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Scott Benner 0:00
This is episode 37 of the Juicebox Podcast and is sponsored today by insulin makers of the Omni pod system, the world's only tubeless insulin pump. You are in for a treat today. Today's episode is a conversation with Jennifer Smith. Jennifer is. Let's see, Jennifer 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, a certified trainer, I believe she is also wonderful. I don't know if you can get certified in that. Jenny works for Integrated diabetes. It's a company that you would contact and say, hey, you know, I have questions about my diabetes care. And they help you and they have in depth understandings of how your insulin pump works, how to read and use glucose. So you know, continuous glucose monitoring data, this this is next level diabetes care really fine tuning how you do things. And what I did today was I took Jenny and I said, Look, here's some things that I figured out on my own that I share with people and helped me fine tune it like See, see where I'm going wrong? And so we talked about some things that you're going to just love you know, I I can't even go over all of it with you just trust me just listen to it all the way through. If you are managing type one diabetes for yourself, for someone else, this episode is less Listen, podcasting absolutely is just a reminder that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making a change in your health care plan. And this one's going to be a treat for you. Okay, hold on. That's text messages, not Skype. Hey, your Skype ready?
Get my chair in the right place.
Jennifer Smith, CDE 1:59
Hello,
Scott Benner 2:00
Jenny Smith, how are you?
Jennifer Smith, CDE 2:02
I'm great. How are you? Delightful. Thank you.
Scott Benner 2:05
So this is the quickest podcast interview I've ever put together.
Jennifer Smith, CDE 2:09
Oh, really, I know, I was listening to the one that you did with ginger. It was really, really funny. You're like, I totally don't plan anything. I got married within like a week of proposing and getting married. You're very funny to me
Scott Benner 2:22
about 45 minutes ago, I'm like, I'm gonna go take a shower and think about what to talk to Jenny about. And then I got in the shower and spent the first few minutes. Well, first of all, I'm going to admit something to you right now. It's something I don't do very often, that threw me completely off, I put the conditioner in before the shampoo. It really messed me up for a couple minutes. I can't lie to you. But I'm
Jennifer Smith, CDE 2:44
going I've done that before to like actually at the gym, when you're kind of just fumbling and you want to get done with your shower and get out and you're kind of like, oh my God, my feet are touching the floor, we're 30 other people's feet have touched the floor. And, you know,
Scott Benner 2:58
I just I put it in. And then I was like, this whole thing is just a waste of my time. Like, I felt like I should rub it out with a dry towel and just give up, you know, but nevertheless, I bounce back gently, I don't want you to think it kept me down. I then spent the next couple of minutes dutifully thinking about a book I want to write instead of what I was looking at.
Jennifer Smith, CDE 3:18
You know everything I heard something not too long ago about kind of, you know, priorities. And a lot of people say, I don't have time for that. I don't have time to do that. And truly what people are saying is that's not a priority for me. It's if there's time for something you've made time to do it. And so it's all about prioritizing, in my opinion. So
Scott Benner 3:42
now you sound like my wife when I tell her that there's no time to put holiday lights on the front of the house. Because in all honesty, I just don't want to do it.
Jennifer Smith, CDE 3:52
Yeah, so it's not a priority for you. Right? So
Scott Benner 3:54
I think that my nature is going to be a great lead in for our conversation. So let's start like this. Right? You're Jennifer Smith. But you work for a guy who in the diabetes world if I say his first name 98% of people fill in his last name. So tell me where you work and what you do first.
Jennifer Smith, CDE 4:15
So I work for Gary shiner,
Scott Benner 4:20
Gary. No, I'm sorry.
Jennifer Smith, CDE 4:22
I know actually, the funny thing is, is you know what, I'll email people when done like leave or vacation or conferences that he you know, speaks at, they'll say hey, I'm Jenny, I'm you know, I work for Gary and I'm filling in I'm answering all the emails and you know what, not for backup, and Gary will email me back and like, don't work for me you work with me? He's He's awesome.
Scott Benner 4:45
I tried to say that the ginger and she She corrected me which is what led me down to this path. I'm like, doesn't Jenny work with Gary and she goes support Gary. I'm like, oh, Gary gets a lot of preferential treatment.
Jennifer Smith, CDE 4:55
And it'll be it's honestly it's very who's the one who's like, you know, we all work together. We are We're a team. And it's true our at integrated we there are three of us. There's myself and I'm a dietician, diabetes educator. And then there's Gary and he's an exercise physiologist, and diabetes educator, and then we've helped Lisa, and she's a nurse diabetes educator. Okay, so we kind of have a really nice, unique team, we all have diabetes. And with that our strength, our while we can run the gamut of stuff, as far as education for people about diabetes, I think we all have strengths in different places. And so with that, all of our clients at some point get touched by each of us. Which is, it's kind of a nice way to be able to work together on a team, and you cover bases that way too. And we cover bases that way. And it's truly I think, from the standpoint of having a job. It's definitely a, this career In, in what I'm doing right now with integrated is, absolutely, by far my favorite. It's been the best place. I get to work from home. So who doesn't love that? I'm a big fan of it. Yes. So I don't even work. You know, I'm remotely close to our office, which is in Philly. You know, I live in Madison, Wisconsin, and I work from home every day, which is fabulous. And I think the nice thing too, is that we get to reach people all over the globe. Because we do education remotely via Skype and FaceTime, and telephone and conference call and whatever works to contact people. That's how we were
Scott Benner 6:38
Yeah, the internet definitely makes the world smaller. And that is fantastic. So what you guys have is it's a private business, right? It is it's a print. Yep. And if I'm having trouble or concerns or questions about the management of my diabetes, you guys walked me through it.
Jennifer Smith, CDE 6:54
That's correct. In all, you know, in all ways, I guess would be the easiest way to, to kind of describe it, because we, we really work with very intensively managed. So most of our clients use a pump or are on multiple daily injections are very, you know, intensively managed, I would say most of our clients, most being about 95 to 98% are type one, okay? We have a small population of people who have type two that we work with, which is great. And we're certainly not opposed to working with any type of diabetes. We have a really good amount of people too, who are adults who are diagnosed, so kind of in the latter category, which is, you know, great. And I think,
Scott Benner 7:43
you know, I just interviewed a woman a couple of weeks ago, who was diagnosed when she was like, 59. Uh, huh, with type one, and she's just phenomenal how she's, how she's dealing with it, but but she, her brother was diagnosed when they were little kids. And she said, I just thought, you know, I thought I made it, you know, like, they told me to tell us 30 years old, like you couldn't you know, if you were right, yeah, like you beat diabetes. If you if you made it past 30 years, all you were not going to get type one diabetes. And she said, but anyway, I'm sorry, she had a great attitude. And but I can see where that would be really helpful. Especially the longer you've lived without it. The adjustments must be pretty, pretty. I mean, I would think they're difficult.
Jennifer Smith, CDE 8:22
They are difficult, I think because you know, kids are, you know, we say that kids are like sponges as far as their age of being able to learn and absorb information at that young age, kind of the same thing is true for change. Kids are very malleable. They are willing to change. And if something, you know, is moved or adjusted or whatnot, they haven't really gotten into an adulthood of pattern yet. Whereas as adults, there are a lot of things that we have to get done, right. We have a lot of time, specific things in our schedules, we've got a lot of things that we have to pay for and take care of and manage. And food becomes kind of part of that and what we do with our day to day, life becomes part of that. So as an adult, I think diagnosis is definitely harder.
Scott Benner 9:18
Yeah, I mean, Arden was diagnosed when she was it was a couple of weeks after her second birthday. So when sometimes people say to me, like, Well, how do you get her to do that? I tell them like, you know, we set a precedent and she doesn't know anything. Like she doesn't remember not having diabetes. So yeah, and we set a precedence coming out the door, like you know, I think I've put it a number of different ways on this podcast. Basically, when I was a kid, I grew up right outside of Philadelphia, so I'm aware of where Gary is. Okay. And so I kind of have that vibe like that. That kind of blue collar kind of Philadelphia vibe I grew up with, oh, you know, watching give me one second. You can, you can be with me here why Pre-Bolus origin for her lunch, fabulous Arden's blood sugar is 91 right now? Awesome. She's going to begin eating in 20 minutes. I pretty sure her lunch is around 65 carbs, okay. And in a second, she's going to tell me how much 65 carbs is, then I'm going to manually bump it up probably to somewhere where I actually want it to be. And then she's going to, she's going to Bolus with her on the pod. And then she leaves. Like I said, about 15 minutes from now and she walks to the she's in class. They'll she's in science right now. Okay. And so she'll go down to Oh, she just said, Okay, bye. Because I didn't ask her how much insulin it was. She's just like, all good brother. So yeah.
Jennifer Smith, CDE 10:43
And, and how old is she now? 1111. Okay,
Scott Benner 10:47
yeah, but but so to the point, right, is that we set a precedence, right? I always think back. And I think that if I went to the doctor, as a child, and the doctor said, look, here's, you know, here's the answer. There's this pill, and Scott has to take it for 10 days. It's pretty big, and he's going to have trouble swallowing. My father would, you know, would make me swallow the pill? You wouldn't. If I got home, and I was like, Oh, it's too big, or I can't I can't imagine my dad looking at me and going, Oh, well, that's okay. Then you take it. Yeah, fine, right. And so and so kind of with diabetes, that's sort of the edge we have, which is, I know, this isn't fun. I know, you don't particularly enjoy it. But this is what we're going to do. I get that you're hungry right now. I'm hungry, too. So I'm not going to eat either. But we are still Pre-Bolus thing for this meal. Like, everyone's just going to wait 15 minutes, you know, like that kind of stuff. And you set that precedence early on, and then it grows with her. Now, that's our expectation, you know,
Jennifer Smith, CDE 11:42
and that's kind of how it was to when I was diagnosed. You know, my, my parents went about it as this is everything that needed to be changed, let's say was changed for the family. Yeah, sure. It wasn't changed for me if I needed, like you said, kind of a Pre-Bolus. Or I needed to wait because my blood sugar was high. And we wanted it to come down a bit before I started eating. Everybody did. It's not that I just had just,
Scott Benner 12:13
yeah, I mean, we're a family, it's like, offer one on one for all, like, we're, you know, we're all in this together my son's 15 He's going to be 16 in the, you know, in the early part of 2016. And maybe there was once or twice when he would look at me and go, Well, you know, my blood sugar is not high. And I'd be like, Dude, shut up, you know, like, like, I'm not even gonna bother explaining this to you just, your sister needs a couple of minutes. We aren't you know, and then I'd say to him, Look, it might not be diabetes, but think about all the time she stood on a baseball field to watch you play baseball, she wasn't looking to do that, you know, like, we're all here to help each other. And so, um, anyway, so here's what I was thinking and tell me if this makes sense to you? Yeah, I think I've come to a lot of the a lot of the understandings about managing Ardennes type one diabetes, very slowly and without much of a medical background. And I'm also a little stubborn. So I haven't read books or anything like that. These are trial and error, you know, life in the simulator ways. But I would love it if we could spend the rest of this time because I think it would be helpful to the people who listen to the podcast who already know how I handle things. You tell me what I could be doing better? Does that make sense? Sure you like that idea?
Jennifer Smith, CDE 13:24
Or kind of an analysis of what you're doing and what to change a bit.
Scott Benner 13:28
I like that idea. Right, right. Okay, so here's let me overview you for me. Sure. Okay. Anwar is an omni pod insulin pump. Soda. Why delightful. And she actually on the pod sponsoring this episode of The Juicebox Podcast, and she wears a Dexcom. Right now. It's a G five, continuous glucose monitor.
Jennifer Smith, CDE 13:49
Yeah, eating until my warranty is up in December, and I didn't want to pay for the upgrade.
Scott Benner 13:55
Here's the thing. Here's what you get. And I haven't done a review of it yet. You don't have to carry the receiver anymore. Right. That's pretty much it. But there's, there's more. Don't get me wrong, but that's the big one, you know, so she's using the G five. She's been using CGM since seven plus. Okay. And she's been on the pod since she was four. And so,
Jennifer Smith, CDE 14:16
almost I've been on Omnipod since 2006.
Scott Benner 14:19
Oh, wow. You guys are right around the same time actually. And so and she uses a pager. Okay, so that's pretty much the understanding you have now. Arden is not much of a sweets kid. Although she's not not a sweets kid. She does like her carbs. I believe there was bread and mashed potatoes at dinner last night. And we don't limit too greatly. I mean to say that, you know, we don't limit food. We don't really limit food at all. And at the same time if her blood sugar was 200 and we were leaving the mall and she pointed to like Ice Cream Frappuccino. You know, I'd be like I'd say no. And but I probably would say listen, that's not good for anybody, you know, excuse me, and we wouldn't move on. I do manage 24 hours a day. Because I see overnight as this great gap of time where there's no food. And as long as you're not afraid of lows, and the CGM definitely helps me, you know, believe that fear. I don't like giving away 10 hours to a 180 blood sugar just because it's simpler, you know? So I am a little tired. That might be important to know. And did you get last night oh my god, at least four and a half or five hours. And so. And Arden is not much of a breakfast eater. So her blood sugars at school in the morning are not particularly difficult to manage. She is growing and maturing quickly. And I do think like the last week or so of her life was kind of overwhelmed with growth. Like every time, every time she says her ankles hurt. I know she's getting taller. And then I know I'm not going to sleep as much. I spent about the last seven days, you know, just dumping insulin on Earth and not really seeing much of an effect of it. And was
Jennifer Smith, CDE 16:13
it an all day you know, growth? Hormones for kids typically have kind of a time of day that their heaviest. But some kids experience it kind of across the board. So does she have a standard that happens when you see she's growing?
Scott Benner 16:27
What I saw on her CGM graph was this is it normally twice a day, if there's going to be peaks in our blood sugar, they happen twice a day. And instead of being very in range and having to peak to like spikes, we had two moments of being in range and everything else was high
Jennifer Smith, CDE 16:44
was high. Okay, so she's kind of an across the board sort of 24 hour growth hormone.
Scott Benner 16:49
Absolutely. And I was like, you know, like, some some perspective, I think Arden weighs about 68 pounds.
Jennifer Smith, CDE 16:56
So she's tiny, she's
Scott Benner 16:57
lean, and she's laying on top of it. And she's and you know, if Arden's blood sugar is 200 A unit of insulin would be too much. And but during these peaks, I was giving her two and three and four units at a time just to get her to move. She was she was hydrated and everything. I am really aggressive with insulin. Okay, and I do that, you know, with with, you know, the idea
Jennifer Smith, CDE 17:24
that I think it's safe because you've got to CGM, right,
Scott Benner 17:27
I wouldn't ever say to somebody just pour it on if they didn't if they weren't able to see their blood sugar's you know, you know, but, um, but so that's sort of how I go. But having said that, I have no technical or scientific rhyme or reason for why I do anything. It's all just what I've figured out about how Arden's body reacts to the carbs, the insulin
Jennifer Smith, CDE 17:46
well, and I think previous experience teaches a lot. And I think, kind of going back to why we work with a lot of the clients that come to us is because they've had the unfortunate experience of going to clinicians who have the clinical, they've got the book background, they've got the physiology of the body, and this is what happened happens if you do this, this is what should happen. But that's not living diabetes, 24 hours a day, two o'clock in the morning, this is what happens. They don't see that.
Scott Benner 18:19
It's not even close. It's it's, it's it's like a it's like a dummy speed limit on a corner. Like I talk about that all the time, like, you know, 35 miles an hour is for the slowest junkie is the oldest car on the road. Right? Yeah, right. Right. And you know, other people could probably go through that corner like 65 and be like, I have no problem with us. And so the least common denominator, everything? Absolutely. What it leads to is a lot of high blood sugars for a lot of people
Jennifer Smith, CDE 18:43
correct and sustained high blood sugars out of a rule of keeping things, quote unquote, safe. And safe may not be healthy, long term. It may be it something that makes it honestly makes parents a little bit more, I guess, feel a little bit better feel a little bit more safe. But long term, you know what, what you're doing with with your daughter is much better. Because you're paying attention. And yes, right now, you might be more tired, especially with the overnights and stuff. But I think with what it sounds like, she's, she's not struggling with how you're managing with her. Correct. She's
Scott Benner 19:30
asleep overnight. Arden can drink a juice box in her sleep and not recognize that it's hard to remember. Right. And so her life's pretty, pretty good. You know, and yeah, I mean, it's not. I mean, listen to hear, here's how I kind of think of it. I know. Some people might say, Oh, she's 11 She should be very involved. Arden is involved, but she's involved to the extent of the way I parent about every issue which is I'm not just going to one day look at my son, push his laundry into his room and go, You know what this is on you now? Like, like, you know, like, I have very slowly over the years been like, you know, I started off with Hey, bring me your dirty clothes. Hey, you know what your dirty clothes are? They're they're folded in here. Can you carry him into your room? You know, when he was little I'll put them away now he puts them away. And now he's learning, you know, and slowly giving over tasks slowly. I don't see diabetes is anything different than that?
Jennifer Smith, CDE 20:23
It's not it's not that someday you would ever dump that in a lap and say, hey, you've been watching me now takeover? Yeah. And
Scott Benner 20:29
so she gets it little by little. And I can see it every once in a while. Even in little moments, when I'm like, Hey, Bolus for 65 carbs. And you know, we'll play the like, you know, I wonder how much insulin that's going to be or something like that, or, you know, hey, we Bolus two hours ago, remember that? I wonder what your blood sugar is right now, that kind of stuff. And as you're doing that, you can see you're picking it up quicker than I even think it's happening sometimes, you know, and then that's, that's kind of how, that's how I say it. So a lot
Jennifer Smith, CDE 20:56
of diabetes management, as you've obviously, you know, found over the years with her. A lot of management is a it's almost a sixth sense that comes once you have had years of understanding fluctuations, and their personal fluctuations. And that's why again, I think when I especially when I'm working with people, you can say, well, this is where we would start or adjustments, or this is where we would start to do some analysis and some evaluation for some change. But know that these are just starting places, you will need to evaluate and do your own as kind of taking from from Ginger, her own science experiments, right, her whole book on doing that. Life with diabetes truly is sort of a series of your own science experiment. And I think in the child years, especially and through the teen years, those experiments are more, mainly because there is such a rapid chain that's happening. Once once we kind of get into adulthood, those changes should not be as frequent unless you've truly got a very unstructured life. Yeah, and
Scott Benner 22:17
diet, right. And diet
Jennifer Smith, CDE 22:18
and, and there's just nothing that's kind of set in stone from a day to day basis. But in some people, that is the case, but for the most part, you know, from what you're looking at, you're using your CGM data, that's some of the best information that you can use. For changes, depending on you know, growth patterns, your guesstimate to how much to kind of use could come from analyzing previous growth. And seeing so if you marked on the calendar, again, this, this takes a little bit of planning.
Scott Benner 22:57
I know I can do.
Jennifer Smith, CDE 22:59
But you know, even a calendar most people have like a wall calendar or something. No, just around their desk or in their phone or something. And, you know, if you can mark down and say, Okay, this looks like it was like a seven day period of growth. This is about how much extra insulin it looked like I was meeting just to keep her underneath 200. So the next time that comes, it's a little bit less of a guesstimate
Scott Benner 23:21
how much of of day to day management do you find is like I always, you know, like the other day Arden was out with with her mom, and they were one place and we were another and I texted and it's such a hard thing because you don't want to step on someone else's to your spouse's toes while they're taking care of it. But I texted I was like, you know, she needs insulin. And she's like, I gave it to her. And I said how much and she told me and I'm like more. And she was like, based on what I'm like, based on it needs to be more, you know, like, like, based on my feeling that it needs to be more just and that's a really strange thing,
Jennifer Smith, CDE 23:55
or intuitive things and you're watching a CGM. You're seeing Okay, the insulin was put in here. It looks like she was here before the insulin. And she's still here and it doesn't look like it's flexing or changing. And with the kind of insulin, she uses a Piedra, technically, that's supposed to have a little bit of a faster response than some of the other you know, rapid insulin.
Scott Benner 24:21
And it's funny, I don't see it as I guess it is faster. Like it begins to work sooner, I guess. But I see it more to steadier or steady. That's what it's been for us. It's the two arrows up two hours down. Okay. Lifestyle is gone with the future for us. Okay. Yeah. And that's how it's working best. And I'm sure it works differently in a bunch of other people. I also, I also don't think we get as much time out of our pods because of it. That was one of the questions I was going to ask you is I bail on? I bail on pump sites pretty quickly if they're if they're not working. But sometimes it's so difficult to see the depth Since between a site that's kind of gone bad, and you know, just you miscounted carbs or something like that, and so I, you know, I don't do it right away, but I'm not a fan of watching my daughter's blood sugar be high for three and four hours, you know. And so
Jennifer Smith, CDE 25:16
in general rule of thumb was any pump, regardless of the brand that you're using is, if you have a blood sugar that's high, and it's an odd high, meaning you've gone up after something that has been eaten before very similarly. And it's much higher, or it looks like it's a high that's more rapid. Those are kind of those intuitive feelings that you have that something is just not right. And or, our recommendation is that you correct the high. And if it doesn't start to change within an estimated amount of time, you test again, if it's still high or a tire, you change it, okay? You may not have gotten an alert, you may not have gotten a pump error or anything wrong. But as soon as you get that high blood sugar, you've corrected and nothing is changing, and nothing else is out of the ordinary, like stress or illness, let's say, then you change it out. You don't wait.
Scott Benner 26:13
Right? That's definitely how I mean, and sometimes in that specific situation, if the, if the pumps been on for a pretty short amount of time, sometimes I'll Bolus with a needle, just to check to see if it was the pot or not. But that's not even a perfect situation because you you might not be getting your background insulin either. So you know, but But yeah, I just don't like I have a basic concept and tell me if how right I am about this because here's something I say a lot much easier to affect a low or falling blood sugar than to affect a high blood sugar. Do you find that to be true? Like it's easier to stop a falling blood sugar, or a just a low one than it is to get a 300 down to where you want it?
Jennifer Smith, CDE 26:52
Correct. And the higher the blood sugar, the more true that is. What we usually find is anything kind of under that two to 20 to 240 Mark technically reacts better to corrective insulin, or even if you Bolus using an injection versus using the pump. But when you are truly in an effing insulin deficit sort of place. That's usually when you're above 240. And it's definitely going to take a bit more insulin possibly than what your correction tells you. And the main reason is, if it was an odd high blood sugar, like you just said, you might have also been missing Basal insulin besides the Bolus,
Scott Benner 27:37
if that makes sense. Yeah, I just I can't. I mean, I've I've just spent too many six hour portions of my life going, here's insulin. Oh, that didn't work. We'll wait to see if it's gonna work. And then here's more Oh, God, it didn't work again, the next scene or your six hours into this problem, you know, I can't do that anymore. And I just and I want to be perfectly honest, like I bought so you were with me at 91 was Arden's blood sugar, just under CGM before she before lunch, right? So we Pre-Bolus at 91 She's steady still an 83 now and she's now seated and eating. Yes. So my goal is that in the next 10 minutes, her blood sugar is about 75 Diagonal down as the food starts to kind of work, or you know, as the carbs start kind of getting absorbed and doing their thing. Does that seem okay to you?
Jennifer Smith, CDE 28:30
And as long as the food that seems okay to me, yes. As a short answer as a little bit more in depth answer I'd say it also may have relevance to the content of what she is
Scott Benner 28:42
eating. Because we need to work in a certain amount of time.
Jennifer Smith, CDE 28:45
Exactly the food needs to go in it needs to be being digested in a certain amount of time. So she's eating something like a let's say she's eating a typical sandwich and you know, some fruit and you know, typical kind of kid fare. That's gonna that's going to work way that you've planned it absolutely going to work. Now if she was sitting down to buy black bean chili that I make which is very low glycemic and I actually Bolus for that over an hour. I use extended Bolus rather than anything up front because of the way that it digests. I would say your strategy may actually have her low for quite a bit before that food starts to get in. Right.
Scott Benner 29:24
And so it is very thin. So I am using this as and you're right today. She's got she's got a juice box. It's a low it's got a carbs in it. She's got a handful of grapes, which God knows how many carbs from them, let's say five.
Unknown Speaker 29:38
She's got a quarter of a sandwich per grade. A carb for grape. Harper Great. Yep.
Scott Benner 29:44
Okay, so I'm probably right about saying about five and then she's got a quarter of a sandwich with Nutella on it. So and she has something else. It's kind of a cookie thing that has about 18 carbs in it.
Jennifer Smith, CDE 29:59
There she is. pretty curvy. And it's gets a little bit more processed carb. It's not as slow.
Scott Benner 30:07
But it's good and I'm expecting it to work quickly. Yep, yeah, exactly your
Jennifer Smith, CDE 30:11
Pre-Bolus was spot on with decision. You're ready for
Scott Benner 30:15
an ad. Of course you are. November is diabetes Awareness Month and there are a lot of pretty compelling reasons to choose on the pod for your insulin needs. Starting with the freedom you'll experience, then there's the convenience and the control on the pod gives you or your child the freedom to do what you want, when you want sleep in exercise and just live life on your own terms. Because you don't want to be tethered to your insulin pump, or a schedule. The best way to understand on the pod is to try it for yourself, you can go ahead and and get a free demo kit including a sample nonfunctioning pod by going to www.my Omni pod.com, forward slash demo, and you can see what you think of it, there's absolutely no obligation. Look, here's the thing, I only took the ad from Omnipod. Because I believe in it so strongly, you know, if you hear any ads on the Juicebox Podcast, they're going to be because I have the utmost respect in the company in the product, and I have first hand knowledge of the efficacy of what they're doing. I I'm telling you that the Omnipod is a huge part of how we keep my daughter healthy, how we keep her a one clo, you know, and you're listening to Jenny right now who, you know, is a CD, she's a person who talks about diabetes care, you know, at the next level, and she's told you already, and if she hasn't told you already, it's coming in a second, she's gonna tell you she was a nominee, Vaughn since 2006. I think she said, I just think if you're looking for an insulin pump, do you think an insulin pump is right for you, it really would be worth your while to investigate on a pod. So again, go ahead and visit www.my Omni pod.com Ford slash demo and give the free demo pod a try. I mean, it can't hurt to try. It's you know, the more information you have, the better decision you're gonna make. So now, here's something that happens to me sometimes, in the same situation at lunch, let's say it's the same lunch. But it's 20 minutes before lunch. And her blood sugar is, let's say it's 78. Now, I'm a little worried I don't want to give her I don't want to give her four or five units of insulin, have her wait around for 20 minutes and then start eating because I think she's going to be in the 60s by the time she starts eating or maybe, you know, maybe a little lower that I'm uncomfortable with while she's at school.
Jennifer Smith, CDE 32:29
Yep. So there are two options in that case. One is deliver the Bolus that you're recommending or that the pump is suggesting delivered over 30 minutes.
Scott Benner 32:40
The whole thing because sometimes I bought was like 40 or 50% of it now. And the balance over the like a half an hour, like a half hour to an hour. That makes sense to me, except she gets high after I do that.
Jennifer Smith, CDE 32:52
Okay, so in that that would have been my other suggestion, it would either be Bolus the whole amount over a half hour knowing that she's got about 20 minutes of insulin that's just drip, drip dripping in before she actually starts to eat. And she is on the lower end already. So you don't want that Bolus up front, which is going to have much more oomph than a drip drip of insulin. Because if you imagine that drip drip of insulin truly isn't going to have as much upfront effect. It's going to be active more into the time that she's already started eating comparative to the upfront Bolus, and the reason you're doing the Pre-Bolus with the whole thing up front is so that she has it active by the time she takes that first bite of food.
Scott Benner 33:42
And that leads me to a different question, which is are very small Bolus, as I say this, can they be less effective than larger ones? Like did you ever do you ever see and it's like a blood sugar. That's, you know, let's say it's 130. And you want to bump it, but because she's so little, you know, you're giving point one five, but it never really moves off of the 130. Is there something to that? Because I always feel like there's something to that. But do you see like, like, if I were to give her a unit right, then she'd be 50 And in a half an hour. But if I but if I give her point, one five, nothing happens.
Jennifer Smith, CDE 34:18
So I guess it's actually a really good question. Because, you know, as people become adults, we use more insulin doses will get larger, right. And what we've actually seen is there was a paper on this quite a while ago already about the dose effect of, of insulin rapid insulin for like a Bolus. And the larger the Bolus, if you imagine injecting five units into like a marble size little ball. Okay. You can imagine that insulin is made of lots of little particles, right? Yeah. Five units. is going to be very, very densely packed in that little tiny ball. And so the particles that are closer to the outside of the marble are gonna get absorbed first. And the ones inside to the very center of that marble are going to have to wait for those order outer particles to get absorbed before they of action. So you can see that larger Bolus is actually have they have a sometimes a slower effect, but they could be longer lasting. Whereas smaller boluses are less densely packed with particles, one unit into that same little marble size ball, more particles are going to have the ability to touch cells and get absorbed faster. So with your experience with let's say, point one five of a unit for a blood sugar that you want to just bump down slightly. It may be that it's something relative to something else that's happening in the time period, maybe it's 130. And it's kind of stable there because she had something that was fattier. So maybe that point 515 isn't quite enough to offset whatever's in the background that's keeping her at 130. Okay, that makes sense.
Scott Benner 36:16
It does make sense. And it very nicely leads me to my next question, which is why I don't have to plan these things, by having a nice conversation that leads from one to the next conversation. So it's gonna work. So here's something I don't understand at all. When I hear people say, Oh, you're having this trouble out of protein to that, oh, you're having this trouble out of fat to that do that? I have no thoughts about that whatsoever? I don't know. I don't know the first thing about that concept that proteins or fats affect how your blood sugar may or may not be? And could you give like a like a high level overview of that idea?
Jennifer Smith, CDE 36:53
Yeah, so proteins and fats are different, let's say structures than carbs. Carbs are really easy for your body to break apart, if you imagine like a pearl necklace. Okay. And each little pearl is like a glucose, okay, or a sugar. And so your body when it gets it into the digestive system, it can easily like slash slash slash in between each of those little glucose, it breaks it up, it gets it into the bloodstream, and it does its business, it raises the blood sugar, and it's in and out. It's kind of a quick and quick thing. When is it
Scott Benner 37:29
possible in those simple sugar situations that you don't really need carbs, or insulin, excuse me, like I feel like sometimes, there's some such simple like, like a popsicle or something like that, like you'll see a spike, but then it comes back on its own sometimes, or insulin that covers those carbs seems unnecessary.
Jennifer Smith, CDE 37:49
That might be relative more to what's happening around the situation, usually, and I bring it up mainly because like a popsicle for your example, is usually consumed. on a nice summer day when a child has been pretty active, you may see a little bit of a bump like that, and it may come back down, but it has relevance to what the background insulin is doing
Scott Benner 38:11
good needed those carbs to begin with. And without that popsicle might have gone lower. Okay,
Jennifer Smith, CDE 38:15
true. I'm usually quick carbs though, if it's truly a simple carb, like you said, a popsicle, a sucker a piece of candy. Many times, because of the fast action of simple carb when it's not consumed with fats, or proteins or other food, nutrients that take longer to digest and break down, the insulin could seem to have a bit of a faster effect than you would normally see in a combo situation. Okay, so your question is absolutely it's, it's, it's good observation, I would say very good observation. And it's just something to pay attention to. And watch, you know, she likes a popsicle like that. And it's, you know, a day when she's actually just sitting around and not doing very much. Maybe if you see that up, down, maybe she only needs half what she would normally what you would normally count, even if she's just sitting around. So again, that's where it kind of the personal look at what effects happen, can make a difference, individual to individual. But proteins and fats definitely are a bit different sort of structure. Fats are very, very dense, which is why we get more than two times the amount of calories per gram of fat than we get with proteins and carbs. So fats are about nine calorie per gram whereas proteins and carbs are four calories per gram. Okay, so fats densely packed with good nutrition. We don't want to be fat free, but when we have have a high fat environment, let's say you go out for like, awesome John's pizza. And it's like really really got a lot of cheese on it. And you can see the fat on the top of it and the crust has cheese stuffed into it and or like mac and cheese or a burger and fries or Alfredo sauce, those kinds of things. Fats, unfortunately, we're not taught that that we require insulin to cover fat, because fat isn't sugar, right. But fat can have long lasting effects on the body because it causes something that we call insulin resistance. It's almost like fat sits on the insulin. And let's say your Basal rate is running at point five. In the time period where fat is active, the fat makes it seem like your Basal is only running at point two, five. Okay, so in a fat rich environment, we may actually need to bump up that's a good use of our temporary basil, we would need to bump our background basil up for many hours, usually six to eight hours after consuming a high fat meal. In order to offset the sustained high we would otherwise see from the
Scott Benner 41:13
fan. And that percentage that you would bump the Temp Basal that would be trial and error probably
Jennifer Smith, CDE 41:18
it is you know, what we start with is a 50% at the end of a high fat meal, you turn your Basal up 50% And you set it for about six to eight hours post meal to run. I usually recommend when playing with that, to do it at a lunch meal, especially for kids, You're not asleep at all. So you're not asleep while it's happening.
Scott Benner 41:36
Okay, so that. So then this leads me into something that I don't think gets used enough by people. And it's amazing is is temporary Basal rates. So reasons to use Temp Basal. Yes. And the first reason I got excited about getting an insulin pump to begin with was the idea that when Arden was very tiny and very young, I'd always have these feelings like I wish there was a switch to shut off her love Amir when she was using a slow acting insulin that was injected. And now that kind of exists sometimes sometimes when she's in bed late last night was a great example. She was 91 at like 1130. And I'm like this 90 One's not gonna hold up overnight. Like, you know, and so I just shut her basil off for a half an hour. And she just sort of drifted up to 110. Okay, and that and that worked. But my question is, specifically is when I increase a Temp Basal or decrease a Temp Basal in real time, say I do it at noon? When does that effect actually start happening?
Jennifer Smith, CDE 42:33
Yeah, that's great. So when you, when you change Temp Basal, you can assume that it takes a minimum of 30 minutes, typically about 60 minutes to be effective in the circulating insulin level in your bloodstream. So that's why we say you know, what, again, good recommendation by many endos is always turn your pump off when you're gonna go and run. Well, unfortunately, if I turn my pump off, one that's going to affect me well after my run, but to it's not going to affect my blood sugar. What's happening to my blood sugar during activity during the activity? Because I've missed the boat.
Scott Benner 43:12
It's such a ham fisted statement, isn't it? Like it's, it's more that statement more says, Hey, if you shut the pod off, you probably won't die while you're running. Right? Isn't that really what they're saying? Like, like you don't forget health? Forget you understanding the management of this, this is probably going to keep you from going facedown in a cold a sack
Jennifer Smith, CDE 43:30
in a cold. Right, right. But yeah, it's usually I mean, the recommendation is at least 30 minutes, if not 60, especially for adults, it's typically 60 minutes is needed to elicit that change in circulating insulin level. And that's the case of whether you're turning your Basal down or turning your Basal off that 30 minutes to two to an hour. Like I know presentations, I've given presentations at many conferences, and the adrenaline, the stress of that while I enjoy doing it, I have no problem doing it. standing up in front of 700 people at a major national conferences,
Scott Benner 44:09
dress it up a little bit right,
Jennifer Smith, CDE 44:10
pretty good stress, right, and it can kick my blood sugar up. So having experienced that and also experienced the typical rise that I've seen from that, I will usually turn my basil up about an hour prior to my presentation. And I will keep it raised through about 50% of the way through through my presentation. So if my presentation is for an hour, let's say I'll run that Temp Basal increase for about an hour and a half to get me through that halfway point, knowing that that circulating insulin level is still going to be high until almost the end of my presentation and a little bit beyond.
Scott Benner 44:49
I can't imagine anybody listens to this and thinks that a glucose monitor is not something you should be walking out of the hospital with when you're diagnosed.
Jennifer Smith, CDE 44:56
In fact, one of the things that when we when When we get clients who are on MDI and do not want the connection of a pump, let's say my biggest recommendation is a CGM. I don't care which one you choose. Although, you know, we really liked Dexcom.
Scott Benner 45:16
I always say this too. If you can only have one take the glucose mama CGM,
Jennifer Smith, CDE 45:20
right, absolutely choose the CGM. I know a lot of the women that I work with their pregnancies. If they either can't get or don't have access to getting a pump, we need to have a CGM. I don't care how you get it, what ropes your doctor has to polar cutter, whatever happened to get a CGM, because I need to see what's going on so that we can control better. And in ginger herself. I think when you talk to her, she mentioned the fact that you know her, her MDI, her multiple daily injections during the course of her pregnancy escalated considerably. But you could do it. And she could manage it. She could micromanage. I mean, she was doing many, many, many little tiny, more injections. But she could do it because she had a CGM to show her how to do it. Right.
Scott Benner 46:09
Right. Yeah. And if you're not trying to avoid the insert the needle sticks then right is long as you can see it, you can see it. It's just it's it just it doesn't make any sense to me of what we're talking about the rollercoasters and putting insulin in before and after and spacing and all this stuff. Like if you can't see what your blood sugar's doing. That's how people end up erring on the side of caution. And in their mind. Caution means higher, high. And then what happens is, is your kid didn't pass out today. But 15 years from now, we're not sure what's gonna happen. And that's not that's not a way to live. And that's not managing this, that's just cross the bridge when you come to it, which is a terrible way to live your life. Never say we'll cross that bridge when we come to it. Because often you get to the bridge, and it's like broken.
Jennifer Smith, CDE 46:53
Exactly. I work with a lot of athletes. Well, athletes who have all of the fancy gadgets, you know, they've got a heartrate monitor, they've got the pump that does this, and it connects that and they've got the CGM. But they're not, I think a big piece behind this is data. If you aren't looking at data, or don't know how to look at your data and pull the necessary information out of it, then what good are the instruments that you're using? How is
Scott Benner 47:23
that new clarity software? I haven't installed it yet. So far, I've only used the mobile app, which is a very like one day snapshot thing, but is it? Do you find it to be good?
Jennifer Smith, CDE 47:31
You know, the clarity that I've gotten so far from clients who are on the G five and have sent me their clarity reports to look at? The reports are fine. I'm in a, in a perfect world, I think they could be better.
Scott Benner 47:49
Okay. Can I tell you why I'm asking? Because tomorrow, I'm talking to the guy that runs the software for Dexcom. So what he want me to tell him guys, I'm writing a note. Yeah. So
Jennifer Smith, CDE 47:59
I think the drawbacks to clarity that are not that are wonderful. And already there in the real in the studio software, the overlay pattern of like seven days, or 14 days or whatever, where you can see all of the lines. That's not there in clarity.
Scott Benner 48:23
And you as a new as a CD need to see that.
Jennifer Smith, CDE 48:25
And as a CDE. And even people who are really looking at their data, they need to see that they do have a 70 what is considered kind of an overlay, but it's more of a it's more of an average. And so you don't truly get to see patterns as efficient. All right. The other component is I'm a big user of the event marker in my CGM, because when I download to my my studio software, I look at my day to days below it and I see the events that I've marked and I'm like, Well, this is why I had the blip here or look at here. I took insulin and then I decided to take our dog for a walk that was impromptu and look at that I you know, should have eaten something extra or this is what happened. But on the clarity while the events are marked. It's not it's not as clear.
Scott Benner 49:21
No, that's that's really good. That is not as Okay, well, I'm sure though, I'm hoping they'll continue they seem like a company that continues to take they take outside you know? Yep, suggestion as well. So I will make that suggestion for you tomorrow. So now it's funny. A little while ago you were talking about speaking in front of people. And you talked about adrenaline stress, literally 12 seconds before that. I wrote down the word adrenaline which as I'm looking at it now I'm pretty sure I spelled wrong but nevertheless what
Jennifer Smith, CDE 49:51
I can't see it you know what it says? So,
Scott Benner 49:53
let's all think it's just it's spelled correctly. I know there's like an A in the middle or something and it freaks me out that I don't exactly know but nevertheless, let's forget that. Let's remember this. It took me a long time to realize when I want to see if I'm right, that when my daughter does something activity wise for fun, and it's anaerobic, her blood sugar falls. If she does that same activity, and they keep score, her blood sugar goes up. And so she's a she's a competitive person who plays competitive softball. You know who plays basketball? Basketball is the one that took me a while. You bring her in a gym, and her blood sugar's 100. You've got a Bolus for 15 carbs before she starts playing, or her blood sugar will be 180 halfway through.
Jennifer Smith, CDE 50:43
Yep. And it's great that you've figured that out. I mean, that's that's typically what I say with with the weightlifters that I work with adrenaline will spike your blood sugar. And because weightlifting is an anaerobic, but it it causes that adrenaline release, we typically see rises. And what I say is, see what the rise is, and cover that with the right amount of insulin to offset the rise, whether it's a Bolus up front as you found to do or if it's an extended Bolus to drip drip, drip it in. But
Scott Benner 51:15
it even could be, as I'm thinking of it now like I, I started this process by what I said to my wife is I'm going to Bolus for a juice box because if she doesn't need it, then the insulin will do what it needs to do. And if for some reason the adrenaline's not here today, then the juice box, I'll cover it because that really is interesting. Because she could show up one day randomly, and I don't know she thinks the team they're playing is not very good. And then she doesn't feel the same spike, you know, of like, oh, wait, we have to go kill them, you know, and so but here's the the other thing that I think I feel like I'm saying, please tell me if I'm wrong. Adrenaline while it's there is pushing the blood sugar up. The minute the adrenaline disappears. It's not like a car, but it doesn't linger in the system. Is that true? Because, okay, so because so you can like so it feels to me, like I'm in a bad comedy. And someone's trying to shove a door open and I'm on the inside and I'm pushing the door back. I'm the insulin pushing the door back and the adrenaline's on the other side, shoving the door open. And I'm pushing, pushing, pushing, pushing. And then at some point, the adrenaline leaves and I fly through the door jamb and go flying across the room. Because at the end of those basketball games, if I don't drive home and have her eat, she's going to plummet. But she needed the insulin in the moment, am I right?
Jennifer Smith, CDE 52:38
You're absolutely correct. And again, having worked with
Scott Benner 52:42
Jenny, I am not holding my arms over my head in triumph. In case you're wondering if that's what I'm doing or not should
Jennifer Smith, CDE 52:47
be holding your arms and that and that's great. Again, it's it's pretty common on race day. For for many athletes, they have done all of their training, they've done their 20 mile plus runs to get to their marathon length. They've had these awesome, you know, training days and blood sugar's are we've got it all in. And if I don't educate them about race day, and if they have not experienced small little race day events leading up to that their experience on race morning, starts them out, lately off what they normally would have started a day like that app. And the main reason is adrenaline. And so we're also very conservative, with the effect of of insulin for correcting when we talk about adrenaline, because like you said, once that adrenaline is gone, like once you start a race, let's say or once you kind of get into the game. Some people find that that bump of insulin worked great, even them out. But like you said, if you don't feed her as soon as you get home, there's this amazing drop. Yeah,
Scott Benner 53:58
by the way, it's also a great primer like on a Saturday morning, when the game's over. And she's like, can we go to the diner and have a waffle? And I'm like, Yes, this is the perfect time for a waffle.
Unknown Speaker 54:11
But then you're like,
Scott Benner 54:13
oh my god, yeah. Let's not even ask the lady for the sugar free syrup. They're fine. Like, and so and but but yeah, like, so it's funny too. And I want to bring this up to people. If you plan these things out a little bit. You can have these kind of like, you know, what, what I think a lot of people want to think of as normal meals, which by the way, I think having a giant waffle with syrup on it's not normal, but if you but if you want to have like a normal meal, there are ways to plan the management around it so that you're not treating this like a diabetes treat. Like she doesn't need to know that right now that she can have a waffle after basketball because I had to give her a bunch of insulin for adrenaline like you don't you mean like it can just be a normal thing. Like let's go to the diner have and you can get whatever you want. Yeah, and so Okay, So we're getting up to like 15 minutes here. And I want to, I think we've covered a lot of things that are helping me and that will help people listening. I'm going to ask the big question, why does blood sugar go up in the morning? And why is it more difficult to affect in the morning hours.
Jennifer Smith, CDE 55:20
So there, there are a couple of schools of thought and a couple of more than thought, but truly good reasons for that insulin resistance in the morning time. One of them is just relative to the hormones that are ready to get you going for the day. And they typically start being active between about three and 8am. And that's that it's a bump off in your need for insulin. And that's just a physiologic thing that happens if we had a monitor on somebody who doesn't have diabetes, and we're looking at what their pancreas does to manage blood sugar as it's supposed to be, through the day, we would see that normal physiologic kind of bump in that timeframe. So that's one, there's more insulin resistance going on due to some of those hormones in kids that can even be heightened, because they've also got growth hormones going on, right? Another component to those blood sugars, especially surrounding the breakfast meal and why it can be harder. I mean, some people's insulin to carb ratios are like half of what they would be at lunch and dinner, when we have a breakfast. And the main reason is some of that resistance. But another one is, breakfast is really what breaking your fasting period from the overnight, right? And so when we break a fasting period, our stomach has the tendency to more rapidly process and break the food down and get it into the system. Because your body is saying, hey, I need to be fed.
Scott Benner 57:01
So is a Pre-Bolus. Even more important in the morning
Jennifer Smith, CDE 57:05
in the morning? Absolutely. Yes, I might. My typical Pre-Bolus for breakfast is 30 minutes, by usual, excuse me, Pre-Bolus for lunch and dinner is about 15 to 20. And that also is dependent on my activity and whatever happened kind of around those other meals. But usually, I mean, breakfast is typically 30 minutes. I can tell you that when I was pregnant, my Pre-Bolus for breakfast was 60 minutes.
Scott Benner 57:33
Yeah, I mean, listen, if Arden's blood sugar's a little high before a meal, like like, like, last night is a good example. Like it. She came home from she tried out for the basketball team from school, she came home and she was hungry, but I wasn't going to have dinner ready for an hour because I was at the school standing off to the side because I wasn't sure what was gonna happen at this basketball trial. And, and so her blood sugar had gotten jumped up to like, 180 I Bolus an entire meal, like an hour before, you know, because I knew that by the time the food was ready, and we were eating that, that I could get that 180 down to about 75 or 80. But if I would have just bumped the 180, then I wouldn't have I would have felt like I couldn't Pre-Bolus Then like I don't know if that makes sense or not like it. Like there's times when I see a larger blood sugar. And I'm like, let's get it down. Like let's let's time the food with the drop. And
Jennifer Smith, CDE 58:26
some reference to to knowing how her digestion is. Yeah. And again, the content of the meal. Yeah, for sure. So, you know, usually in high blood sugar circumstances, our best recommendation is to bump the blood sugar. And then if you still want a bit of a bit of action on the meal, meaning a heads up before the meal, then try to Pre-Bolus yet again, for the start of the meal, maybe 10 or 15 minutes.
Scott Benner 58:55
Okay, so I could still split that insulin like a fact that I affect the number and still Pre-Bolus the meal. Yep.
Jennifer Smith, CDE 59:01
In fact, I know you mentioned before to kind of watching that arrow on the CGM. And a good a good thing when you started by bumping a high blood sugar back down before a meal so that you're not starting to eat when it's so high is kind of watching that arrow. And once you get sort of a downward trend, either on the line or with an arrow, that's then a nice time to actually do the Bolus for the meal.
Scott Benner 59:25
Right. Okay. All right, that makes a lot of sense. Yep. Um, oh, wow, Jenny, we could do this all day. But that wouldn't be fair, that wouldn't be fair to you, and it wouldn't be fair to integrate a diabetes. So is is Integrated diabetes. Do you guys take insurance? Are you a private just a private company
Jennifer Smith, CDE 59:43
or a private clinic? And so while we do not technically take insurance, we do supply billing, so that people who are covered for educational services can then take the billing with the paid paid receipt from our service. They can submit it to insurance and get reimbursed? And
Scott Benner 1:00:02
would you say that? I mean, this isn't this isn't like psychotherapy, I don't have to do this for the rest of my life with you. Right? So it's it's how, what's the kind of standard amount of time? Somebody would be with you?
Jennifer Smith, CDE 1:00:16
Yeah, most of our people, let's see, our initial consults are pretty lengthy. They're about 90 minutes. And that's because we really take a good assessment of everything that's going on. And we want to establish, what are your goals? What are your What are you coming in with questions about that you specifically want answered? And then when we've looked at your logs, and whatever else you've submitted to us, what do we see as needs within those goals. And then we work out typically people start with a three month plan, our plans are called retainers. And the retainer for three months, there are a couple of options. And common choice is our pump management retainer. So over a three month time period, you would get four visits, like kind of like we're having today. And the pump management includes really good information about true pump use, which most people who are on a pump, and I've really not gotten good education about all those fancy features, like you mentioned before, the Temp Basal. I don't know how many people I've talked to, they're like, Yeah, I know what's on there. I've tried it, it doesn't really seem to do anything, or it does this or it doesn't do that. And when I give them the information, they're like, Wow, I didn't know what he told me.
Scott Benner 1:01:34
The Dexcom to the all the technology really, it's somebody gives you a bazooka and you're out killing flies with it, you know. And so like the Dexcom was, like I said to somebody the other day, I said, I think so many people just think the CGM is like a, like a don't die in your sleep machine. You know, and the fact of the matter is, is, oh, my God, there's so much more you can do with it. And really help yourself, you know, and, and sometimes I think it's overwhelming. And it's difficult to figure out plus, you know, as I'm sitting here telling you, like, I spent the time like to figure out my daughter's physiology and all this. I'm also a stay at home dad. So I wasn't running to work. And those times, you know, if I stay up really late at night, I can, you know, faceplant on the sofa for 20 minutes, if I'm gonna pass out in the middle of the day, like, you know, I have, there's reasons why I'm able to do that, you know, and for a person who gets up every day and goes to work and is still trying to take care of their children, I think sometimes good enough, is the best they have, they think, you know, and if they can get help with, right, right, if you have to figure it out on your own, then good enough, ends up being good enough. But if someone could come in, like you who's got such a great way of presenting this, and I don't want to say spoon feed, but maybe spoon feed it to me so that I can I can get it quickly. I mean, I'm sure it's a little bit of cost up front. But at the same I didn't have you really on to the blog, the business but but I'm sure it's a little bit of a cost up front but aggregated over your whole life. It's, it's
Jennifer Smith, CDE 1:03:05
it's absolutely. And that's why I said most people choose about a three month plan to begin with. But we actually have had Gary's been in business for over 20 years. And he has some clients who are very long term clients who have been with him since the very beginning. And while they may not be every month we visit, you know, like a typical retainer they have one of our packages is a 1212 month maintenance, where we get to chat, let's say four times a year, whenever something comes up, you want to talk about something you want to bring it up or something's changed, or you're going to take a trip and you want to plan it the best. They choose that so that they have the option to talk with us. And then in between, and the nice thing about all of our retainers is unlimited ability to data dump. So you can download your pump, you can download your CGM, you can email us questions, we can help analyze in between all of those visits. And that's an ongoing process that most people do not have with their endo or even an office CDE
Scott Benner 1:04:11
Jenny, I gotta tell you something at this point, if it wasn't for if I had if I knew how to do a blood test for my daughter, I don't even know if I'd go anymore. Like I don't know what i i get to listen, I've said it before Arden goes to A to the Children's Hospital, Philadelphia, it's a good institution. And these people are I'm not saying they're slacking or anything. I'm just saying there's a there's a saturation point where they're asking me questions when I get there now, like, you know what I mean? Like, Hey, are you seeing this but this like, really me? Do I get to charge you $40 Like, like, like, you know, like where's my copay on this? But there's a point where you're just like, there's almost like there's nothing left because they're not living with you. You know, they're not with you day to day so even the good information they have they don't really know how to apply it to your situation. Right? Yeah,
Jennifer Smith, CDE 1:04:58
I actually found that you know, we live Have we lived out in DC for eight years prior to moving to Wisconsin here, and having worked out there and lived out there and also had clinicians who served me? You know, I, I looked and looked and looked for a clinician who could answer my questions to my, to my ability, because I have I know that I've got a lot more because of my background as well as my personal experience, right. But I needed a clinician who could meet me and go beyond that. And it took me I think I, I wouldn't say fired, but I met with, you know, worked with and I was like, You know what, you're just your basic, and I'm really sorry.
Scott Benner 1:05:45
Yeah, I need a little more than that, please. No, I that really, it does really make sense to me, I think you do have to, and especially adults, from what I understand, it's harder to find a good endo as an adult than it is,
Jennifer Smith, CDE 1:05:58
is I would say for adults, even for kids who are getting into the teen years and looking into moving from pediatric to adult endo coverage. I always think the best thing for endos for adult endos is ask them when you call to make the appointment. How many people in your practice? What percent of people with type one do you see? Because, you know, we know that the wealth of people with type two with with diabetes is are much type two. We are not the vast majority.
Scott Benner 1:06:33
And I don't need you to write me a Metformin prescription. So I'm, yeah, I need a little more from you than then you're writing the scripts and telling me to watch my diet.
Jennifer Smith, CDE 1:06:41
I need you to know how to download my pump, how to look at the information, how to pick up data and see things that I'm not seeing because I'm looking at my data.
Scott Benner 1:06:48
Right, right. Yeah, no, I completely agree. That's excellent. Jenny, this was good. You are great. First of all, secondly,
Jennifer Smith, CDE 1:06:58
was awesome talking to you. Like I said, I've read your blog before I didn't realize that you were doing podcasts. So this is fabulous. Yeah,
Scott Benner 1:07:05
it really does. It's a great way to reach people reading is almost completely extinct in the world. As I'm wondering about writing a book, and
Jennifer Smith, CDE 1:07:14
ginger and I are writing a book too. So hopefully that's not the case. I know.
Scott Benner 1:07:18
It's so um, so when I heard ginger was pregnant, I sent her a private email and I was like, you have to document this whole thing and write a book about and she goes, I'm way ahead of your buddy. And I was like, Okay, so. So here's an interesting, like, kind of ending to this. We are 55 minutes in, since I gave Arden her insulin for her lunch. And her blood sugar is 75. Okay, and it's drifting, I'm seeing it. It's crawling up. Not enough to move the arrow yet, but it's just that there's a slow drift, just slowly drifting up. And now, and now I won't know, the funny thing is, I won't know how well we did with this for another 40 minutes. If this wasn't enough insulin for some reason, I'll know 40 minutes from right, you know, but, but what I try to avoid and what I tell people all the time is, is that in this range, this hour range, if her blood sugar was going up now, you know, I would be giving her more insulin and I that goes against anything a doctor would tell you, but it but if her blood sugar's over 160 An hour after she ate, I feel like I've made some sort of an error and calculation. You know, it just it shouldn't it shouldn't get that it doesn't have to get that high.
Jennifer Smith, CDE 1:08:34
And that's where again, clinical recommendations lack because you've seen and you've tracked and you know enough about like her physiology, her physiology her digestion, the food that you fed her. You know enough about it to actually be proactive.
Scott Benner 1:08:51
Yeah, it's just in that's the shame of it is so many people and listen whoever's listening, listen to what I'm saying here. First, let's remember that nothing you hear on the Juicebox Podcast should be taken as advice medical or otherwise and I am not a doctor but a doctor in check with them. Absolutely go to your doctor and check but you do not live your life with a with a guy Sandy here let me bump your your basil around a little bit. Alright, come back in three months, we'll see what happens you do not want to wait three months to see if this works or not.
Jennifer Smith, CDE 1:09:19
Oh, and that's again, that's that's the deficit that we're kind of filling with integrated is because we have so we have such close contact. It's as some of my clients email me almost every single day, especially my pregnancy clients. And your unfortunately you're not going to get that in an endo office. They don't have the time. It's
Scott Benner 1:09:39
It's It's of all the odd things insurance is the biggest problem for people to get good to help because like you said, nobody has the time to give to you. You know if a doctor builds you for for what you guys are doing, cost me a million dollars to know how to use my Basal rates. And you know, alright, see now we're gonna prom I could just keep talking to you. This has to stop Jenny Stop it. Stop being delightful for five seconds so we can say goodbye. Plus, we've had everyone say goodbye to Jenny.
Jennifer Smith, CDE 1:10:07
Hi, everybody. Thank you so much.
Scott Benner 1:10:09
Hey, if you're interested, I have a good idea. Hey, if you're interested, I have a giveaway going on on my blog right now Arden's de.com. Two winners will receive 10 pairs of the blue diabetes circle shoelaces. I don't know if you've seen them online, but their shoelaces adorn with different blue circles for diabetes Awareness Month. They're courtesy of Novo Nordisk. And all you do is go and there's a bunch of different ways to enter and then there'll be a drawing and to two winners will be taken randomly US residents only please. If you are enjoying the Juicebox Podcast, go to iTunes, leave a rating leave a review, tell a friend do something to help spread the word about the podcast. And here's an interesting note. It is now two hours and 35 minutes since Arden got her Pre-Bolus for lunch at school. She's actually on a bus now on our way home. And her Dexcom has her blood sugar at 124. That is about as high as it went in the last two hours and 35 minutes. All right. So next week, when we'll be talking to the gentleman who designs the software and apps for Dexcom. I will talk to you later. Come back next week to hear all about that
