it, like, you know, the money, the money we saved for college, we could buy a house with now or something? Well, and

Jennifer Smith, CDE 31:48
that's I mean, those there are, I think, really, there are really good reasons to utilize birth control all around, there are. But in a case like this, it's almost a necessity in order to get containment of something. Now, the other thing is, you know, is this something that's just, it's just the way that her body is gonna continue to work even into like adulthood, where she continued to have to have this level of birth control, you know, management, so that she doesn't have this problem. That question, you know, I had

Scott Benner 32:22
constantly like, when do we just like, stop at once and see what happens? You know what I mean? Like, but I don't understand any cause and effect reasons why using birth control for a while, would you know, quote, unquote, regulate things and then you wouldn't need it anymore. Were was this just a cycle of her life, and it was going to pass on its own. And we're never going to know, as long as she's on the birth control pill. Right? I keep saying, I keep thinking maybe, you know, a few months before college, maybe we like, would try to bail on at one time and see what happens. Because when you've done

Jennifer Smith, CDE 32:58
enough work already to know, I mean, she's used several different types of it. So you also have an idea of what works, what really did nothing good. And what does actually work because there are so many kinds of birth control that are available. And so many mixes of hormones that you could use, or some are single, single hormone, some are a mix of hormones, at different levels. They're taken different ways. I mean, there are

Scott Benner 33:32
at one point, our our pharmacy benefits changed her over to a generic things were going great. And then they change the generic and it went right back to where it was again. Oh, and then we had to swap her back to another one.

Jennifer Smith, CDE 33:45
So funny, right? I mean, if it was the same thing, only a generic what's different about it? Right?

Scott Benner 33:53
I have no idea. This is the this. Jenny in one way or another vaginas are the bane of my existence. They're, they're torturing me from different angles and different perspectives all the time. And, and on the Ardennes period has been, I mean, a roller coaster, it has not been fun for her for the people trying to help her. Well, and I

Jennifer Smith, CDE 34:17
think you see it from a perspective of you want the best for her. You want her to be healthy and enjoy life and everything's you see it really as a it's problematic, not from a physiologic standpoint is problematic and what it brings into the picture of her management, you know, you may have a very different look on it. If she didn't have diabetes.

Scott Benner 34:42
Yeah. Yeah, I guess I there's so much about I wouldn't even understand or pay attention to her. Right, Senator. So I, I'm basically having this conversation to tell people that I'm going to start doing what I think you should do, like I'm going to I'm going to set up my own tracking app. And I'm gonna track Arden's like insulin in bushes, Jenny's making a face because I don't,

Jennifer Smith, CDE 35:05
I'm pretty AMI like, you don't do things like

Scott Benner 35:10
she's gonna leave for college and either bleed to death or having a onesie and the aids like one of the other. Like, it's just one of the others gonna happen.

Jennifer Smith, CDE 35:18
So and typically I mean that is it's also another piece in the mix too because you brought a lot of things in that could be happening in periods that are mismanaged, right? Someone who has excessive bleeding can bring in a lot of other health risk problems that can also make the diabetes management piece even harder to figure out and manage around. So it's really important. I mean, on average, don't quote me, but I think I read at one point, like the average woman with a normal healthy cycle length, and not excessive bleeding, really only loses about a quarter cup of blood through the whole period, which is it's a tiny amount, right? I mean, if you know what a quarter cup measuring cup looks like. So I mean, if you're saying gosh, excessive, clearly excessive is like lots and lots that shouldn't be happening.

Scott Benner 36:14
Here's the one measuring stick for you. Arden's ferritin gets down to like the teens, she gets an infusion. They tested again, it pushes it into like the 130s. It gets pretty high when you get the infusion. Yeah, within three months of not being on the period. She was back in the teens again, teens again, yeah. So and just I mean, for people who don't know, anemia, low blood, low iron, whatever, you know, however you get to it. I mean, just can't hardly pick your head up. Oh, freezing feels horrible. You feel like you're dying, the whole time, shortness of breath. You can have heart palpitations. Like, it's not good. You know, you get like pain and you're like muscles and joints and like, it's, it's terrible. So Arden's gonna stay on this as long as she needs to. But yeah, but it's funny, while she was home, aren't chill at home, like when she was going to school from home, she needed less insulin. As soon as she went back to in person I knew her needs, were gonna go up again. And I did the thing, where I was bolusing too much and didn't adjust settings for a little while to like, it happens to everybody, it's sure doesn't not happen to me, because it's my podcast, like, you know, like, you're so used to managing one way. And then this big piece of your life changes. And you don't even realize it for some reason. And that just made me sad, or when I realized that thinking about this, because basically, on your period, your life is changing. Like every couple of weeks, you know, like there's this impact and an end, it might not happen to everybody, there are some women who will listen to this the go, oh, that doesn't happen to me, or, you know, just like, Oh, my God, well, in fact,

Jennifer Smith, CDE 37:59
I've got, you know, some women that I've worked with, you know, even outside of like preconception planning, just in terms of diabetes management. And obviously, the cycle is a piece that we talk through and talk about, and some women who actually have the higher blood sugar levels during their period. Not before. It's more really an onset, while they're actually having their period, which is not the typical of what I've seen, but again, I've heard it enough that it's also not odd or rare,

Scott Benner 38:30
ya know, in the questions that I sent to you that that I found online, it was almost like people were like, hey, during these days here, my blood sugar is incredibly easy. And then somebody would come along and say, well, in those same exact days, my blood sugar is incredibly difficult. And yeah, I'm sure if we could, you know, Doctor House, every person in the world you might find, but I don't think that's gonna I used to love that show. I mean, right. sarcoidosis usually. Right? And I don't even know what that means. But, but so did you see anything in these questions that you definitely wanted to go over?

Jennifer Smith, CDE 39:08
I was just gonna go back to because

Scott Benner 39:14
because at some point, too, there were a number of questions about menopause, too. And some women are asking about what about when they take hormone replacement? Is it going to happen then, and I don't know, but it seems like the same as taking birth control to me, right your your address, you're adding hormones to your daily intake. If you're living with diabetes, or the caregiver of someone who is and you're looking for an online community of supportive people who understand, check out the Juicebox Podcast, private Facebook group Juicebox Podcast, type one diabetes. There are over 41,000 active members and we add 300 new members every week. There is a conversation how happening right now, that would interest you, inform you, or give you the opportunity to share something that you've learned Juicebox Podcast, type one diabetes on Facebook. And it's not just for type ones, any kind of diabetes, any way you're connected to it, you are invited to join this absolutely free and welcoming community.

Jennifer Smith, CDE 40:23
And hormone replacement therapy is usually for the most part centered around like the menopause kind of time perimenopause, menopause kind of time, it's supposed to help to ease much of the hormonal transition that's creating some of the symptoms, things like the hot flashes, and the energy swings and the insomnia and the, I guess, level of irritation, one woman may experience versus another. Right? So that's supposed to technically, even things out more. And it's a good question to actually ask, if you haven't, and you're considering or already taking the hormone replacement therapy, you know, asking your physician if they know anything, really about that piece in terms of what they should expect. My expectation would be that with the replacement therapy, if it's going well, and the dose is well managed, technically, you should have actually more stability than in how you're feeling, which should also bring more stability to your glucose management, right?

Scott Benner 41:35
Well, I guess while we're in this area, what about somebody who's had a hysterectomy? Did they lose all of those, that the cycle is just gone? Right? So that is, but it's all the hormones are all the hormones gone to?

Jennifer Smith, CDE 41:49
So although I mean, there's a good question, because quite honestly, you could have a partial or you could have a, like a total hysterectomy, right? I mean, so there are hormonal imbalances that can definitely happen with partial hysterectomy. It does, for the most part, from what I know cause less dramatic change in hormone levels than a full hysterectomy does. So in terms of that, you know, your hormones definitely shift because obviously, there's nothing there to cause that trend of hormones change, right, there's the period, right disappears. So, you know, overall, while there may be some initial management that needs to be done, I wouldn't expect that there would be as much I've worked with many women who've had hysterectomy. But I wouldn't expect that there to be as much fluctuation, as they probably usually had. I mean, when the menopause obviously is kind of similar in that when that happens, obviously, your ovaries stopped producing enough hormones to continue the menstrual cycle. Right? So if you had a hysterectomy, which includes removing the ovaries, you would then be essentially moved into sort of like a premature menopause kind of time. Right? So

Scott Benner 43:19
all right. Well, you know, if there's one person that asked such as a detailed question that I think Yeah, way they broke it down might be valuable for us. So her first question was, why does the body become more insulin resistant during different phases of the menstrual cycle? Just the laid out for people now that I think we haven't, but is the answer, just simply there's more hormones at different parts?

Jennifer Smith, CDE 43:43
Right. And so that's, you know, initially we're talking like what is the surge of the different hormones through the course of pregnancy or through the course of of a menstrual cycle? Right? So in terms of that rise up in insulin need, you know, there are a couple of points of time for different hormones, one of them progesterone, as its kind of rising, in terms of, are you going to find out you're pregnant? Or are you now you don't know if that you're pregnant, or you're not going to be pregnant, so you end up having a cycle. So then that climb in progesterone is again that typical time period before your cycle starts, that you would have insulin resistance creep into the picture. It may creep slowly, like seven days before you start to notice you've got that rise in blood sugar, okay, maybe you change up your overnight settings or, you know, whatever it might be. As you get closer to your expected first day of cycle, you're going to see a lot more resistance. I mean, many women find 20 to even 40% more insulin needed in that time period of climb in hormone, and then that most women experience the most significant and resistance the day before their cycle starts

Scott Benner 44:55
the day before the cycle starts which is the day yes leading

Jennifer Smith, CDE 44:59
day before there. Put yes there before their period starts, there's their bleeding happens, the event here, but in the event, there you go. So you know, that could be, you know, a visual point of saying, Well, I'm not crazy, I didn't need to change my pump site and change to new insulin or at nothing was really wrong, I see that this is the pattern and this is what's always happening. So how high did my blood sugars go? How much more insulin did it look like I continually used in the past two or even three months, so that you can expect it now. And you can make a, I guess, a wiser shift in your insulin rather than just sort of like completely guessing. Right? Oh, I'm gonna take three units today because clearly two and a half yesterday didn't work well. Okay. But if you have some back knowledge, you can say okay, this is definitely how much more I needed. And I can adjust better here. Now

Scott Benner 45:53
do you know there are months that Arden's period doesn't begin on the first day of the placebo, it happens sooner. Which doesn't make any sense at all. She's definitely kooky in her belly, like like, something's, something's going like when that happens. So two days ago, I saw as much resistance from her as I as I had in the month. And I said to her, like something, you're gonna get your period. Soon she goes, I have like four pills left. And I was like, okay, so then yesterday, dude all day, like we had to cut her insulin back. Crazy yesterday. So when she got home from school, I was like, did you get your period? Because No, I still have a couple of days left. But her body acted like her period started yesterday starting. And I'm like, I wonder if the bleeding is now adjusting back to where it's supposed to be. I also wonder, sometimes like Kelly's, you know, still still matched traits, my wife still fertile.

Jennifer Smith, CDE 46:52
That's a good thing. The longer you actually have your cycle, the healthier for you. It reduces a lot of the risk of female related cancers. Because the longer you have your cycle, and the length of the cycle matters, too. Not that this is diabetes specific, but it's a piece in the mix of if you've bad cycle, regular cycle, and the longer you have it in the life the better for you.

Scott Benner 47:16
Yeah, well, that's good news. But what I was wondering was is you know how you kind of sync up to people? Yeah, like I I've often wondered if Arden and Kelly even being near each other is messing with Arden.

Jennifer Smith, CDE 47:29
Very likely because in college, I had three other roommates. And at that point, we we all within a week had our periods at the same time. Yeah, like it was not a house

Scott Benner 47:48
or buying a bigger trash can. Okay, so this person's next question was, do insulin needs change? Only when premenstrual or does it happen around ovulation as well? I think yes. We've pretty much gone over that. Right.

Jennifer Smith, CDE 48:03
Yeah. And ovulation. For some, just in clarification, some women notice more significant insulin resistance around ovulation than they do in the pre cycle or like period start time. And it's often much shorter lived have a is a swing up, more noticeable rise. Post meals often tend to be impacted more if you're going to notice a change around ovulation. But it's only going to be like 24 to 72 ish hours around that ovulation that you're going to notice such significant resistance. So again, we've got this like roller coaster of hormones going on. Making people feel crazy.

Scott Benner 48:48
So I watched a video about how to know when you're ovulating getting ready for this. And there's a lot that you can watch. Oh, geez, I learned a lot about discharge and cervix ripening and feeling sexual and that it sometimes happens and sometimes, to some people doesn't happen to others. Some people get many of the symptoms, some people get fewer Nan. Yeah, you know, I love it when something spelled out to you like this. Here's what could happen unless it doesn't. Or maybe it won't, but K could and you're like this is not helpful, like, say something concrete or stop making videos. But it was really, I don't know, it was interesting. Anyway,

Jennifer Smith, CDE 49:32
there's a really good book I got actually years ago before we even plan to to start trying. It's called taking charge of your fertility. And it goes through it's really, I think, I think that it should be given to women in general. Because even if you never plan to have children, it gives you a really good idea of how the female body works. Yeah, and it Can, from just that standpoint make you feel less like? Like, I've always kind of hated when people are like, Ah, she's getting her period. Like, that's the reason for all of these mood swings and whatever. Well, it's I mean, that's, quite honestly, it could be true. I mean, it's somebody's meaning it in kind of like, not a very nice way. Yeah, but it is true that hormones change in flux a lot. But for you to know that as the person living with it, so you don't feel silly, about that's your body. It's supposed to be doing that.

Scott Benner 50:34
I'm 20% More a feminist than I was before I started paying attention to this. And I was already on the lady side. And so I mean, listen, I've never once been given medical direction that began with start with a clean finger. But I've heard those words a lot. Now, since I've been paying attention to this. And I just thought like poor girls. Like you don't even like Jesus and seeing it happen to my daughter, like firsthand. It really does. I mean, if you're, if you're not moved by it, I mean, I don't tease my daughter or my wife about like, Oh, your periods come and you're acting. But I tell you, when I was younger, I probably said it. But now that I've lived around it, I'm like, it's not. I mean, they should just say you should, you should be thanking them, not telling them. Yes, sir. You know,

Jennifer Smith, CDE 51:19
I know, to some degree, and I'm very happy that they have two boys. Because I'm like, You're gonna go to your dad. This is dad's department, go to your father,

Scott Benner 51:29
whatever he says it's not going to start with begin with a clean finger. I can tell you,

Jennifer Smith, CDE 51:33
nobody asked Bobby about that. And you

Scott Benner 51:35
You're lucky to because you're not going to ever be in this situation that Arden and Kelly are in where your periods are like, No, it just jerking you back and forth on timing. Right? You know what I mean? Right,

Jennifer Smith, CDE 51:45
right. Because I have, like I said, I have experienced that like in college. But I don't think at that point, I was even while I did a really good job of management as well as I could. That technology at that point was not, I mean, there was no CGM. I was still doing, you know, a lot of darn finger sticks a day to see where things were going. But I don't think I was as attuned to even wanting to pay attention to why something I was just like, I didn't even at that point. I was like, it looks like I just need a little bit more insight.

Scott Benner 52:22
I mean, maybe we're a decade into having the technology where you can break this stuff down a person's next question, I really want to thank them for this. And I don't have her name here, I apologize. Is you know, she brings up what are ways to track it, um, you can track it on a paper calendar, you can track it in an app, it's my intention to just like I said earlier to it a quick, easy way, maybe even colors would work, honestly, you know, green, yellow, red for insulin. I would track insulin needs I would track when the period starting, I would try to figure out as much about ovulation as I could. So you can kind of find that window in there about where it is. And I'll tell you to like it sucks, but you could track your mood. You could track your you know, your sexual desire. Like you can make all those little like clicks there. It's yeah, you don't I found thinking sucked for women the whole time, is that things that from an outsider's perspective seem like choice can be driven so harshly by hormones, which can make you feel like you're not doing things purposefully like it's your body doing it

Jennifer Smith, CDE 53:34
telling you to do you telling you to do Yeah,

Scott Benner 53:37
like, like, I would hate the idea of, I'm on a date. And I'm open to having sex tonight. Not because I want to have sex or because I like this person. But because my hormones are in a state where it's telling me

Jennifer Smith, CDE 53:50
they're kind of telling me to feel this way.

Scott Benner 53:53
Yeah, do this now. Because sperm will live in you for five days, and then we can get you fertilized and give you a good chance that, you know, of bringing this egg along. That's, I mean, it's kind of which brings

Jennifer Smith, CDE 54:07
in a lot of interesting fact, especially for the teenage. Right, yeah, where I mean, the majority of teenagers at this point are not considering conception. They're not they're beyond that, you know, for many reasons, but those are some of the things that your body is supposed to be telling you to do. Right? And you know, what's the reason? Well, eons ago. People were getting married when they were 1415 years ago old and having kids at that point, in fact, you know, if you weren't married by the time you were like 25 was like it was over.

Scott Benner 54:49
Window, right, because you were five years away from dying and probably it's um Well, I mean, I listen. It's beautiful, like you know, in a nature kind of natural ballistic weigh like, it's amazing. I just found myself feeling badly that you could be having feelings or thoughts that aren't the ones that you decided to have. But then I kind of brought it out larger. And I thought, when my iron was lower, I wasn't who I was. Right? I mean, we're all just, you know, some dialed up level of different chemicals and hormones and impacts and everything. And I, you know, I think that I hate to say that I think this episode could have been like, Hey, you should track your period, and then make better decisions about your insulin. Like, I really think that could have been the end of it.

Jennifer Smith, CDE 55:36
And then well, I think there's other I checked, there were a couple other questions in here that I think that do go. I mean, they they kind of go into, yes, that's the base, track your insulin, see what you need, and then make the decision on how to make your insulin delivery system. Do what you want it to do before you right, but there were a couple of questions. One of them was on MDI. Che change my diesel in a certain point of my cycle to deal with increased or decreased position resistance. And I should I also focus on adjusting my Bolus is I can say that, absolutely, you'll need to adjust at least your Basal insulin even on MDI. I mean, when I was MDI, and had caught on to the fact of needing more, based on what my blood sugar was doing, I knew that I needed a certain dose, that was three units, I still remember it was three units higher than my baseline dose for the time period of resistance that I needed. So you know, in terms of that, I could always adjust and unless something shifted and changed, you know, I would have maybe used a little bit more, or a little bit less. But overall, it was, it's funny that I still remember three units, where it was always what I use when I had my period. So yes, you could use more. And if your doctor isn't directing you to do that. Our doctors don't direct us to do many things that we end up doing. This is not advice or recommendation to do that, but discuss it with them. But it definitely bring in maybe some of the logs that you've kept and say, Hey, I'm noticing this, would you agree? I'm thinking I need this much more insulin, right? I mean, always check with somebody, obviously, if you feel that you need to boluses could they need to adjust? Absolutely, they could.

Scott Benner 57:32
Well, you know, I just did the math real quick, three units is only like point 125 an hour if you're on a on a Basal program for a pump. So right, it's but but, but it might have been significant for you. Do you remember what your basil was back then?

Jennifer Smith, CDE 57:48
Yeah, I do my basil. And overall was sitting at 12. And I needed 15.

Scott Benner 57:56
Okay, yes. Okay, so that makes a big jump. Even though it doesn't look like a big jump per hour. It is a big jump percentage wise, it was a

Jennifer Smith, CDE 58:03
big jump percentage wise, and it was a bit I mean, it looks like a big jump like Gosh, going from 12, all the way up to 15. Oh my gosh, like, that's a lot more insulin, right, especially when you talk about, like adjusting things. Okay, we're going to add one unit more of your Basal insulin. And we'll see how this manages things over the course of that whole 24 hour time period, right. The other one that I thought was good to focus on would be using algorithm driven pumping systems. As a female, the algorithm was not, it wasn't built for this to deal with hormones. It was not it wasn't built for hormones, it wasn't built for pregnancy, you can successfully use it. If you know how to manipulate settings, right? I I personally find that it's better for me to just adjust my baseline profile in my system. And then the months that I am more resistant on top of that, then a temporary adjustment up using a temporary Basal or an override or you know, whatever your adjustment is for the algorithm that you're using. I adjust up using that. Yeah.

Scott Benner 59:21
Is this whole conversation really similar to what you would have if you were talking about like, a teenage boy who's going through a lot of growth and hormone changes and stuff like that, like just it's just not on a cycle that you can see as well.

Jennifer Smith, CDE 59:38
Right? It's not on a cycle. That's as I mean, it doesn't seem to be from the team guys that I've worked with. It doesn't seem to be as cyclic. Yeah, predictable, right? It Right, right.

Scott Benner 59:50
This really is predictable, though, within reason,

Jennifer Smith, CDE 59:53
within reason. Yes. And I can even see if you're the person with the irregular sight Goal, let's say 25 days, one month, 29 days, another month back to 30 days and then back down to 25 days. Despite that, the things that you're seeing happen to your blood sugar in that time period will continue to happen for you. Yeah. Right. So even if your cycle length isn't about the same, if you start to see those in a time period that could be soon enough to be close enough to like an early cycle. Or maybe you're gone back beyond that, and you haven't seen changes yet. And up now I see changes.

Scott Benner 1:00:36
Okay, right. Yeah. Well, I was just thinking that you're talking about like variables and inside of variables inside of variables. You can, you know, you know, food, food cravings are not uncommon, right around hormone changes. So you could you could have forever thought, why is it sometimes I'm really good at nachos. And other times, I'm not really good at nachos. And maybe it's because once in a while you have nachos when you want them. And sometimes you want nachos? Because your hormones want them. And you're already in a situation, that's more difficult. And then you add in food, because what made me this was the question here is like, should I eat differently or exercise differently through different phases of my cycle? She's a great question. And it made me think, you know, I'm not into telling people how to eat. But there are definitely foods that are easier on you that take less insulin that you might want to try eating, while you are having an increased need for another reason, because now otherwise, you have to increase needs correct difficult food and your hormones at the same time. Right.

Jennifer Smith, CDE 1:01:39
And the hormones are driving a desire for things that otherwise you may have very, you may have very easy management around, right. You may love nachos, but your typical serving of nachos is appropriate and, and fine. And if it's a hormone driven time, you know, you might eat much more of your batch.

Scott Benner 1:02:00
You know, while we were adjusting Arden's birth control pills and getting it right, she couldn't stomach meat. She was not a vegetarian kind of person. And for a while she couldn't stomach meat. Like just get it away from me, she couldn't smell it, she definitely couldn't even think about eating it. And then as her as the pill, we found the right pill. And it got kind of like set in stone. Now that's come back a little bit.

Jennifer Smith, CDE 1:02:25
It must be something to do with the hormone levels in the birth control she's using because it's actually not uncommon for just thinking about hormones in general. Many women have some aversion to meet during pregnancy. Yeah, many women can't stomach red meat specifically. Okay. So I wonder if it's something hormonally similar. That was weird happening for her before it got regulated.

Scott Benner 1:02:52
I'm running around the house pointing to that my wife's like, that's crazy artists like you don't like Arden just thinks I pay too much attention to her. So she's like, stop paying, like caring. I tried to level up to the OB the OB is like, I don't know, I'm like, god dammit, I'm right about this. I was like, no one's watching these people more than me. You know what I mean? Like, um, they trust me, they'd all be dead without me, Jenny. Like, in one way or another? My wife, like, you know, like with the thyroid stuff, like, I'm the one who's kind of like, stepped back. Like you guys hear me talk about on the podcast, like being micro and macro. Like, on my family on macro. Like I step back, I look for big picture stuff. And I don't worry, but when I start seeing stuff over and over again, I don't know. It's just who I am. Like, I just, I don't know, I worry about people. So

Jennifer Smith, CDE 1:03:36
that's not a bad thing necessarily bad

Scott Benner 1:03:39
for me. It's great for them. You never noticed me worrying about myself. But

Jennifer Smith, CDE 1:03:46
was this I think this kind of me answers some of the question. I see and hear about age. Do you how old was Arden when she had her first cycle? Do you remember? Of course you remember?

Scott Benner 1:03:57
No? I don't know if I do. It was a little later than her friends. Okay, maybe,

Jennifer Smith, CDE 1:04:05
as was, as was I have a couple of questions here. And, you know, just relative to like, When should I expect this in my daughter? Honestly, could be as early as age 10. Wow. Honest, and it could be I mean, I was I was definitely late. I was definitely late in getting my cycle comparative to all of my friends. But I also think, in terms of that, my, my management wasn't then what it could have been if I were diagnosed in today's age, right. So I think that the management style that I had, at that point was not managing well enough to allow my body to actually be consistent enough to start my cycle at the time that it technically should have started. Yeah,

Scott Benner 1:04:57
this is Jenny's third attempt to let You all know to go back and listen to all of the pro tip episodes, you can do a really great job of getting your settings right understanding how to make changes for yourself how to Bolus for meals, how to keep high blood sugars from happening, like she is very artfully telling you, it's the ability and understanding is the is the firm foundation of living with diabetes. She's just, she's so nice about it when she says, Say what Jenny saying, y'all aren't doing a good enough job. You gotta get in there and try a little harder. You know, it's funny, I think Arden was 14 Having just turned 15. And I don't remember the date. I remember the situation we we, along with a number of her friends, were on our way to go swimming. And this was Arden's first time swimming with a period. And a bunch of little girls disappeared upstairs in my house, and came back 20 minutes later, disheveled, sweaty, rocked, and the end the one girl just we couldn't get it in. And apparently, this is apparently at one point like a mechanic

Jennifer Smith, CDE 1:06:08
and how funny that they actually like. I mean, they felt comfortable enough with you that they actually announced it to like a guy. I would have been like mortified, telling my dad something.

Scott Benner 1:06:19
No, he just described to me as Arden was a car on a lift, and the girls took turns trying to change oil and couldn't figure out how to do it. Oh, that's interesting. So that's about what happens around here usually. And well. Actually, I gotta say that's not usual. But but it didn't work out. And so I'm thinking it was the end of her 14 right around her 15th birthday. If I'm paying from guessing right? If I'm wrong about that, then it's no, it's not 1516. She's been at this for a while. I think it's 14 to 15. But yeah, like this could like you could have kids getting their periods, all kinds of crazy, just like what I used to hear like the hormones and cow's milk or making girls develop sooner or something like I don't know if any of that's true. But you know, there are girls walking around sometimes where you're like, are they 20 or 10? Or like what you can't tell?

Jennifer Smith, CDE 1:07:09
Yeah, I know. Yeah. The I mean, I think that that's like a rabbit hole of we could dive in there. But it would be a long, long discussion.

Scott Benner 1:07:18
We should make euphemisms about holes while we're talking about periods. So. So I mean, do you think I'd see it? Do you think there's anything else? Like? I mean, I feel like this is a good conversation. I mean, perimenopause, people are asking about different kinds of birth controls, like there are non hormonal birth control, like, ways, right. So, I mean, there's, I'll tell you, more than two people asked about Plan B. Whether it has an app, whether or not that would have an impact on blood sugar's and I wasn't able to find that out. You know, I

Jennifer Smith, CDE 1:07:55
that is a really good one. I can actually ask my my old mayor, may MFM, I can actually ask them if they have any reference to that having worked with enough women with type one? I don't know. I mean, the goal of that, obviously, is to not conceive. So it has some level of hormone shift to prevent pregnancy,

Scott Benner 1:08:22
you would think it's an overwhelming of hormones to kind of stop

Jennifer Smith, CDE 1:08:26
whether it has an impact on blood sugar? I don't know. It's a really good question. I

Scott Benner 1:08:32
don't know enough about how that works. How about IUDs? Do they impact blood sugars? That I'm sure you've seen in practice? Right?

Jennifer Smith, CDE 1:08:40
Right, those more they seem smoother than other birth control methods. From what I have seen. So do they have impact? They probably have an impact in terms of initially having one and then the outcome of what now your sort of monthly cycle, if there is still one remaining. What does that look like? Do you see any shifts? I've I've seen women who don't actually have any visible cycle whatsoever, right? Who have noticed a minor shift that appears to be cyclic, but most of them tell me that they don't even adjust around it. They just end up taking like a little more corrective at the next mealtime the correction seems to work well enough, kind of gets them, you know, back to where they want to be. And they never make any shifts in their insulin at all.

Scott Benner 1:09:37
I have to say that Ardens OB was pushing, pushing, she wasn't pushing. She was saying if we don't find some stability with blood with birth control pills, she wanted Arden to consider an IUD now Arden's like a little young, like we walked out to shoot, like the first thing she said to me was like, I'm not doing that. And I was like, gotcha, but it was, you know, she's like, you know, in the future, we might have to keep this in mind. Yeah, I don't I, you know, that is another thing I don't know much about. But you look like you have something you want to say, what did you find? No, I

Jennifer Smith, CDE 1:10:06
was actually just looking up a little bit about whether I could find anything on the plan B and blood sugar specific to type one, but I don't really see anything at all that documents that

Scott Benner 1:10:21
Okay, how about so is PCOS somehow related to diabetes? And or no? Like, why do you use it just because I only apparently at this point in my life, I only talk to people who have diabetes that I I start thinking things are more common or

Jennifer Smith, CDE 1:10:37
right PCOS is more common in those with other metabolic shifts that include insulin resistance and PCOS can bring more resistance into the picture, right? Other metabolic things being have more difficulty with weight management, they have higher cholesterol levels may already have higher blood pressure, despite potentially doing all of the healthy lifestyle things to manage those. But PCOS is more common with the type two. But interesting. In the past, I would say five years, I have had more women more normal, like healthy body weight and healthy lifestyle, who have actually been diagnosed with PCOS. And part of the part of the reasoning in terms of like sending them to their back to their doctor to say, hey, I don't understand I am doing everything in the picture of management. And I need so much insulin to keep things where they are. Something else has to be in the picture. So a mine is always Why don't we look for PCOS? Because if that is in the picture, one of the long term even in women without diabetes with PCOS medication that's very common and uses Metformin. Okay, it helps to dial down the resistance. And from the PCOS level, it helps with some of that cystic nature in the ovaries, and it helps with evening some of that out in terms of hormones and everything. So Metformin is definitely a heavily used additional medication that could be, you know, beneficial.

Scott Benner 1:12:35
Yeah, somebody mentioned Metformin. In in one of those, I forget where it was. I didn't bring that question over for some reason, because they were like, because they were talking about like, can I could I just use Metformin during certain times of resistance around like, you can't stop and start it right?

Jennifer Smith, CDE 1:12:56
That's no, that's not the way that Metformin is meant, you know, if you're gonna use it, we started a low dose, evaluate tolerance. I mean, it's one of the older oral medications it typically for most people is well tolerated after you get over some initial like first week or so of like, some stomach upset. And as long as you're tolerating it, it increases to like more of a therapeutic level. And then you continue use of it, you don't start stop it use

Scott Benner 1:13:23
the Advil during one section of your I only, I brought it up here, because if somebody was thinking maybe somebody else was thinking, I did not think that was a good idea. So, okay. I don't know like, there's this moment where I go, Are we good Johnny that I do we do it or?

Jennifer Smith, CDE 1:13:42
Yeah, I think, you know, I was looking at more of the questions just to make sure that P A mean in terms of talking specific like cycle, I think yes. I mean, I think discussion around things like menopause and that kind of stuff are it's such a transitory time in terms of

Scott Benner 1:14:10
that ever, right? Like menopause can go on for years. It can

Jennifer Smith, CDE 1:14:15
go on from very long time. Absolutely. I mean, and that's really perimenopause. Right. Once you're fully in menopause, you have no longer have to cycle for a year's time. Right. Then are you are menopausal. perimenopause starts with many women notice a shift in their cycle. Let's say you have had a regular 30 day cycle consistently, you kind of getting into the age of and what age in general about 50 ish, but women with diabetes have from research sort of proven to start earlier than the typical like age of 50? Let's say. So, any shifts in your cycle, without any lifestyle changes or anything like that, you know, now you're having 25 day, the next month, It's 30 day, this month, you have three days and a really light cycle next month. It's really, really heavy and painful and it's just not your typical. It could be very likely that perimenopause is kind of in the picture. And there aren't. I mean, many women would say, Well, can I, you know, get hormone testing levels done to see in this point of perimenopause, it's not typically recommended. It really isn't until menopause, that they would recommend doing testing of hormones to actually sort of prove the case that they have come to a level without a cycle, you're no longer ovulating. And some women actually haven't done the testing to make sure that they're actually not ovulating. From just like a sexual standpoint, they're just ensuring that they can't get pregnant any longer.

Scott Benner 1:15:53
Yeah. Okay. That's how you imagined having a baby when you're 50. I'd be so tough.

Jennifer Smith, CDE 1:15:58
I personally, I can't I,

Scott Benner 1:16:01
I would be so tired. That's all I can think of.

Jennifer Smith, CDE 1:16:04
Yes, I mean, from an age No, I can't.

Scott Benner 1:16:08
So no, my God. Last night, Kelly was like, can you imagine if we had had three kids? And one of them was just a couple years younger than Arden. Wouldn't that be nice? And I was like, No, I don't think so. It's it's 930. And I want to go to bed. How would that be a good thing? That child would end up being feral? I'd be like, just try not to die. I don't know if I'd have the energy to take care of it. I really don't. I don't. I mean, good for you. If you do. I don't think I could. That it were good. I think that's it. You should be good. All right. So thanks. On the whole that's everything.

Jennifer Smith, CDE 1:16:42
Probably not everything, but you know,

Scott Benner 1:16:44
is it. Alright, cool. All right. Awesome, Jenny. I really appreciate this. Thank you so much. Thank

Jennifer Smith, CDE 1:16:51
you. Yeah, you're very welcome.

Scott Benner 1:16:53
I want to thank assenza diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free contour next gen starter kit at contour next one.com forward slash juice box for E meter, while supplies last US residents only. If you're enjoying the remastered episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org. A huge thank you to one of today's sponsors G voc glucagon, find out more about Chivo Capo pen at G Vogue glucagon.com Ford slash juicebox. you spell that GVOKEGLUC AG o n.com Ford slash juice box. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She's a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years, and she works at integrated diabetes.com If you're interested in hiring Jenny, you can learn more about her at that link. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bumping nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low Beegees in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two in Episode 1008 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025 We talked about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the pro tips series when our son was diagnosed last summer, it really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active, took me already from a decent 6.5 A one C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.

#1023 Diabetes Pro Tip: Honeymoon

Scott Benner and Jenny Smith dive deep into the topic of honeymooning in diabetes management. They discuss the challenges faced by parents of children with type 1 diabetes as well as newly diagnosed adults. The episode serves as a valuable resource for navigating the difficulties of the honeymoon phase of diabetes.

You can listen online to the entire series at DiabetesProTip.com or in your fav audio app.

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:04
Hello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right, you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CD and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisit double. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. While you're listening please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have an amazing offer for you right now at my link only contour next one.com forward slash juice box free meter you can get an absolutely free contour next gen starter kit that's contour next.com forward slash juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries G voc hypo Penn Find out more at G voc glucagon.com. Forward slash juicebox. Okay, so we're recording I want to tell you that this lovely woman named Isabel has been helping me with the Facebook page. And she came to me recently and said, You need a pro tip for female hormones and you need a pro tip for the end of a honeymoon. She said these are things that people ask about constantly. And they must not feel like they're getting what they need out of the podcast on this. Now Jenny, you know, in my heart, the end of the honeymoon just means use more insulin. And when you get your period it means use more insulin but darn it. Let's dig in. Let's just dig into it and find out the details. Okay.

Jennifer Smith, CDE 3:05
Sure. Yes, they're both good. Good topics. Yeah,

Scott Benner 3:08
details are apparently what is needed, and I am happy to deliver what is needed. And by that, I mean dig it out of your head and record it so people can hear it. Sure. Okay. Because my only experience with honeymooning that my only experience that I'm aware of personally with honeymooning because Arden had diabetes was diagnosed so long ago, and we had a little meter and some needles. I mean, I didn't really know what was happening in her. So Right. One thing that I can tell you is that I called my friend who was my children's pediatrician one day, and I I told you this before, but it fits in this this episode. So let's put it here. And I told him I preface my conversation by saying I know what I'm about to say is ridiculous. But is there any chance Arden doesn't have diabetes? And he said he sounded sad. I think sad that I asked him and he's and he said why? And I said, but she hasn't needed insulin for about a day and a half now. Right? And that lasted maybe? I don't know, 72 hours, and then it was just going yeah, anyway, that's my entire personal experience with honeymooning but I know how difficult it can be for everybody. So

Jennifer Smith, CDE 4:28
well, another good question. And that I mean, as you sort of began with I just give more insulin right? Well, a good piece of honeymoon is or coming out of honeymoon, right? When you're you've kind of moved through that lack of insulin need or really really, some people can get by on just Basal insulin. They might not need anything for their meals or their blood sugar's don't go high enough to correct or anything right. But did you notice also Oh, that after that, like three ish days that her insulin needs were higher than they were before that. Here's

Scott Benner 5:06
the here's the honest answer. I don't know. I didn't know what you don't remember. I forget that. I don't remember. I didn't know what I was doing. Right. So like, I think that feeling maybe encapsulates more honeymooning and the and the leaving of honeymooning for people more than anything like, right so somebody you or your child gets type one. It's a whirlwind. A, it's, you know, and if you're honeymooning, insulin needs are changing kind of radically sometimes. So just when you maybe get the nerve to, I don't know, Bolus two units of a basil, you know, and then the next day Your fight is 60, blood sugar all day that won't go up. And then the next day you think, well, maybe I shouldn't use the two units of basil and then you don't and then your body doesn't help that day and your blood sugar's 300. All day, that uncertainty, I think, is the main characteristic of honeymooning, don't you

Jennifer Smith, CDE 6:00
true and honeymoon is it is really different person to person, as well as the like, movement out of honeymooning is different person to person like you didn't have Arden didn't have a very long honeymoon at all. And that's not uncommon from the studies that have been done. It's not uncommon with kids under the age of five who are diagnosed to have a much more rapid rapid onset of type one very quick, very aggressive, really high blood sugars, you know, unless they've been watching for it, or they know because of previous antibody testing that it could be coming, you know, DKA, all of those kinds of things. And what that results in is causing enough of the betas to be stressed enough, and the body kind of decreasing them enough in, you know, in amount that now diabetes presents itself. So but in older kids, and especially in adults, there is often a slower progression of type one, like, you know, here it is, and all those symptoms, and that often leaves more betas in the picture. Also, what's been found is that the sooner you get containment of blood sugars after diagnosis, you give some relief to those beta cells. And because now you know, you're either injecting or you're pumping insulin. And so that's something that's helping to take care of the blood sugar levels. And your betas that do remain can actually help out. And so honeymoon then often comes in, you know, were usually somewhere between about one to four months post diagnosis is the typical, like, honeymoon, time to expect that to come into the picture. And how long it can last again is person to person. It could be a couple months, it could be three days, it could be a year or two that you continue to have this like lack of more typical insulin need.

Scott Benner 8:13
It's the consistency that you're that you're missing and and then yes people's hearts I think I'll tell you after interviewing so many people, I've heard, I believe every variation of time and distance about honeymooning from adults and children and, and crazy stories where blood sugars are suddenly super normal super out of whack. One lady I'll never forget told me like she thinks her honeymoon lasted years. And then I'm wondering like, is that? Is that honeymoon? Or is it a slow onset? Like is that like, and I guess it doesn't really matter? Right? Like, what matters is that you're using insulin now. And there's going to be this variability to how much until things, I guess you could just say settle. But obviously it's not settle. It's until your beta cells give up. Right, right completely. Do do some people just not see a honeymoon at all? Where does that happen? I'm not aware of it. In

Jennifer Smith, CDE 9:11
talking with so many people that I have, and you know, it's always something I asked about is diagnosis. If somebody wants to talk about it, you know, or if it's been very, very soon after I get to talk or you know, before I get to talk to them, it's been very close to that time period. And it seems like again, everybody is a little bit different. A little people again, very little people tend to be the ones that I hear the most. We didn't notice very much anyone, okay. Or, you know, parents are concerned because they're like, I don't know, I feel like we never had a honeymoon. I feel like we never needed just like a little bit of insulin. We just went from not using any really using insulin you know,

Scott Benner 9:55
so functionally, how do people deal with it? So we And you know, let's say I came to you and I said, Hey, here's my seven year old kid. Yesterday, this basil and this meal ratio worked perfectly. Today, it's a hot mess. And I'm saving low blood sugars all over the place. I don't know what's going to happen tomorrow. But as I look back, this is bouncing around. It's two days of this one day of that. But how do you find reasonable stability until things get normalized?

Jennifer Smith, CDE 10:30
Well, some of it again, in that early time period is, it's a bit of estimation, you can base it on Well, yesterday was a really sensitive day, if it looks like we fought low blood sugars all night, and we're entering morning time again today, with lower blood sugars yet again, that's a good visual that maybe today needs to be covered similar to yesterday, or even less aggressively than yesterday, right. So some hindsight can help. But then, you know, tomorrow morning, you wake up, hi. You didn't do anything strange overnight, and you're all of a sudden, hi, today might be one of those days that you're going to need more insulin. And so it, it's hard, because it takes us out of the picture, a lot of the things that we've done. In other we've discussed in other episodes, like testing, right, and doing things like Basal testing, in this time period, it's kind of hard, because you don't really know exactly day to day, how things are going to move overall, the general idea that kids before puberty, once remission, has kind of gone away, right? Once that honeymoon period, you're expecting it's over. Insulin needs usually are about point seven to one unit per kilogram per day of insulin,

Speaker 3 11:52
say 2.7

Jennifer Smith, CDE 11:55
to one unit, per kilogram per day of insulin. So and if you don't know pound to kilogram conversion, just take your pound weight and divide it by 2.2, then you'll have your weight in kilograms. But that's a it's a baseline, you know, if you were really, really, really low to begin with, and now you're doing a really low carb diet as well. You may not really see that insulin dosing kind of go along with what we would expect in terms of overall insulin need, right? Usually, people are considered in remission, if they're at, you know, point five or less point five units per kilogram per day or less of insulin. And then, you know, once you get to puberty, gosh, I mean, you could use anywhere between a unit to two units of insulin a day during puberty, and that's completely normal. Absolutely, and completely normal. So, if you're not so sensitive anymore, you definitely see these swings in blood sugar, you know, especially in that growth period overnight, or in the aftermath of meals, and is lasting and lasting and lasting. guarantee you're probably not in honeymoon anymore.

Scott Benner 13:09
Well, you know, you I've said it to you, I've said to everybody listening, you have to meet the need. And I don't know if I'm right or enough about that. But if one day the need is greater than meet the greater need. And if one day the the need is lesser than meet the lesser need. And, and flexibilities just it's completely key. It's what you're saying. It's like you have to sort of I don't think that I don't think that during honeymoon, you want to look real macro. Not all the time, right? You want to kind of just deal with diabetes in segments of of half days or hours or something like that. Like, here's what's happening right now. If it starts trending one way than adjust with it, if it starts trending the other way, then adjust with it. But I don't think there's a lot of value. Unless you're matching an apples to apples day and going well last Thursday. You know, she was really low. So I don't want to be aggressive six days later. You don't I mean, like, today's got nothing to know. Yeah, correlation between now and six days ago when you're in this honeymoon fluctuation. And I know that people are gonna think I'm flipping but I think you could just retitle this episode, diabetes pro tip ministration. And I don't know that we're gonna say too many different things when we get to it, which is why maybe for some people, they gloss over it when we talk about these basic ideas of like, it's not always going to be the same all the time. You can't always ask for a cut and dry answer. I mean, if you want to get through a honeymoon period, and it's, it's particularly, you know, Rocky, I think that just staying flexible, meeting the need, you know, taking a little bit of historical knowledge off of days that were similar to the one year clearancing now, I think that's really the whole thing.

Jennifer Smith, CDE 15:03
I think that's the best that you can do oftentimes, especially in honeymoon and then even, you know, coming out of honeymoon, there's, I know some people use the word like it becomes more stable. Okay. Sure. I mean, more stable in the fact that you're not like giving only one unit and that whole talk takes care of your whole day. Yes, absolutely.

Scott Benner 15:32
One day, the units necessary then the next day. It's not necessary. But there's consistency. I think they mean,

Jennifer Smith, CDE 15:37
there's more consistency is is it exactly. And I mean, in honeymoon, again, there are ups their downs, yes, you can, you can choose to use insulin from some hindsight from again, I know on a really, really busy day like this. My child needs a lot less insulin, but is running high today. Yeah. Okay. Again, it's the then meet the need in terms of where the blood sugar is right now. And thankfully, these days, I mean, you didn't have an I certainly didn't, does a kid have any visible to where my blood sugar was going at all. It was a one number, it could be rising in 10 minutes, it could be dropping in 10 minutes. And that's what it

Scott Benner 16:21
will. I wonder sometimes when I'm like, speaking to this person, now who's got a very small child who I think still their needs are, well, they're not honeymooning, they were just, they had too much basil going. So it's, you know, by using too much basil, they were getting drops, that didn't seem to make sense, right. And so it took a day or two to figure out that the basil was too high, to bring it down a little bit. But in there, while we were trying to figure it out, this person was using pens. And so they were relegated to point five units at a time. And I just said you have syringes, and she did was like just eyeball less than a half. Next time we go for this meal, and did that and fixed a lot of their problems. And so while this kind of unseen force, obviously I'm talking about basil that we needed to fix though, but you know, let the unseen force be up, you know, your pancreas working all of a sudden, was dropping her down. The limiting factor was the was the measurement on this on the pen. And like, for some reason, your brain doesn't jump over that and go, Well, this might be too much what your brain says this is all I'm able to do. Do you know what I mean? Like and so but the minute we drop, like these quarter of units, then suddenly there was far fewer spikes in the meals and then far fewer lows afterwards. And I'm just wondering like during the honeymoon period, if you are that scared of these crazy drops, do you maybe just draw back your basil a little bit? And then on days when that basil is not enough, just increase your meal insulin a little or do you really mean like, because also these these poor people are probably MDI in this moment. That remastered diabetes Pro Tip series is sponsored by assenza diabetes makers of the contour next gen blood glucose meter, and they have a unique offer just for listeners of the Juicebox Podcast. If you're new to contour, you can get a free contour next gen starter kit by visiting this special link contour next one.com forward slash juice box free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juice box free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen. It fits well in your hand and features Second Chance sampling which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash juice box free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips you can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now, through your insurance. Contour next one.com forward slash juicebox free meter go get yourself have a free starter kit. while supplies last US residents only touched by type one has a wide array of resources and programs for people living with type one diabetes. When you visit touched by type one.org Go up to the top of the page where it says programs there, you're gonna see all of the terrific things that touch by type one is doing and I mean, it's a lot type one, it's school, the D box program, golfing for diabetes, dancing for diabetes, which is a terrific program, you just click on that to check that out. Both are caused their awareness campaigns and the annual conference that I've spoken at a number of years in a row. It's just amazing, just like touch by type one touched by type one.org, or find them on Facebook and Instagram. links in the show notes links at juicebox podcast.com. To touch by type one, and the other great sponsors that are supporting the remastering of the diabetes Pro Tip series touched by type one.org. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. G voc hypo pen is a ready to use glucagon option that can treat very low blood sugar in adults and kids with diabetes ages two and above. Find out more go to G voc glucagon.com forward slash juicebox G voc shouldn't be used in patients with pheochromocytoma or insulinoma. Visit G voc glucagon.com/risk.

Jennifer Smith, CDE 21:31
Correct most often and like you said, unless they have, you know, half half unit dosed or marked syringes in which yes, if you've got to get good eyes or you have a good magnifying glass, you can get kind of a quarter unit ish in there, whatever it might be, that I've got a good friend that does just that, and she's done it for a long time, and it works great for her. But again, you have to kind of use those microscopic doses. And on pens, it's a hard thing to definitely do, because all you can get is a half a unit. I mean, I think on pumps, honestly, in honeymoon and I know a lot of clinics often don't encourage people to start pumping until honeymoon is expected to be almost over. And I you know sometimes I agree with that sometimes I don't agree with that I think it kind of is individual in need, you have to look at what people are able to do and kind of a knowledge base of where are you already. But those doses they do, they do shift and change through honeymoon. And then you know, going out of honeymoon, you can expect the doses to definitely increase your child your teen your you know, adult that you're living with or your partner to or whatever, you're going to expect that their doses are going to increase. And while kids are growing at the same time as coming out of honeymoon, there are a lot of factors there. Another piece in the mix that often shifts things to higher insulin, and we've talked about it before we talked about illness and management is that if a child is also sick within honeymooning, and is now requiring more insulin, then by the end of the illness, they may actually either leave honeymoon sooner, or they may just be still at a higher insulin need as during the illness, the pancreatic beta cells were trying to assist, and there aren't very many of them left. So they were getting stressed out and can can leave less than

Scott Benner 23:41
that makes sense. So interesting. Yeah, I think that so I think that the next step here, I mean, besides telling people like look, it's gonna happen, you know, if it's happening, it's flexibility is key, it's going to be a little more stressful, but only if you I guess only if you're looking macro when you should be looking micro and then vice versa. Like you just talked about a lot a number of ideas where you do want to pull back and see the big picture, but not about the fluctuations day to day those you kind of got to get on like a bowl and ride them you can't step back and have an existential conversation about whether or not you should be bull riding, you know, so but but the other stuff are their illnesses is their growth, you know, activity, those things are, those are big picture items, but to now. Okay, so now you've figured out a way to ride through this honeymoon. The thing that I see from people over and over again, is that when it ends, you know, like when the honeymoons over, they can't believe it. They can't pull the trigger. They can't ramp up. Think about it any way you want to, but they get stuck in the game, and don't recognize that the game changed

Jennifer Smith, CDE 24:59
now Oh, yeah, I think the big thing there is that especially in honeymoon, the sensitivity to insulin makes people very wary. Yes, of using more, right, because you can get burned, right, by using more thinking you needed more, because yesterday, it clearly didn't work with this, you know, lunch that we provided we're giving the same lunch today. So I'm going to be more aggressive, you know, gave a quarter unit yesterday, today, I'm definitely giving a half a unit and then on the back end of the drop happens, right? The good thing to know is that in, you know, the coming out of honeymoon kind of moving out of that, that phase is that you will have again, more consistency in more need for insulin, you won't have as much potential for those drops, where you learned they typically happen even if it wasn't every day, you probably got a good idea of where things needed to be lower in dose, or, you know, that won't necessarily be the case. Once you're out of time. I

Scott Benner 26:12
feel like you I mean, when I tell people about it, I say you just kind of have to reset at that moment. That's when you go back to the setting Basal insulin pro tip, you start over again, you get the Basal straight, you reevaluate how long your Pre-Bolus time is, you reevaluate your meal insulin after you've reevaluated your Basal insulin. And you just kind of start over that. The truth is, is that I think that the transition from honeymoon to out of honeymoon is not actually much different sometimes than the transition from MDI, to pumping in that it's just the, it's the same game different players, like I don't know how to like how to think of it, it's like, you know, right church, wrong, pew, I don't know what the what the the thing is, like you're doing the same thing. But the pieces have all just sort of adjusted a little bit. And you have to just step back, take what you know about the thing you've been doing, and reapply it to the new situation. Right?

Jennifer Smith, CDE 27:08
Correct. And with pumping, you know that you've got a lot more precision that comes along with that. So if you've been doing things as precisely as possible with, let's say, Just half units, right? And basil that's given once or maybe twice a day. Now you can really address where insulin needs are heavier, and are lighter, through the course of a 24 hour day, you can meet the need more precisely, thus, the benefit of doing some Basal testing again, even if you're just doing it overnight, I mean, everybody wants to sleep. So if there's one time a day that you're gonna do it, do it overnight,

Scott Benner 27:51
part done, and you get that part time to a bunch of a one C and some just good feelings. In general, if you're if you're thinking all 24 hours or just a train wreck, like maybe you can at least get eight or nine of them straight, you know an answer. And it's a good jumping off point for figuring out the rest of the day. I think that when you were saying something a minute ago, this thought just jumped into my head, and I'm gonna put it here. And I think it fits. I think no matter the situation, maybe I'm talking about just diabetes or life in general. But do something is often the answer. People, there's a few people freeze, wondering what the something should be. But if you're watching the same thing happen over and over and over again, if you just change the variables, the stressors on the situation, you might see something new, that helps you understand a bigger picture something different. And so, you know, if blood sugars are, I mean, I don't think it's a joke, but like online, sometimes somebody will throw up a graph and be like, I don't know what's wrong with this. And I'll literally just type more insulin. Because put in some more and watch what happens and then go Oh, cause and effect. I've done this, but they

Jennifer Smith, CDE 29:05
want to know where right. Okay, they want not just more or they're like, but where should I put that more insulin?

Scott Benner 29:12
Like do something right, right. Like, if you haven't been on vacation in 15 years, take $5 a week and put it in an envelope, you know, do something, try to change the situation a little bit. And I get that it's frightening. And I used to think jetting, I used to think that all these things that I saw around diabetes, were so specific to diabetes, but I've been having some personal things going on with my mom's health recently, which Jenny knows. Probably not at all. Yeah, right away. But but the point is, is that I recognize that the confusion and the lack of knowing when to jump and feeling like you're overwhelmed and feeling like you don't understand what to do next. It's life, not diabetes, right. And maybe it's Feels a little more dire in some situations than others. You know what I mean? Like standing in the store, trying to decide between two waxes for your car might not be as crazy as I wonder if I want to add three more basil units to my kid or something like that. But the truth is, is that that inaction, that's what keeps you where you're at. So if you're somewhere you don't want to be, do something,

Jennifer Smith, CDE 30:24
right, an easier one to honestly do. Let's say you are running high, you know, all day long. And you're higher after meals, but you're still just stuck high in that scenario, and a safer thing is just add a little bit more basil. Yeah, add just a little bit more basil, right? If instead, in time periods where you're not actually eating, it doesn't look too bad. And then you've got these big excursions after you eat just about, you know, anything, even a microscopic eight grams of carb, maybe and it goes rocketing up, well, then you may be okay with basil, and maybe the next place to add more. And again, not three units more, but maybe add a half a unit or adjust your insulin to carb ratio by one gram to get a little bit more insulin around the times that you see the change that you don't want to see happening.

Scott Benner 31:22
Arden has been getting up in the morning going to school, and her blood sugar has been rising this this school year, like 30 points in the morning. And I tried to let the algorithm mess with it didn't work. I tried making just some simple basil adjustments wasn't enough. And then finally I just said, Doris, like when you leave the house from now on, we just Bolus three units, please. And she's like, what I was like, just throw in three units, get the car go to school, I was like, because whatever's happening is happening enough. I believe it's happening, I trust that what I know is going to happen is gonna happen. And she's using an algorithm. So if you make an uncovered Bolus, it removes her basil immediately. So her Basal is like 1.2 in the morning. So I figured it was about a unit and a half or so to fix the number or to get ahead of the number. And we got to cover the Basal that's gone. So I was like, just three. And then we adjusted off of that ended up being a little too much the next day, we did a little less than next day, we had a better outcome. The next day, she forgot to do it. You know, on the third day, I was like, see it happened again, like, you know, like, do this thing that made her trust that tried to do it, and it becomes a little more important to her. I just think it's another example of do something. Right, you know, I I've been saying online a lot to people lately. And you'll forgive me because I can't pronounce it. in its in its origin language. In Latin, but I've been telling people lately, Fortune favors the bold. Just try something, you know, they mean, stand up thump your chest and go, I'm gonna take a swing here. Let's see what happens. And then you get back to this stuff you hear in the earlier pro tips, you know, right, it's all well,

Jennifer Smith, CDE 33:13
and I think the bigger thing too, that you're you're bringing in is try something, right? But then analyze what that training did. Right? Don't just try it and be like, Wow, that clearly didn't work. Like, still focus on it. Well, it didn't work, your adjustment either left you too high, or like, you know, happened for you and caused it to be a little bit too low in the algorithm couldn't really save you from that extra insulin well, but now you know, so you use that for that information and you move forward and you say, Okay, tomorrow, we're going to do it this way. I mean, that goes into you know, a lot of things in terms of kind of the exiting of the honeymoon. It does it's try this it looks like consistently in the past week, he's needed more insulin. Okay, great. You're trying to add more insulin? Is it enough? Is it getting to you to the place that you want to be? Insulin needs may actually continue to climb a little bit? It's not like a night and day like yesterday, we needed one unit and tomorrow we're going to need 10 units. That's not typically the exit of honeymoon. But over time, that lack of beta cells that is that was helping you is going to show up very evidently in that you don't return to that minimal amount of insulin.

Scott Benner 34:33
Do you know what made me do this episode when Isabel told me that she thought it was necessary? It was that I had to get over that thing in my head that it's already in the podcast. Like I was like, No, it's in there already. You just have to listen to it. And then I thought, well, it's in there but it's in a different way because what we just talked about what about that? It really is the way when I'm when I was talking about God I don't even know what episode it was now. I guess maybe That's a good point. It's hard to find them all but but when I was talking about like sometimes you know, people's meal insulin meal ratio, sometimes their insulin to carb ratio can be like spot on for a number of meals, but not work for a certain meal. And I always use that silly example, if you have meatloaf and mashed potatoes and green beans, and you count the carbs and it says the carbs say, Oh, this is five units, you make your Pre-Bolus, you spike, you end up correcting later with two units, which brings you down and you don't get low. Well, the next time you have the meatloaf in the mashed potatoes or whatever, seven units, you seven units, right, like you see it happen. And then you take the leap, you stop looking back at the meal ration going no, that's not right, I counted the carbs, it's right, this is five units, very similarly to the idea of you're using a pen that only goes up to a half of unit, and you keep using it and then watching a low blood sugar happen. I go, I'm powerless, but you're not powerless. Like you just need to go get a syringe and do it a different way. And you're not at the mercy of your carb ratio just because it works five days a week, but not on Sunday when you have meatloaf like Right. So it's all kind of the same idea. Like, I know, it sounds trite. But it's all well, and that's

Jennifer Smith, CDE 36:14
I think it brings in a good a good piece too, in terms of, you know, multiple daily injections, and then we moved to pumping. And then we move to the fancy features of pumping. And then you might move to an algorithm driven pump, right? All of these things take. They take like evaluation. And a good example from somebody I worked with a while ago, who had started using one of the algorithm driven pumps. And she's like, this is fantastic. I love it. It's working so awesome. Like doesn't work on Friday night. And I was like, Okay, well, what were you doing on Friday night, that this doesn't work anymore for you. And she had this like, whole thing figured out for her dinner Friday nights that she would go out to with her husband. And on a conventional pump. She could use like, you know, a temporary basil. She could use an extended Bolus, and she had it down, Pat. I was like, just go to manual mode in your pump. And use it that way overnight and Saturday morning, turn your algorithm back on. And she's like,

Speaker 3 37:20
why didn't I think I was like, Oh, I don't know, either. But I hope that

Jennifer Smith, CDE 37:25
it helps. And it it seemed to be much better. Right. So

Scott Benner 37:31
yeah, because we went to a bar and art and got nachos with cheese steak on top of it and had French fries. And I crushed my first Bolus. I was like, I haven't been this excited about a Bolus. And while I was like I was on top of it. And then I started seeing the fat rise. And we hit it again. And I want and like I was over. And then I go upstairs to start working. And suddenly she jumps up her blood sugar jumps up and I go downstairs to my lab. And what happened? I had some gummy bears. She told me and I was like, no, no, we can't put simple sugar on top of fat and protein. I was like, are you all out of your minds? Without like significant I said art, if you were any gummy bears in this situation, the Pre-Bolus would have needed to be causing a fall before you put the bear the bears in, you know what I mean? Then that would have been okay, but she just did the like my blood sugar is great thing through and some insulin, wait a little while and ate it. And it was not nearly enough. We needed to be more drastic with it. And so I was like, so my text, my text said this, I'll bleep it out. It said that it said, open the loop Bolus for you.

Jennifer Smith, CDE 38:43
And let and let the Basal

Scott Benner 38:46
pumping for a minute and stop asking this algorithm to do something that it doesn't know how to do. You know,

Jennifer Smith, CDE 38:51
because it's not it's not a learning algorithm. Unfortunately, it doesn't, you know, it doesn't react the way that we have the experience to say, I know this is what's going to happen. Please don't fiddle with the insulin that I put in purpose

Scott Benner 39:08
is not the time to take the basil away algorithm. Cheese Steak nachos happening right now. Anyway, Jenny, you know, there was in the past, there was a moment when I, I used to worry. And I think like Well, we've already said these things. And people will find it. And now I realize that that's not how this is going to work that these continuing conversations are incredibly important. I think maybe the conversational part of this episode and many episodes is more important even than the technical aspects of what was said inside of it. Right. So like, if you listen to the Pro Tip series, and you had your brain or my brain or your experience in my experience you could derive from the Pro Tip series how to manage a honeymoon. But for people who are in that situation I think they need Get the information here. Yeah, I mean, in one spot. Yeah. And I just, I don't know if I was just like, super hopeful or lazy, I'm not sure. But I used to think like, just go listen to the protest episodes, it explains the whole thing, you know, and it really does. So I appreciate this, I think we're gonna have to, you know, like I said, I want to do one for you know, female hormones, menstruation, that kind of thing. So yeah, pick the next time we record. And then from there, I'm going to say this year, Jenny, because it'll put us both on the hook. In 2022, Jenny and I are gonna go back to certain pro tip episodes, were going to re listen to them on our time, and then incorporate questions that I'm collecting on Facebook, on how to supercharge those episodes. So they're going to kind of that's gonna get part two, kind of a situation. That's what cool that's how we will you and I will spend our time seeing each other through the winter of 2022 sequels to certain episodes, I'm thinking of them as director's cuts for oh, there you go. Older people who you remember the director's commentaries? Yes. You know, where do you mean you flip the movie on and the audio goes away, and you just hear the guy go? In this shot. What I was thinking was that if the sun came in from the left,

Jennifer Smith, CDE 41:18
we could could pan over here and listen to this music from this producer, you know, whatever.

Scott Benner 41:24
missoma Hi, X eyes are glistening. I did. I told the DP like, I don't know if you ever listen to them. They're pompous exchanges, Jenny and I will not do that. But we're gonna go back and listen to what we've said. Because I've done it a couple of times, like in Episode 500. I went back to Episode 11. That's bold with insulin. And I listened to it and like tucked over top of it like so people listening in episode, I think it's 100 Oh, my God. 105. Sorry. In Episode 100, I just basically did a director's cut of that, because I realized that when I said it, I was just saying it. Like there was and now I've lived all this time since then, and had these interactions with people that maybe there'd be more to add to that. And I think that exists for the protest series. Like and I'm excited. I'm sorry that you're going to start getting emails from me that say, please listen to this one before we talk again. But

Jennifer Smith, CDE 42:13
no, that's fine.

Unknown Speaker 42:16
You're a busy person well, and I can do it during

Jennifer Smith, CDE 42:18
my workouts. That's not usually I just, that's my mental like, my moving like mental sort of like strategizing time is my exercise time. I am not like a sit in one space and like meditate. I'm a moving meditator, but I can meditate on the episodes so we can make them better for everybody else.

Scott Benner 42:40
I have a question, then I'll let you go. How do you make out listening to your own voice? Does it freak you out?

Jennifer Smith, CDE 42:49
It's I don't know. It's I guess it's kind of weird to me, because I like I hear myself speak, you know, in your brain like, but when you hear yourself, it sounds different. I guess. I don't mind listening to myself. But yeah, I don't know. I don't think that I sound like what I sound like when I listen. No,

Scott Benner 43:12
no, no, I sound so right now we're recording, I can hear you and me and my headphones. I sound different in my headphones that I sound on the recording. And if I'm just speaking out into the world, I don't think I sound like the person on the podcast at all, but people think I do. But in my ear doesn't sound the same. Although And do you ever get on? Do you ever? Do you ever say anything and hear yourself? I go oh, Jenny, you should not have said it. You should have said it like this. You ever correct yourself?

Jennifer Smith, CDE 43:37
I do. Absolutely. And a lot of the ones that I listen to I'm like, Oh, this would have been a better explanation. Or I could have put this in as an example. And that would have been better. So maybe we Yes, I think it's great to sort of rethink them. Because then we can

Scott Benner 43:51
walk and I agree that there's there's just always going to be other stuff to say. And as we move forward into 2022 and beyond more people are going to be using algorithms. And there's going to be a whole new layer of understanding for diabetes, there's going to be things that you and I don't haven't experienced yet, that that through these experiences over and over again, abusing this technology, you're gonna come out I don't see an end to this podcast, I used to think it was finite. And now I think somebody is going to need to, you know, make up a cure for this podcast not to be necessary. So Well, that's

Jennifer Smith, CDE 44:25
what I was gonna say. I don't think until there's honestly a true like, you don't have to use any technology or anything. You just go in and get your bloodwork done and make sure your doctors like yep, you still look great. It's all perfect. I don't think you know the information that people need, especially with life changing and everything. I think it's purposeful.

Scott Benner 44:47
I appreciate you doing this with this. It's sort of the end of the year. So let me thank you for giving your time so greatly to the podcast. I want to thank assenza diabetes for sponsoring the remastered diabetes. Pro Tip series don't forget you can get a free contour next gen starter kit at contour next one.com forward slash juicebox free meter, while supplies last US residents only. If you're enjoying the remastered episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org. A huge thank you to one of today's sponsors G voc glucagon, find out more about Chivo Capo pen at GE Vogue glucagon.com forward slash juicebox you spell that GVOKEGLUC AG o n.com. Forward slash juice box. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed or starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bumping nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low Beegees in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two in Episode 1008 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025, we talked about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer, he'd really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning that Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active. Took me already from a decent 6.5 A one C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Jennie Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link. If you're living with diabetes, where are the caregiver of someone who is and you're looking for an online community of supportive people who understand check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, there are over 41,000 active members and we add 300 new members every week. There is a conversation happening right now that would interest you, inform you or give you the opportunity to share something If that you've learned Juicebox Podcast type one diabetes on Facebook and it's not just for type ones any kind of diabetes any way you're connected to it you are invited to join this absolutely free and welcoming community