#287 Diabetes Pro Tip: Illness, Injury and Surgery

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

Episode 288 is a companion to this episode, don’t miss it!

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

Scott Benner 0:00
You are listening to Episode 287 of the Juicebox Podcast. This episode is part of the diabetes pro tip series that began way back on episode 210. Today I'll be discussing with Jenny Smith, the topic of illness, but not just how to handle a sick day, the flu, a stomach virus, an injury, a surgery, a dental appointment, all of those medical ideas that might require a little more thought. Today's show is proudly sponsored by Dexcom Omni pod and dancing for diabetes. You can find out more about the dexcom g six continuous glucose monitor@dexcom.com forward slash juice box and the tubeless insulin pump that Arden has been wearing for a decade. More than a decade. Ah the Omni pod my omnipod.com forward slash juice box to get a free no obligation demo today. And if you'd like to learn more about dancing for diabetes, it's simple dancing the number four diabetes.com.

This episode is going to have a companion piece. It's the defining diabetes episode on ketones that will have come out at the same time. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And always consult a physician before making any changes to your health care plan for becoming bold with insulin. Don't forget they say an ounce of prevention is worth a pound of cure. So don't forget to wash your hands before during and after preparing food before eating food before and after caring for someone at home who is sick before after treating a cutter wound after you use the toilet changing diapers. helping a child use the toilet after blowing your nose coughing or sneezing touching an animal animal feed animal waste handling pet foods or treats touching garbage and you know how to wash your hands does anybody ever really told you they got a wet them right so you run some water on them warm or cold doesn't matter. Get them wet and put some soap on. vigorously lather your hands by rub them together with the soap on the backs of your hands between your fingers and under your nails. scrub them for at least 20 seconds. Rinse your hand well under clean running water dry your hands using a clean towel.

Jenny let's do a big Sick Day episode. And so I'd like to try if we can to get through sort of a regular sick day like you know, a little beyond the sniffles. Okay, the flu, stomach virus, an injury like a broken bone or something I might have to take, you know, steroid for and then an actual surgery and have you Where do I want to start? You've had a surgery pretty recently, haven't you?

Jennifer Smith, CDE 2:57
I've had multiple surgeries. I've had awake surgeries I've had I've been out surgeries. I don't like surgeries. But I've had though. Yeah,

Scott Benner 3:05
so let's start there a because you got good information about it and be because Arden is gonna have a cyst removed in a couple of weeks. So I want to hear about this. So let's start with something you were awake for. I guess also, like dental procedures would probably fall in this category a little bit, maybe, maybe not,

Jennifer Smith, CDE 3:26
they could they would be a little bit different only because, um, like a dental surgery if you're going to be awake for it like just a tooth removal or something like that. Usually, the awake component to it means that you don't really have to go in fasting or without any food in your system, you know, those kinds of things. If it were going to be I know now, they usually try to take all the wisdom teeth at once if they're going to do that. And oftentimes now I've heard a lot more people being completely put under my son for wisdom tooth, you know, extraction, I didn't I my dentist said Your mouth is not big enough. You need to have your teeth come out but there's nothing wrong with them as they come in, we're gonna take them out. So as my teeth kind of came out and honestly my wisdom teeth didn't completely come through until I was well into my 20s and so they just took them out in office.

Scott Benner 4:31
Me I'm gonna make a note here to myself, because it has nothing to do with this but my wisdom teeth extraction story is absolutely insane. And I will tell it at the end. So why don't we just made it myself. So okay, so if I'm just going to the dentist to have a cavity done or something like that. Not a lot for me to do probably handle things the way I normally do. You know, I guess

Jennifer Smith, CDE 4:55
the big thing to make sure is especially if you're new to having it done is And you've never had any, like pain medication. No, you may experience a little bit of a higher blood sugar, potentially a stress component from having like the novocaine. I mean, that needle is, it's scary, the scary looking needle that they're shoving in your mouth, right. And it doesn't feel very nice either, as they inject it several times. So for those of you know, those people have never had this done, I, it's not very fun. And if you ever do have to have fun, done, it's not a fun thing. But it could cause a rise in blood sugar because of a pain component, because you're just in a setting that's completely not under your control. So, but other than that, yeah, you shouldn't, you shouldn't have to go there fasting, or make any true adjustments to anything. You know, in the future, if you had a second surgery, or a tooth extraction or tooth work, and you knew what happened the first time, you could potentially look back,

and maybe make adjustments like setting a Temp Basal increase, or taking a small amount of Bolus ahead of time to offset arise if you don't want it, or just correct after if you're not quite sure what's going to happen.

Scott Benner 6:13
Yeah, especially I'm thinking if, you know, if you're trying to I'm not usually up for like, run high to avoid a low kind of situation. But if it's an hour, an hour and a half in the office, and it makes you comfortable, you know, let your blood sugar be a little higher for that. And then and then get at it. And because you're I guess too, if you're numb, taking in juice or gel or something that could end up so you don't want to be in that situation could

Jennifer Smith, CDE 6:35
be harder. Exactly. Yeah. So it's been in some things like that, it sure it's a little bit safer to potentially be a little higher, if it does end up rising. I mean, obviously, don't go in at a blood sugar of 250, just because you're scared. But if it rises up, you know higher than you'd love it to be again, an hour, hour and a half of being too high, you can correct it after without worrying that things are going to drop too much. And you can't chew anything, then that's okay. So this

Scott Benner 7:02
is so funny, I'm going to ask you, when I say leave it a little higher, I have a number my head, what's your number?

Jennifer Smith, CDE 7:09
It's a little higher would be like 180 ish.

Scott Benner 7:11
Yeah, I might be insane. Actually. It's like, I was like, he could comfortably already 35 ish in there, I don't want to get crazy, that thing starts drifting to 160, I got a fight with it, then, you know, yeah. But the point is, is wherever you feel like you can reap the control. And if you're real stable, that could just mean like dialing your bazel back a little bit to just let your blood sugar kind of come up a little bit, you might not have to add something to make it happen. Okay, so that's simple. Now, moving on to the kind of the next step of it. Wisdom teeth knocked out cold. Now, I do know this from my son, if you get a good doctor, you're only under a very short time. But when you come back, you are not in any shape to make decisions. Drink eat, my kids said some crazy stuff on the way home from that doctor. And then even once his head cleared out, which I have to admit, didn't take too long. He's bleeding is his mouth is packed with gauze and everything. So I guess we're in are we in that situation, now we're better high than low,

Jennifer Smith, CDE 8:18
it would be better than to be again, in that case, you know, if you went into that surgery to be put out and your blood sugar was nice and stable, let's say 120 even, it should for the short amount of time of that type of a procedure, it should remain stable, or it might climb again from the stress on the body. In the aftermath of that, though, again, it would definitely be better to be a little bit higher than you're typically running. And again, I'm not saying like 180 200 high, obviously, you could correct to bring that down safely. But if you're running like 140 leave it I that there is no detriment there whatsoever at 140 you know, as long until you can take something in or start to eat, or, you know, whatever the dentist told you for when you could start to eat again. I mean, even with my wisdom teeth being taken out one at a time, I think there was I think I had to take it out the first time it was a bottom and it was a top wisdom tooth. And I remember a couple of days of like just soft it was you know where the chewing component just was not pleasant. So having a plan of action to just like any other Sick Day kind of thing, having some things ready to go especially if you're an adult and you're taking care of yourself. You know having some soup or some broth or some jello or yogurt or popsicles or an ice cream or whatever it is that you can tolerate. soft enough don't have to chew it that you can get something in. I think

Scott Benner 9:52
that I think that my as I'm thinking about this happening for Arden next year, probably my plan would likely be higher, not so high that it could get away from you higher, but controllable. And then if it tries to move, just kind of keep tamping it back down a little bit like so that you're in the power position, right? It's not out of control high. So that you're, you're going, Oh, geez, I've used a lot of insulin here. And it's not low, just you know what it tries to come up, push it back down, like, play play that game for a little bit. So you've got the level you're looking for, but you're still reasonably in control of what's happening. I put yourself in a power position there, I think I'm having to handle it.

Jennifer Smith, CDE 10:31
That's correct. Considering the fact that, as we've said before, the littler incremental adjustments sooner mean less insulin sitting there to potentially dump you down to low later. And then a setting where you can't actually take anything in, whether it's a mouth surgery, or this might even move into kind of like stomach bugs or those kinds of things where you may not be able to take anything in or not quite sure when you can take anything in it. It's certainly better to nudge little by little rather than take this big walk thing adjustment and then you can't eat anything to offset.

Scott Benner 11:07
Yeah, I think bumping is the nudging is the way to go. That's I so as I'm considering it right now, for the first time talking to you. And when Arden's wisdom teeth come up, I think that's definitely what I'm going to do. I'm going to shoot for 140 in that range, take your advice over my advice, maybe more like 141 50 and then just keep knocking it down. If it if it tries to run away, basically, just kind of keep tripping it as it tries to get up for a minute. Nope, nope.

Jennifer Smith, CDE 11:35
And find out ahead of time what her favorite soft or cold things are. So you can have them ready. Well, yeah,

Scott Benner 11:40
the pre like, you're gonna have to prepare, right? Like you're gonna write, this is not something you're gonna want to think about after the surgery is over, you're gonna want this stuff,

Jennifer Smith, CDE 11:46
let her sit in the like parking lot at the grocery store. Well, you run in and be like, what did you want to get in her mouth is full of gas. And she's like,

Scott Benner 11:55
I can't get her to pick food when she's not sick or injured. Like we were at the grocery store. Grab a couple snacks for lunch, whatever you're looking for. I don't know, you decide. And I said, How about this? She goes, No. And I went, well, how you gonna tell me the side? And then I say something? He told me? No. I was like, What if I grab something that she has? If you show it to me, I'm gonna say no, if you bring it home, I'll eat it. And I went, Oh, that's a reasonable understanding of your psyche. I was like, Okay, great. So I did anesthesia, impact it all.

Jennifer Smith, CDE 12:25
So some people, myself being one of them. Not only do I have experience with surgery, I have experience with anesthesia, not my body doesn't like it. So again, if you're going into something where you've never had any anesthesia whatsoever before, just be aware that it can cause some like, post operative nausea. Many people get a little bit like woozy headed, I myself just don't tolerate it at all. I talked to the anesthesiologist ahead of time I say, you need to load me up with whatever tools you have. Because I will probably throw up on the nurses when you get me awake. And there's only literally been one time that I had a I had a hernia surgery and umbilical hernia. And, man, if I could carry that anesthesiologist around in my pocket, if I ever needed surgery again, and his little toolkit of medications, he used post surgery, I was golden. I didn't feel horrible. I mean, you know, normal, but not like nauseous, whatever. So anaesthesia can cause some nausea. So just be aware of that. If you know that's an issue, again, talk to the doctor about it ahead of time, there are many different kinds of medications they can use to stop that.

And it depends, you know, on post surgery,

sometimes they'll try to get you to nibble or drink a little bit of something in the post op when you're you know, recovering waking up. You can also be really really woozy, like in and out of like waking up and then getting really drowsy again and that it takes for everybody it takes a little bit of time to wear off. Usually in a post op setting. They'll probably have you in recovery for at least an hour. It could be longer than that, depending on how you seem to be doing. So it's I've always brought somebody along who knows how to look at my palm, how to potentially do a finger stick for me even though the nurses there could definitely do that for you. So my mom has come to a couple of my surgeries. My husband was there obviously for both c sections that I had. So it's really really, really advantageous if you've got a go to person to be there after

Scott Benner 14:49
so funny. I alluded to this while we were recording recently, but you I have a question that's on the tip of my tongue and if you would have paused I would have asked what you said. I'm like, one of us doesn't need to be here? I'm afraid it's me. So I was gonna say, Did you were your pump? And yeah, you know, how did you take control of it? What did you do? So, as long as you were coherent, you were doing it?

Jennifer Smith, CDE 15:15
Correct. As long as I was coherent I was doing it's also really an ahead of time for any type of surgery. I mean, again, like a dental kind of thing. The dentist could probably really care last as long as things are okay and controlled when you come in. They may if they know you have diabetes, they're definitely going to ask when you come in, or your sugars, okay? Are they controlled? Are you feeling well, you know, whatever, they're not going to know anything about telling you to do or dial back or dial up or anything

Unknown Speaker 15:45
that's a dentist,

Jennifer Smith, CDE 15:46
medical doctors, though, will be more involved will be more involved. And they it's really important thing to talk ahead of time, right? Because

Scott Benner 15:56
there as a default, gonna just err on the side of I'd rather see your blood sugar be 300 for the next couple of hours, they're always going to feel that way. They don't really want to be managing your blood sugar. I don't. Yeah, I've seen now in multiple people in my life type two type one, you know, all the way down to my my friend Mike, who was in a, you know, in a coma at the end of his life? And they nobody would nobody? Gosh, I don't want to say they care. They didn't care. But it was a problem. They they weren't prioritizing, I guess. Correct. You know, it was

Jennifer Smith, CDE 16:29
a secondary issue.

Scott Benner 16:31
Yeah, really, it's the think of it that way.

Jennifer Smith, CDE 16:34
Yeah. And they're they're concerned. I mean, from the medical standpoint, in fact, if you don't address the fact of staying on your pump, and keeping your CGM on and whatnot, as long as you can keep them on, there are some medical procedures that include machines in the operating room that could potentially require you to be off of your products, just from a machine. I guess, interference standpoint, there may definitely be some things, there may also be length time of a procedure or a surgical procedure that determines you need to be on an insulin drip versus being left on your pump. So you know, those kinds of things, there is a definite difference. But for shorter lived surgeries. If you go in with your team, and you talk to them, and you say hey, you know, you know that I'm on an insulin pump. If you've got backing of your endo, you can have your endo write a letter of approval for you to remain on your pump and your continuous monitor through the surgical procedure. Your doctor may even include in it, you know, glucose levels, we've, we've discussed, she or he will come in with a glucose level here to here, she or he will have a temporary bazel adjustments set. Many doctors are a lot more conservative than you need to be for surgery. Many doctors will say dial the bazel back by 50% just

Scott Benner 17:59
seems like a lot,

Jennifer Smith, CDE 18:00
again, which is a lot. And for most people again, there are the rare people who have a drop in blood sugar from that stress impact and whatnot. But if it's not common, it's more common for stress to cause a rise in blood sugar. So, you know, dialing bazel back, kind of goes back to some of our other episodes about like testing things, or going into surgery. First thing, they will usually have somebody with diabetes on insulin, have surgery first thing in the morning, they will not push it into the later afternoon or the evening mainly because they'll want you to come in in a fasting state. And it's easiest to get that in the morning for somebody with diabetes. They're in lies, do you know that your maysles are doing what they're supposed to do? If you've got time?

Scott Benner 18:51
Well, yes. Can you imagine to you're gonna need to be fasting for a procedure at 8am and you wake up and your blood sugar's 45 what are you gonna do? You know, you're gonna have to do something and now you have to show up at the hospital and say, I drank juice this morning, and then they're going to boot you back out again and you have to reschedule. So, alright, that makes sense to Yes, I'm so conversations ahead of time with doctors. I'd like to control my own insulin pump. I can do it when I'm on. You know, when I'm not capable. I've got a person here to help me. Here's a letter from my endocrinologist outlining you know, some of my goals for my blood sugar's that they'd like me to be able to stay on my devices. If I'm MDI, I don't want to be on a, you know, on an insulin drip, I want to I want to inject my slow acting, you know, the way I always do, and probably having a little bit of, I don't know charting the word or records to be able to show the doctor like, Look, here's what I do. Normally, I feel confident I can come in and accomplish this correct, yes, correctly important

Jennifer Smith, CDE 19:51
because it eases

their ability to also chart and say, you know, this is the plan of action. This is where You know, this patient's glucose levels, they're controlled, the insulin doses are here, the glucose levels are usually here. This is where they came in the morning of the surgery, even showing them. I mean, every surgery I've gone into they've all the nurses have been fascinated with the continuous monitor. They've been fascinated with it

Scott Benner 20:20
that happened to Arden when she went into the emergency room for that belly pink. And you and I talked that day, actually. Yeah. And the other nurse who was way in charge, super confident and, and competent. And she, when she saw that thing, she's like, this is amazing. And, and I was like, Yeah, right. And she's like, Alright, well, you know, what do you want to do? And I was like, I, you know, I, it was that moment when I said, Listen, I'm not trying to be like, I'm not, you know, I'm not blowing a horn here or anything like that. I'm like, but my daughter is a once he is incredibly stable. On the lower side, her blood sugars. And I showed her like, this is her blood sugar for the last 24 hours. I'm like, I am completely confident that I can keep her blood sugar here. And if I can't, could we just do like she's got an IV and right, you could you could hit her with, you know, yeah, with glucose dextrose. Right. And so that actually happened, we were there for so long that they did have to run dextrose. And it was really interesting to watch, because it took forever to hit, and then it jacked her up. But if you gave her any insulin at all, it went right away in two seconds is very, very interesting to watch how it works. But when going into that scenario, right away, I mean, after we were settled, like I didn't run in the door yelling, she has type one diabetes, and we're gonna take care of it. Like, you know, after we were settled, you know, we were there for a little while. I'm like, Hey, listen, here's the situation, we'd love to stay like this. And that, to be honest, she seemed thrilled to let us do it. It almost felt like, well, then I won't have to do this. So perfect. You know, it was a little bit of that. And okay, that's actually

Jennifer Smith, CDE 21:50
for the most part, what I've actually what I've experienced, there's almost like you, you can't physically see it, but you can see it because with diabetes, we become very intuitive to other people's like, what you can see them thinking you can like hear their gears going right. And every time I've come in for a surgery, I can almost like, see the nurse like go

like their shoulders like relieved.

They're like somebody has control of this. And we don't have to worry about I mean, they will, they will ask where your glucose is, if you do a finger stick or look at your CGM. report it to them make sure that they know and are aware of where things are going. If you did it all make an adjustment to your insulin doses or take anything, make sure to note it to them so that they can chart it. Because it becomes part of the medical record then. But yeah, I mean, my, the, my first child when he was born, we knew it was going to be a C section. And so we we came in planned everything. And the nurse anesthetist who was there during the C section. She actually at that point in time, I had the receiver yet for my deck. Right, I was still using it. And I she was holding it because my husband was like, you know, with me, obviously. And she was amazed by it. She kept like, she's like you changed again. He's like 81 now like, yeah, it'll give you a new number every five minutes, right? But she was like, she was so just enjoying watching. She's like, this is a really steady line. And I was like, yeah, that's what happens when your insulin is dialed in the right way.

Unknown Speaker 23:38
So,

Scott Benner 23:38
you know, to your point, I'm recalling a conversation I had with a nurse in a in a hospital setting. And we talked about this. And she told me that one of the things she dreads the most is running up on somebody who really, you know, doesn't have a firm idea of what they're doing. And she's like, but but it's, they feel like it's working for them. Yeah. And then you feel like you're in the position of explaining to them like, Oh, this isn't Okay, this should be more like this or more like that. She's like, and that's not my job. And you know, and they don't take it well, and they're already under stress over a lot of other things. Right. And now you're you are in the corner of the room going, oh, by the way, you don't do a very good job of taking care of your diabetes. Here's what you should be doing. She's like, it's not the right time.

Jennifer Smith, CDE 24:22
No, it's not at all. In fact, I when we went in for my second son's birth, you know, management had already been established endocrine and my MFM team and already written Jenny will manage, if she's unable her husband is here, he can help her manage, she will remain on her pump, etc, etc. and the nurses were really really surprised by that because they had had a woman the week prior, come in on a pump. And they thought she knew just like, you know what everything I was saying. They said okay, we need you to dial back You know your rates by this much blah, blah, blah, cuz she didn't come in with a plan of action herself. And this woman unfortunately literally didn't even know how to button push on her pump. So I don't I don't know the whole story other than the fact that the nurses and the doctors were like, well, we you can't safely we cannot allow you to stay on your pump. And so she was so excited. She's like, so glad you know what you're doing. Like, this was the scenario we had.

Scott Benner 25:24
I hope hopefully that'll This will give the confidence to other people to make these kind of like pre planning decisions too. Right? Um, okay, so let's, you know, injury. And I only have one example. But Arden got hit really hard in the kneecap with a softball bat in softball once and her blood sugar began to rise almost immediately after the pain hitter, and stayed up for the better part of 18 or 24 hours, she needed a lot more insulin. Now, I you know, I don't think there's a lot to say to this other than there was an impact coming from her body that required more insulin, I gave her more insulin. But that's is that is that a hard and fast rule that pain? Put your blood sugar up in constant pain can hold it up? Or is it that's person the person I would imagine to?

Jennifer Smith, CDE 26:11
For the most part? Yes. I mean, as as kind of just a blanket statement. Yeah, if, if you're in pain, and it's considerable pain, blood sugar's will be higher. If the pain ebbs and flows, you may find a little bit of kind of a drop down as things feel much better. And if it starts up again, maybe between pain medication or whatnot, it may start to escalate again. So So yes, pain, pain is a horrible thing. You know. And that's actually one of the things that I in having had two births. The management of P and post delivery was, most women's insulin needs fall dramatically, after they deliver child and placenta and everything, and all those pregnancy hormones are gone. But after a surgical delivery, like a C section, or a more traumatic delivery, potentially, you may actually see that the stress of that, and the pain that you're in, could leave those glucose levels higher requiring more insulin despite the pregnancy hormones being gone. So that's kind of a similar example or swapping the hormones for the pain.

Scott Benner 27:25
Right, right. And I did see with Arden's knee that when pain issues only taking Advil, but when it worked for she needed less insulin, and then at the end of that Advil if I if I didn't overlap it correctly, then she'd start to go up again. Okay, well, I just wanted to hit that but now we're gonna we're gonna jump into the like the illnesses you know,

Jennifer Smith, CDE 27:45
yet one, can I can I make a comment on one thing, of course, prior to illnesses, since we've been talking about, like, planning for surgery, and all of those kinds of things, if you do have a plan of action, and you know, you'll be going into the hospital. The other things to definitively know is your length of stay.

Or that

okay, because you do have to plan ahead for how much may you need to bring along as far as supplies, right, especially if you're on a pump. If you're on a CGM, you want to make sure that you have enough that you don't have to either send somebody home, the hospital will not have anything to help you out with your pump

Unknown Speaker 28:23
supplies,

Scott Benner 28:24
they're not going to offer you an omni pod, if you know,

Jennifer Smith, CDE 28:26
they're not going to

they you know, I mean, certainly they've got glucose glucometers in the hospital, they've obviously got insulin, if you're really stuck on your type of rapid acting insulin, or another example, and you've got something planned coming up, make sure to bring your insulin to the hospital with you, you may have to give it to the nursing staff, they may have to hold it in in the medical area with your name and label on it. But otherwise, you're kind of going to be at liberty of whatever's on formulary at the hospital and it could be the kind of rapid insulin either you've never used. Or maybe it does doesn't work as well for you.

Scott Benner 29:02
So you ever. Have you ever had an experience yourself or spoken with somebody who's had the experience where they go into the hospital, the hospital wants to leave their blood sugar higher. The people say I don't want that. But the hospital resists. And then the person sort of Mission Impossible style gets insulin to themselves, because I've heard that from a lot of people. Like um, I had, I had to hide my pin from the nurse like that kind of stuff.

Jennifer Smith, CDE 29:29
Correct. Now that in fact, I'm sure she wouldn't mind me answering it because ginger who I wrote my book on type one with Yeah, you know, she is She is an MDI. She takes multiple daily injections. She doesn't use an insulin pump. And her first delivery. That's what she had to do because the nurses were like, We don't want you I don't know where they told her to take her insulin dose down or up by so much that ginger was like, that's gonna kill me. She's like, you can't Do that. And so yeah, she had her like insulin pens in her room with her. And when the nurses weren't in the room, she just dosed herself. Now, am I advocating for that as a healthcare professional? No, I'm advocating that you talk to somebody. But you know, what if in the case of the question that you asked if they're just leaving it, like, so much higher, detrimentally higher than would be healthy for healing. I would advocate for bringing in like, a patient advocate asking the hospital to bring somebody into the room to talk with because there has to be a safe work around that. You're being safe. And the hospital staff knows what you're doing, but that you're doing what you know is better for you.

Scott Benner 30:48
You know how this always happens. It happens in so many different walks of life in and around diabetes and separate the two, especially at school, by the way, with, like how people take care of their children at school. There's this idea institutionally, this is how we do it. And when you come in and say, hey, that's really cool. I'm glad that works for people. I would like to do it like this. No, no, no, this is how we do it. But no one remembers why this is how we do it. Right. Like and it really is. It's the meatloaf story. You know, it's it's that if I ever told you the meatloaf story. I'll do an abridged version of it. Mother and a young girl it's a pot roast actually mother and a young girl and making a pot roast. Mother gets out the pan cuts the ends off the pot roast, puts it in the pan sticks it in the oven. The daughter says Why did you cut the ends off the pot roast? mom thinks for a second says I'm not really sure that's how my mom made pot roast. So they find the grandmother asked her grandmother says I don't know. You're gonna have to you know next time you're at the old age home, find my mom and ask her why. So they visit the old age home they find the mom she's 100 years old, all curled up in a ball. Great Mom, do you remember why we cut the ends off the pot roasts? You know, when we make them? And the old lady thinks and thinks and she goes? Oh, yeah, I had a really short pan. Right? Yeah, you know? Exactly. So. So you don't know why the hospital saying what they're saying? You don't know why the school is saying what they're saying. And sometimes you just have to be reasonable, like you said, and talk and say, I get this is what you normally do. But hey, this is what we do. And look how well it works. Couldn't we? Couldn't we find a middle ground here? Correct. The problem is sometimes that communication breaks down because of I mean, I know on my end, when it would break down for me in the past, it's always emotion, like, you know, you're very emotional and you feel like, oh, you're gonna, you're gonna ruin my kid's life or something like that, or you know, you're gonna hurt somebody and you feel and then you start wrong. And then before you know it, you're arguing. And so you have to really, you got to come at it from a real calm place. But But yeah, I'm not advocating anybody doing that either. I'm just saying that the number of people I know who have done that is more than I can count on my fingers.

Jennifer Smith, CDE 32:56
Something that kind of goes along with that, too, would be sort of an emergent type of setting where you come to the hospital unplanned, like an emergency room, right? a really important thing is that you if you can, if you're awake with it, or somebody who's with you can advocate for you. It's not allowed for them to want to disconnect a pump. Do not let them disconnect your pump. Say that like more forcefully or whatnot. I mean, if you are with it enough, do not let them take your pump, right? Because it they don't they don't know. I mean, emergency department personnel. They're they're great clinicians, but they see a host of things like trauma problems, issues, whatnot, they are not schooled in insulin pump management, they're not. So that's a really, really important one.

Scott Benner 33:55
And these are emergencies that aren't the top end of the emergency like if you're really injured. You know what these people try to keep you alive. You stop thinking about you're in some pop now, but like that, that kind of stuff, right? But yeah, in moments where you're Cognizant, it's, it's a weird thing. Like why would you give over the control of your insulin pump to somebody just because you broke your toe when you're in the emergency room now? Correct. This doesn't make it exactly

Jennifer Smith, CDE 34:17
okay.

That's also the benefit of having a

Scott Benner 34:22
medical ID. Oh, look at Tony is wearing her bracelet, don't you? Oh,

Jennifer Smith, CDE 34:25
it's always on. I think actually, I glued it closed. Because I've lost it. It comes from American medical ID by the way. It's they do a great job. But my class had come like it unsnapped twice already and I've had to reorder the same bracelet. So now it's glued closed. Like they would literally have to cut it off of me to get it off. I was

Scott Benner 34:48
gonna joke that Jenny is making side money, the mentioning America medical bracelets on the podcast, and then she said it broke twice and I thought well, that's probably not what they want people to hear.

Jennifer Smith, CDE 34:59
I'm quite sure sure that it was, you know, my fault of patching it, whatever. But, yeah, it's so actually, it's funny because when I went into the hospital the last time where my kidney stone was not fun

it was a whole bunch of extra visits and whatnot

after, but I told them I was like you, they wanted like all jewelry and like everything removed, and I was like, well, you're gonna have to cut it off then because it's glued together and the doctor was like, Okay, well, we'll just put them whatever it's called, like, Cole ban, or Kay ban or whatever around it, and he's like, you're fine. We'll be fine.

Scott Benner 35:35
Oh, there you go. There's Jenny's had diabetes for 30 years, and she's wearing her bracelet now. Don't you all feel bad for not wearing your I don't even think Arden has one. So I'm feeling particularly bad in the moment. Oh, I'm sorry. You know, it's funny. It's when she gets older. Like, then I think of it like right now she's with somebody constantly. Who knows she has diabetes. It's you know, but it's those other moments. I guess it's the ones you can't plan for, you know,

Jennifer Smith, CDE 36:04
I've got a lot of friends who've gotten tattoos, actually, you know, type one wrist tattoos. I've actually got a good friend in Michigan, who she even talked to some EMTs. And she asked specifically about her design so that she could know from a medical perspective, would this be visible enough? Would this be recognized as a medical ID and whatnot. So there are some beautiful designs that are out there? I just have never one day go that route. I have a tattoo but I just don't have a tattoo on my wrist.

Scott Benner 36:40
Are we sharing where your tattoo is? Or? No,

Unknown Speaker 36:42
it's on my leg. Okay.

Scott Benner 36:44
I have a couple of tattoos. I have one of the top of the crack of might now. I'm just kidding. It's on my shoulder and one of my shoulder one. Well, mine aren't that cool, though. Maybe they are. I don't know. I've had them for so long. That sometimes I look in the mirror and I see it and it startles me. The one of my shoulder happens with him sometimes, like what is on me? And then I realize that 25 years ago I got I've had to and i don't i don't see it because it's behind me. Anyway, okay, so. So let's start with the easiest version of a sick day, right? Like a cold. sniffles a cough like something that doesn't you know morph into something worse, just something that is you're under the weather. How does that does that always present with your blood sugar the same way, like for you personally. All the ads are going to be right here. First up Dexcom, the G six continuous glucose monitor you need it. You want it? You're feeling it with me right now. You've been listening to the podcast for a while you're hearing people making these adjustments to their blood sugar's using the information they're getting back from their Dexcom, you're thinking that's the next level, I want to be at it. And that's just one reason you might want the Dexcom JSX. You also might be looking to be able to watch your child's blood sugar while they're at school or at a friend's house asleep over. Maybe you want to help your sister out he lives halfway across the world. These are all ways Dexcom can help you. But at its core, the Dexcom g six is a beautiful way to see the speed and direction that your blood sugar is moving. You'll be able to see this, of course, as the user on a receiver or on your phone, iOS, or Android. And as a loved one. If the user should give you access, you can also see their blood sugar on an Android or iPhone. What do you do with that information? Of course, in our experience, we use the Dexcom information not just for safety and peace of mind. But for dosing decisions, seeing blood sugars move, deciding how to attack them with insulin or how to maybe take some insulin away when needed. This is where the Dexcom is, in my opinion, exactly what you need. Go to dexcom.com Ford slash juice box to find out more. When you do you'll get yourself some peace of mind. And the ability to look at information about your blood sugar that makes real and lasting changes. improvements, your health and welfare.

The holidays are coming and you deserve a gift. Something it's warm and meaningful, something that will add to your life not take away something that you can get for free. What That's right. You can get a free absolutely with no obligation demonstration on the pod sent right to your house so that you can try it on where it decide if it's something you might like to have in your life. That's right You can get a free no obligation demo of the Omni pod to boost insulin pump sent directly to your house itself. swim with it. I mean, if you're in a warm weather place, you can bathe in it. You can frolic with it, you can play sports with it on. So why not get the demo and do all those things do those life things wearing this demo so you can understand what it would be like if you were using the Omni pod tubeless insulin pump like my daughter has been for 11 years. Every day for 11 years, Arden has been wearing an omni pod. And the addition to her health is immeasurable. The ability to manipulate insulin in forms of temporary bazel rates, extended boluses the ability to keep her insulin going while she's involved in activity in the shower. All times when people with tube pumps have to disconnect doesn't exist with Omni pod. You got to give it a try. Like I said, they're not going to charge anything to get the demo. You don't have to commit to anything. So you might as well give it a whirl, right? Give yourself a little present here at the holidays. Miami pod.com forward slash juicebox. Get that demo sent to your house. It's fun to open up something you didn't pay for. Last thing check out dancing for diabetes today at dancing the number four diabetes.com whip out your little phone there check them out on Facebook, and Instagram. They're on all the Grammy facie things, dancing for diabetes, dancing the number four diabetes.com does that always present with your blood sugar the same way? ache for you personally.

Jennifer Smith, CDE 41:34
For me personally it does. I've found that just the typical sniffles. I'm not really feeling bad. I'm just feeling kind of like stuffed up or something. Typically, I don't see any change in my blood sugars whatsoever. I don't see any change in my insulin needs whatsoever. It's not really until I start feeling sick, where I might feel a little more fatigued, tired kind of rundown, like I could go to bed like at 8pm instead of 1030 you know kind of thing that I like a good thing for me to know that I really don't feel good is that I just don't want to work out because I typically do something every single day for a workout. And if I really would rather like skip the gym, feel like I know that I'm really not feeling great. But blood sugar wise, I've already I already know that I'm not doing great because I'll see an incremental creep use me I usually need about 20 25% more insulin with something that's got me kind of just not feeling the best at all right

Scott Benner 42:38
so with Arden when she has the regular just sick day sickness she needs her blood sugar's are so easy to control those days. I don't like it and not not like I'm coughing and my chest hurts or there's, you know, she's not flying out of my nose or something like that, right? She's a little under the weather. Her blood sugar's easier. Now maybe if I really delve into that maybe she doesn't eat as much during those days. But like there could be another reason that I'm wrong about. But I have heard people say, you know both ways, like I need more, I need less. And so for this right? hydration really is got to be step one in probably all of these right? You have to stay hydrated. Keep food in you. Yeah, as best you can. So you don't get into one of those deficits where you've got a bunch of insulin going and there's nothing inside of you and you drop quickly. It is kind of morphing that from just a regular sick day to a slightly more sick day where you're under the weather maybe have a bit of a fever is the biggest fear. What if I need to eat and I can't or what if I get sick to my stomach and my stomach empties like what do you think of the biggest fear around being sick as being

Jennifer Smith, CDE 43:49
I would say it's more the it's not like the congestion, the nasal the bronchitis, the ear infection, that's usually not it's more the bugs that hit the digestive system that are the fear for most people. High blood sugars. Most people will realize that they need more insulin, whether they're just throwing insulin and correcting because they're staying high or they actually intuitively are like huh, I need to bump my basil up I'll use a Temp Basal here because I obviously I'm just running across the board high. That's not so much the worry it's more the Gosh, I really don't feel very good things could be coming out one or both ends and nothing really seems to be sitting well or you have consistent enough nausia that you can't really do more than a sip every hour. Yeah, those are more of the bugs that worry people. So I mean there are there are some kind of hard and fast rules. You know if your blood sugar is on the lower and declining or dropping and you can catch it ahead of get being to low you can if you're using an insulin pump set at Temp Basal decrease about 80%, or about two hours, okay, so if you're really nauseous to the point that you can't take anything into stop that drop off, you can decrease bazel enough again, before you actually are too low, to stop the drop and sort of curve you off until you could get a little bit of something. Usually extreme nausea doesn't last like nine hours at a pop, it kind of ebbs and flows through a stomach bug. So, you know, at some point, you could get in something even in the case of honey, you put put honey in the gum and sort of just massage it in, you don't even have to swallow it, but some of it does start to get absorbed in you know, through the mouth,

Scott Benner 45:49
right. So it's funny, so you just described exactly how I help Arden sleep in really long. So on a on a Saturday, if she you know, she goes to bed late, and or she's been really exhausted all week or something like that, this this out is going to be one of those like, she's got a lot going on this week. And I know she's going to sleep in, there's a moment, like in the in the beginning of the day, the six o'clock 789 o'clock hour, it's like a 50% decrease in her insulin. And that keeps her at 90, right. But if she starts power sleeping into that 10 o'clock, 11 o'clock, 12 o'clock, I sometimes have to go down to like an 80% decrease, just because everything in her body that could possibly keep her blood sugar up is gone. Now it's just, it's really gone. She's been asleep for 12 hours, you know, 10 hours, it's really gone. So I've learned that I can't take all the insulin away. Because if I do that, she's gonna jump up or be really high two hours after she wakes up or something like that. So you have to leave summon, but almost not enough for it to impact the moment at all just for to help overall. And right and then from there. It's great. I mean, the idea of the honey in the cheek, something that doesn't make it to your stomach, because the the lining your mouth is really absorbent for things It is so your cheeks under your tongue, right? Yeah. Yep. That kind of stuff. So you can get sugar in there without actually swallowing? I'll tell you, I'll tell you two in a panic situation, if you don't have anything, even table sugar, you know, you can dissolve sort of in the saliva of your mouth and leave it there. Yep, yep, there's a lot of ways, but you're going to have to get creative unless you're planning to head right, and you have sports drinks that you can take these kind of micro steps off of throughout the day, you know, yeah. But all we're talking about here is, is maintaining that balance with the extra variable of your stomach, maybe being sour or incapable of holding the fight, right? When it

Jennifer Smith, CDE 47:53
comes to also prepping similar to other illnesses and whatnot, kind of, you know, like the discussion about mouth surgery, just prepping and making sure you've got some things on the shelf in your house, kind of, if it's popsicles that you always keep in the back of the freezer that have a sticker on that, say, don't touch Unless, you know, sick days, six days stash or whatever it is, there's actually a really good electrolyte. It's not pre mixed, it comes in like one of those little two, not tubes, but like packets, kind of like Crystal Light, almost. It's called drip drop. That one works really nice. I think each packet, if you consume the whole thing, it's only about like nine or 10 grams of carb. But the nice thing is that it's got the electrical light component to it to for replacing what might be coming out.

Scott Benner 48:40
Yeah, um, so just some options. It's very dense with what you need to and I know about it for a completely different reason. But when Cole was recruiting for college, he got stuck at this three day event in August. And it was like 115 degrees. And he was playing baseball for three days in a row trying to you know, it's like, look at me, someone take me on their damn team. But he was downing Pedialyte throughout the day to stay in that. So yeah, it is really impactful.

Jennifer Smith, CDE 49:11
The other component to stomach bugs and adjustments would be if you are able to take in a little bit usually because of stomach bug means that you're not absorbing well. digestive leave, we really expect that you're probably absorbing only about 50, maybe 60% of the carb amount that you might be taking in one don't Bolus until you know that it's going to stay down. So in this circumstance, you're not doing Pre-Bolus thing at all. You take the food in you make sure it's gonna sit there it's gonna stay you Bolus only for about 50% of what you actually consume. This

Scott Benner 49:45
is survival situation, right?

Jennifer Smith, CDE 49:46
It's a survival and again, if you see it coming up, sure that's where that like little bump nudge, kind of with a little bit more, maybe a little bit more whatnot, but be conservative to begin with because stomach bugs don't last long. There. Not like the common cold five to seven days, maybe even 10 days, usually stomach bugs are gone within about a 72 hour time period, you may still have decreased absorption for days after you're feeling better. So don't don't think it's odd that you might be dropping a little bit low when you're back to eating what you consider normal food after meals, it might just be that your digestion is just not up to par yet. So

Scott Benner 50:26
if you're a person or a parent of someone who is prone to stomach issues, is having a prescription on hand for so friend or something like that. Is that a good idea? Like an anti ship medication? Yep. Yep, we'll talk about that.

Jennifer Smith, CDE 50:41
There's another one that's over the counter. It's called Emma trawl, m e, m, e, tr, O L, I think it comes in a little white bottle, it's got a rainbow on it. That was something that the my second. My second wisdom tooth extraction, the dentist actually recommended for me, okay, um, for nausea. So and it seemed to work really well. So

Scott Benner 51:06
so and if I'm on MDI, and I have this illness coming up. How do I cut back my, my slow acting insulin? Is it a percentage do you think? Or where do I start to,

Unknown Speaker 51:17
you know,

Jennifer Smith, CDE 51:18
it again, in the circumstance that you wake up in the morning throwing up, or, you know, just not feeling the greatest and you're taking your basal dose in the morning, you can adjust it absolutely. And you could take it back by 10 20% as a starter. If it's really considerable nausea, and you're not really sure that you're going to take anything in, you may cut it back even a little bit more than that, and then just cover with boluses of your rapid insulin, if you are riding higher through the course of the rest of the day, but don't take an additional dose of your long acting insulin from what you missed. From the initial dose to make. Don't just wait, the next time you need,

Scott Benner 52:01
you know, so, you know, when you're talking about taking care of kids. I mean, anybody who's a parent who's had a child is sick, you realize, you know, for sure, like everything in your life stops, right? You know, it work doesn't matter. You know, the television show you really want to watch tonight disappears out of your life, you know, the weather doesn't, you're, you're keeping your kid alive. But But what if I'm an adult, and I'm alone, right? I'm living by myself and I have type one diabetes. I'm sick, and I'm exhausted. And I know I am going to fall asleep and stay asleep. Like, what? What do I do before I fall asleep because that kind of illness you see people sometimes 10 hours there, they're out like a light, right? And it's the kind of illness in the in the stress on your body. You might not wake up if you have a problem. And you don't want to be in that scenario. You don't even want to wake up with an extremely low blood sugar. Like imagine having a 40 on top of a stomach virus. Right? It's got to be horrible. I'm guessing. So do you ever? I mean, how long you been married? You ever live alone? Like what would you do in that scenario? Would you

Jennifer Smith, CDE 53:06
I've personally never lived alone. I either I went from my parents to having college roommates, to having off campus college roommate. To then I think I lived alone for about a month between my college roommates moving out graduating and then getting married to my husband,

Scott Benner 53:25
your husband should take a lot of comfort in the fact that your face did not go Oh, geez, I do have to get divorced. Isn't that what's that saying? No, no. Jenny has to fly.

Jennifer Smith, CDE 53:38
I've done but I've traveled alone. Right? You know, so in that circumstance, too. There are always like safety pieces, you know, and I, when I travel alone, I actually set my CGM alert for a little bit higher. I'm over in the overnight time period. Just because I want to know sooner than if my husband was sleeping next to me cuz he's usually the one that hears it before I do.

Scott Benner 54:03
I got hit the shoulder last night. Don't you hear that? And I'm like, No, because I'm sleeping. Like Yeah, beeping I was like, Alright,

Jennifer Smith, CDE 54:11
but for those living alone, I think some some strategies again, this would be a staying safe, by being potentially a little bit higher is actually better. So if you know that you are just like done and you are out and you are going to go to bed and you may not be up for the next 1012 hours. Just set a Temp Basal decrease. Or again, if you're going to bed at night, and you know that wake up in the morning at six o'clock is probably not going to be until 10 o'clock because how horrible you feel. Maybe you take your basal insulin injection dose down a little bit. You know, I mean, there's safety things. Yeah, you may wake up higher than you want to be. But it's in this scenario of being alone. That would be the safer case. I'm not advocating obviously for waking up at 200 or 300. or whatever. But yeah, you wake up at 180 instead of waking up at 100. You know what, at least to see?

Scott Benner 55:08
Well, I mean, the idea is to get through this unconscious time period and back attack the conscious safely. Correct. That's what you're shooting for.

Jennifer Smith, CDE 55:16
The other component too could be, you know, setting alarms on your phone, or setting an alarm clock in that time period, just to wait. I mean, as much as you want to sleep and need the rest, because you don't feel good. If you really are worried because you already took your basal insulin, and you can't adjust it now. Or you're getting to that point of just needing to lay down and you just had a meal, and you're not quite sure what that bolus is going to do for you. set an alarm.

Scott Benner 55:43
Right. Yeah, I mean, everybody should have an old $8 windup alarm clock back and pull out of a drawer and set across the room so that you can just reach over and touch snooze on your phone. Yeah. And, and, and get out of it that quickly. Okay. Well, that's, that's really, I think we're finding a lot of good ideas here. Um, so real quick medications around illness, cough medicine, you know, they make some without sugar, I guess. Or I could Bolus for like

Jennifer Smith, CDE 56:10
they do. It's called diabetic tostan. diabetic testing.

Scott Benner 56:14
That's what it's called. We really just called it diet testing. But all right, I mean, I'm not a PR department over there.

Jennifer Smith, CDE 56:21
It's cough syrup that doesn't have any sugar added to it whatsoever does the same job but doesn't have any, you know, glucose raising component to it.

Scott Benner 56:31
Chris Rock in his stand up, it was like, rub some tussen on it was that my mom used to say Robson? Was that

Jennifer Smith, CDE 56:37
Who? I don't remember figure

Scott Benner 56:38
out? I'll figure that out. Okay, so diabetic tossin was, what about is there? I mean, steroids. steroids are going to push my blood sugar up the entire time they're in the body, right?

Unknown Speaker 56:53
Correct.

Jennifer Smith, CDE 56:54
Yes. And the increase can be considerable, depending on the dose. So injected, injected steroids, like a cortisone injection into a joint or something like that, those will cause considerable increase in blood sugar, definitely within the 12 hours after, you're going to need an increase at least 50%. Many times people see 100% increase. And then that that increase will last for a couple of days until the dose from an injection sort of starts to dissipate. I mean, the impact of it stays within the body, but the impact of the actual it's called, you know, cortisone, or whatever else has been injected on what other kind of prednisone or whatever it might be, it's going to dissipate enough that you're going to see the need for that increase in in bazel dose come back down. I, you know, it's it's not odd to see 100% more 150% more bazel dose, especially many people who are also paying close enough attention will often also need an adjustment down in their insulin to carb ratios, the correction factors. A, as far as oral steroids, depending on the dose, and again, on a potential hard stop or a taper of the dose. Most often, those are people who have like a Bronxville illness, and they have like a background like asthma or some other type of lung condition that the doctor really wants to attack the illness to prevent pneumonia or something else, you know, progressing. Those types will usually again, increase the need significantly, and the insulin to carb and the sensitivity factor will need to be adjusted.

Scott Benner 58:48
Okay. And I guess how to medications that may have a side effect of nausea, you should be careful about if they want you to take them with food, give yourself a chance to not show up, you know, make yourself nauseous when you when you might need to hold something down. And what I double back a second to the idea of an alone adult or even a kid whose parents, you know, might feel like it's slipping away, like, when do I it's so funny to ask this question, because we spent some time talking about the fact that hospitals don't seem to particularly you know, value, like your blood sugar that much but the winds the moment when you wave the white flag and go to the hospital, like like when am I like, you know, not that you should be running every time you're sick. And by the way, I feel terrible because some people get sick more frequently than others. I can. I can count on two hands. The Times both of my children have been ill. Arden doesn't get sick much at all. Which by the way, too, for those of you who do, what a horrible joke that is from nature, right? Your immune system was strong enough to beat the crap out of your pancreas. But it can't make bronchitis go away. You're like, Whoa, come on, man. But, but so when do I like what's the Mendoza Line four when I think I better get the professional help. And why do I want to do that? Like, what is it I'm avoiding,

Jennifer Smith, CDE 1:00:06
that kind of comes in. And I know we had a whole discussion, an episode all about ketones and how to look at that and whatnot. But that kind of brings that into the picture as far as blood sugars and or hydration. And if you are ill, and you're really not feeling good check ketones, you know, because in the case of moderate to high ketones, those often especially if you are not feeling well, and you can't get enough hydration and fluids in, you may very well need to go to the emergency room. In that case, it's just your blood sugar's may not look like high enough to say, Gosh, I this is really bad, I have to go on both, you know, to the emergency room or the hospital. But if your ketones are at that moderate to high level, you definitely need some help clearing those or you're going to be in trouble.

Scott Benner 1:01:03
And IV would help with that, right as

Jennifer Smith, CDE 1:01:04
an IV would help with that. Because they're not going to make you down a whole bucket of water via your mouth. They're going to put an IV in and they're going to push it in through your vein. Because if

Scott Benner 1:01:16
you could, you would, too. And and I know I know that because and I think I've told this here before but Arden woke up one time with should have bent Canyon one bent Canyon, like 14 years is amazing. But she was pretty. She woke up with a higher blood sugar. She was nauseous. I tested her ketones, they were high. And I said to her, I'm like, Look, here's your options. Now she wasn't sick, like you know, I mean, shouldn't have a stomach virus. I said, You pound this water down. I crush you with insulin. And you promise me that you can eat something to stop the fall. Right? Like and or we're going to the hospital. And and she's like, uh, she took a bottle of water for me and Arden is I've mentioned this here before she's a princess slipper. When she drinks water. It's like a little bit a little bit. She took that bottle of water. And she pounded it all down. And she was like, Is that good? And I went, yeah, you can sip it. The next one, you know, and we got like three bottles of water in or over two hours, we made a big bolus. she, her blood sugar broke, and her ketones began to fall. And we caught it with a little bit of we caught it something and that was it. It took us three hours to not go to the hospital. But she was willing to do it. And it was hard. She told me later that drinking that water was incredibly difficult because of the pain she had from the elevated ketones. Yeah, she was she felt very nauseous from it. Obviously, she wasn't sick. But yeah, at some point, there's gonna be a safety issue, please don't get to the point where you're calling an ambulance, you know what I mean? Like, like, you might have to give up at some point,

Jennifer Smith, CDE 1:02:54
right, you're doing this kind of, it kind of brings into it. A component of like nausea in pregnancy can be a very considerable thing for some women, especially in early pregnancy. So if you have significant enough nausea, and you're not literally able to take things in, or you've gotten to the point of actually vomiting, because of the significant nausea, it's always better to try to go and get at least IV hydration so that you don't run into an issue of ketones even though blood sugar levels may not be elevated in that circumstance. You could develop ketones mainly because you're just not keeping anything in. And that's very, very, very bad in pregnancy.

Scott Benner 1:03:46
Can I ask you a question? And I don't usually put you on the spot for this because it's a massive question about how to do the podcast. When I put this episode out, I was thinking to put the ketone, defining ketones right with it, you see them as these are companions to each other. Okay,

Jennifer Smith, CDE 1:04:00
absolutely. That's a great idea. I will definitely do that, then.

Scott Benner 1:04:04
This is usually the time where I say is there anything I didn't say that I should have said?

Jennifer Smith, CDE 1:04:08
The only thing I would say is for all of this, the biggest thing comes from like my years with Girl Scout, be prepared, right yet to be prepared. And one of the best things I can recommend doing is having you never know when you're going to have to run out the door to like an emergency, like situation, right? Or even in the case of I know this isn't illness specific, but this is like just being prepared like you have to run out of the house because I don't know your stove is on fire. Right? I mean, if you have a diabetes, emergency bag packed, get a backpack, a red backpack, cheap, go to Target or wherever get one put in it. All of the things you could potentially have to take with you quickly out of the house. Hmm, it'll be a lot easier in a an illness emergency especially, especially somebody has to take you out of the house, right? If you got stuff pack to go at least you know you've got, you know, a set change and extra test strips and batteries and whatever they're all in.

Scott Benner 1:05:17
So Jumanji situation when giant vines and lions are going through your living room and you really need to get out, you want to be able to grab this bag. Correct. And at least have it pack somewhere and no, it doesn't have to be hanging by the door chasing

Jennifer Smith, CDE 1:05:29
you through the kitchen. Whatever you very mean in that movie. He were the

Scott Benner 1:05:35
Robin Williams and now I'm now people are like Robin Williams wasn't in that movie. That was the rock. How did you confuse those things? And who is Robin Williams, but there's been two Jumanji movies, so young people, please leave me alone. I want to close by saying that as we were talking, I was proudly struck by how much of what is normally spoken about on the podcast translates very well to this idea of sick days. That, you know, obviously there's heightened scenarios, but that the tools you use really aren't much different. You might use different ones in different times than normal, but, but it's not like. And the reason I say this is because when people are trying to figure things like this out, I oftentimes see them believing that there's some extra special knowledge that they don't have about diabetes that applies only to the day you're sick. And I still think that one of your greatest diabetes tools is common sense. And so I think that, you know, we obviously broke things down a lot more granularly here, but it's still the tools. It's the pro tip series right now applied slightly differently. So right um, I thought this was really appreciate you doing this. And we talked so long that I can't ask you to define Lada so I'll do that next time. Okay, so that you can go, I will say thank you.

Unknown Speaker 1:06:53
You're welcome.

Scott Benner 1:06:56
Huge thanks to Jenny Smith, who of course, you can find out more about at integrated diabetes.com links in the show notes. And of course Dexcom on the pod to dancing for diabetes for being long time. heartfelt sponsors of the Juicebox Podcast, go to dexcom.com forward slash juice box to find out today about the G six continuous glucose monitor. Or go to my on the pod.com forward slash juice box to get your free no obligation demo of the Omni pod sent right to your house, they'll mail you a tubeless insulin pump to try yourself. And of course dancing for diabetes on Facebook, Instagram, and at dancing the number four diabetes.com. And if you're just finding the Juicebox Podcast now welcome shows been around for five seasons. And not like you know other podcasts are like they put up like five episodes like that was a season, a season of The Juicebox Podcast is 52 weeks long, you might want to call it a year, and you're gonna get two episodes. In every one of those weeks, there's always going to be an interview with someone who's living with type one diabetes, and then more of a management episode. I call those defining diabetes, diabetes pro tip. Ask Scott and Jenny. These are all episodes where we break down more management ideas. So find those and check them out. The feedback I get from listeners is really encouraging. As a matter of fact, I will go right to a review right now just whatever the most recent one is. See, there's a bunch of them here, here from November 30. This podcast should be prescribed to all diabetics at diagnosis. I have read books, scoured the internet and attended hours of training at the end Oh, and I've learned so much more from this podcast series, I cannot recommend highly enough to check out the podcast and maybe you'll have a similar experience to this person who said life changing podcast. And I am not exaggerating. Within two months, I lowered my one C from 7.4 to 6.1 with obvious and easy to follow instructions. All right now I owe you a story about my wisdom teeth being pulled. So I grew up incredibly broke. It was me my mom and my two brothers. And my mom had a job that I think at the time must have paid about $4 and 85 cents an hour. So we didn't have like fancy stuff like you know, health insurance and dental coverage and stuff like that. As I'm growing up 1819 My friends are having their wisdom teeth pulled out. I just keep doing what poor people do all over the world. I ignore the fact that I have wisdom teeth and that they're probably eating to come out. But then one day I'm 20 or 21 they really begin to hurt. So I go to a local dentist's office, you know have to go in there with my head down. I don't think I've been to a dentist and forever and I'm like, Look, I don't have a lot of money but I'm having pain and I was hoping you could help me. So he looks and says it's almost like he ignored what I told him about. My money situation is like, Oh, those wisdom teeth have to come out, I'm gonna give you the number of a, an oral surgeon, he can take them out for you. I said, Wait, like in the office or hospital, he starts telling me about, you know, procedure, they'll be taken out, said, Man, I can't afford that I don't have any insurance. And he says, well, they have to come out. I was like, Well, how much do you get to pull a tooth? And he says to me what I'm like, like, if I had to pay you cash to pull out a tooth? How much would you charge me if I didn't have insurance? Like I says, $50? I said, $50 a tooth? They said, Yes. I said, Okay, I'll give you $200 to plot my wisdom teeth do it right now. Well, he's horrified, obviously, not how things usually go. And I'm just very insistent, I'm like, Look, if you think these really have to come out, this is the only way this is gonna happen. I cannot afford to go to this oral surgeon you're talking about. So he numbs me up. And calls in a dental assistant, who I swear to you stands behind me above my head, as I'm all the way back in the chair. And he takes his two palms and puts them on my forehead. And his job is to push down on my head while the dentist is pulling out the wisdom teeth.

And boy was that unpleasant. The pulling of the teeth, even with the guy like laying all of his weight on my head was pulling my head up off of the chair. And at one point, I could tell by the dentist's face, he was horrified. He was thinking to himself, I should have never done this. I should not have gotten started with this. But it was too late. You know what I mean? We were in for a penny in for a pound at that point. And he had one of the teeth out. So he's pulling the guy shoving down in my head. I'm trying not to freak out. And next thing I know, we're done. All four out. I'm late 200. He sends me out the door with the great medical advice of don't go to the gym for a couple of days. And that's how I got my wisdom teeth taken out. My son got to go to a beautiful dentist's office. It was put to sleep and a wonderful slumber woke up and he didn't have teeth anymore. I tried to share this story with him, but I don't think he has any context. So I didn't seem to penetrate him. Quite the way maybe would somebody else penetrate is not a word I met penetrate. But I don't have the heart to go back and edit it out. So let's just call this the end of the podcast. Don't forget, oh, the defining diabetes episode about ketones that Jenny mentioned is out right now to well worth your time. If you're thinking about sick day treatment. I hope you don't get sick. Don't forget to wash your hands. cover your mouth when you sneeze into like the you know he's supposed to do in your elbow now, right? They changed the rules on sneezing. You know, when I grew up, you just sneezed on your hands but turns out that's not a great idea. retrospect It was pretty easy to figure out. I don't know why we were doing it. But you know, the 70s whatever. Get out there. Stay safe. Get a flu shot. If you're going to get a flu shot. Do your best. Try not to touch your face. Oh my God when you're on airplanes, right? Don't breathe. Just trying to breathe on an airplane. Just hold your breath for that. Just hold it in as long as you can on the plane. Alright guys, good luck. I hope nobody gets sick if you do. I hope this episode helps.

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#263 Diabetes Pro Tip: Fat and Protein

Diabetes Pro Tip: Fat and Protein

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 0:00
Hello friends and welcome to Episode 263 of the Juicebox Podcast. Today's episode is sponsored by dancing for diabetes Dexcom and Omni pod, you can go to dancing number four diabetes.com my omnipod.com forward slash juice box or dexcom.com forward slash juice box to find out more. I hope you're ready for another diabetes pro tip because this episode with Jenny Smith is all about fat and protein. That's right. How do you Bolus for the thing that they tell you? It doesn't need insulin, but really does. We're gonna tell you right here. And after you're done with this episode, Episode 263 special bonus episode number 264 is available right now. That episode is with Vicki. Vicki is eating keto. She's going to talk us through how she boluses for her keto diet. Because guess what, you need insulin for protein. In fact, if you don't know that, you're gonna love this episode. Now, even if you're not eating keto Vicky's episode is going to give you a ton of insight into the timing of fat and protein. It's actually sort of interesting to look at. If you're not a keto Well, it's interesting if you aren't keto, but if you're not, it's still really insightful. Because you get to strip away the carbs and just see where the protein comes into effect. It's almost like that, you know, do Row row row your boat, you start singing and then the other side of the room starts singing like when does the second tier of row row rowers come in? When does the fat and protein start working? Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And to always consult a physician before making any changes to your medical plan or becoming bold with insulin. You however, do not have to talk to your doctor about going to Juicebox podcast.com, picking up a T shirt or a mug or something like that, you know, to help support the show a half an hour before you and I started recording this someone sent me a message on Instagram and said, How do I deal with fat and protein overnight because I was bawling all night with my kids. So I texted them back and I said hey, great timing. Can you see my recording calendar from where you're at? And hold tight? Because the answers coming? This is another one that Jenny proposed that I'm really interested in. And I don't know how much help I'm gonna make. Why don't we start with what I know? Because it's so little. So forever seriously. So for everyone who listens to the podcast and knows that I'm just sort of fluid with insulin, right? Like more, more need equals more insulin. And so because of that, I don't usually stop and think about whether that means it's protein or fat or what it is just if Arden's blood sugar seems to require insulin, I give it more. I'm assuming I'm been handling fat and protein rises for ever.

Jennifer Smith, CDE 2:58
You're not dissecting her meals, you're just saying I see the need. I'm giving more insulin. That's kind of what you do.

Scott Benner 3:05
Yeah, I see diabetes is a forest fire and I fly over it with a giant plane full of water and just drop all the water on top of it. And I go, oh, I've got most of it. And, and

Jennifer Smith, CDE 3:16
Oh and look at that's where the fire started where the fire man comes in and looks at and Scott's like, I didn't really care where it started. I just want to take care of anything

Scott Benner 3:24
was to me, I'll go get another plane full of insulin and drop it back on again. So. So I never really think about stuff like that I do a little more obviously, as you and I have been speaking as the years go past, but I find it to be it's another level. Like sometimes I joke about things being like like ninja level, like, I think that you don't really need to know about fat and protein if you're doing what I do. But you do need to know if you want to start understanding things in a bigger way. So I'm really excited to do this. Now, the only thing I know about protein is that I do indiscriminately bolus for protein. I don't know why I do it. But I do it. So where some people might look at a plate and go, Oh, there's potatoes. Well, that's, you know, this many carbs. But then there's a, you know, a cheeseburger. Well, that's me, I don't do that. And here's a roll that rolls 25 carbs, and you know, and we're gonna have broccoli, and I don't know, broccoli probably has five or six cards or like, so I look at my job I look at I look at a plate, I go broccoli, and six, the roll. Let's call it 30 then I look at the potatoes and they go I don't know 35 and then they look at the burger and I go, yeah, let's call it 10 and we'll extend it for a little bit. And and so that's me looking at a cheeseburger with mashed potatoes and broccoli, right. I don't know why I do that with the. I've heard that. I know. People who eat incredibly low carb, who tell me that they bolus for their protein but farther out from when they actually ingest it. Huh, is any of that right? If visiting dancing for diabetes is wrong, I don't want to be right. Not about this, I want to be right about the fat and protein thing. But I would not want to be right about visiting dancing for diabetes being wrong. If it was wrong, which it's not, I think you should definitely do it. Dancing, the number four diabetes.com. You know, studies show that if ads are incredibly confusing, they work so much better. Check out dancing for diabetes on Instagram and Facebook, throw them all like to really great organization, dancing, the number four diabetes.com. Even if you're not interested, could you go like their pages? Because they paid for this. And now I'm listening back to it. And I didn't do a very good job. So let's at least give them their money's worth. Is any of that right?

Jennifer Smith, CDE 5:47
Because, yeah, so I and again, I from the standpoint of looking, you're not doing this in a blind way, you have, you have the method that you've developed for analyzing looking at Arden's control and her management and what happens here and what happened there. And you remember it, you've got like this, like library of like, times have this has happened, you can like pick from them, Scott, and you're like, I know this happened last time. So let's time this time for the burger and broccoli, we're gonna give 10 for the burger, because I know what happened last time and something was off, and the carb count for everything else was right. in context, though, for everybody who's listening, and why would you need to Bolus for protein. It's really typically two points that you'd need to Bolus for protein one, you brought up the low carb eaters, or those who are eating lower carb at times, if you've got a meal that's typically less than about 15 to 20 grams of carb, and a normal amount of protein, not like this big 16 ounce steak, but a typical, you know, five ounce chicken four or five ounce chicken breast, let's say, You're usually going to need about 4050, sometimes even 60% of the amount of protein in the aftermath of that meal in order to accommodate for your body's own digestion of protein in a low carb environment. Because remember, carb is the body's natural first fuel, right? If there's not enough of that first fuel there, your body looks to another source, like protein digest sit down, and you get a usable amount of glucose out of protein. Even if it's not a huge amount of protein eaten in a lower carb environment. The opposite of that would be let's say, she has a high carb meal, or anybody has a high carb meal that's like the meat lovers pizza, okay, and which is not only a huge amount of carb, as well as a huge amount of fat, but you've got this large amount of protein, let's say instead of your standard, like 25 gram portion of protein, which is like about the size of the palm of a woman's hand, that's about 20 to 25 grams of protein, that's pretty normal amount, okay, if you've got this huge amount of protein that you're taking in, even in a normal amount of carbs, or a high amount of carbs, you're still gonna need an Bolus for about, let's say, 50% of that protein, but it's going to be a drawn out type of insulin need. So both of those scenarios would require you to take, you're doing like a dual bolus, you're extending some of it assuming you're meeting that protein kind of need for a while. Protein bolus typically is a good idea is at the end of the meal to set an extended bolus with zero percent delivered up front and 100% extended out over about a three hour time period. And that's just for aware proteins impact usually starts impacting about two ish hours after a meal. And then by about three hours, you're too high and you might sit high and correct to try to get it back down. When in effect had you used what you use to correct to actually Bolus for the protein you wouldn't have had the rise to correct to begin with.

Scott Benner 9:17
Yeah, I got it. It's parallel to the idea of over Bolus and like when you can't Pre-Bolus and you throw in a ton of extra to handle the rise before the right yeah. Okay. So yeah, exactly. I Bolus the meal normally. Then I finished eating and I put in this amount for the protein in an extended bolus, zero right up front, the rest of it out over maybe three hours.

Jennifer Smith, CDE 9:39
Correct.

Scott Benner 9:40
Correct. So basically, I'm creating a heavier blanket of insulin over the timeframe where the food is going to have

Jennifer Smith, CDE 9:47
where the protein is going to have the impact or where you're assuming from previous experience with meals like that. That impact is going to kind of fall in and fat is even longer. As we've kind of talked about before fat can have impact on To 10 to 12 hours after eating high fat.

Scott Benner 10:02
How does that technically happen? So these are where my questions exist. And by the way, I just everyone listening, I just stared at Jenny while she said that and thought, Oh, I'm in a Master's class about diabetes. And so, so fat as an example, when How does fat does it slow down digestion? Like, why does fat hold up blood sugar? I don't understand, I guess.

Jennifer Smith, CDE 10:26
Yeah, so one, it's also usually the reason as you just said, fat does slow digestion a bit, it's a it's a tough nutrient for your body to break down and make use of. So even if there's a ton of carb with it, it's often the reason that somebody eats a pizza. And they're like, wow, I must have nailed that carb count, because my blood sugar is like, beautiful rock, steady, flat, no rise at all. And then all of a sudden, later, they get this like creep, and the creep happens, and it happens. And then you ride high, and you're like throwing insulin at it and dumping the plane worth of insulin. Here, you know, it's, it's and it's annoying, right, especially for people who may not realize where it's coming from, because they've never been told what it potentially could be. So it's not a missed missed amount of car. But it is the reason that you had that nice flat look, in the aftermath of eating that, let's call it pizza. Otherwise, if you just ate the pizza crust, I guarantee that pizza crust is going to give you a rise without the fat being there, right? Even if you did Bolus,

Scott Benner 11:32
right, right, right,

Jennifer Smith, CDE 11:32
right bread or potatoes or whatever it is. Now fat The other reason it impacts blood sugar is because as it gets to the system, a creates a rise in triglycerides in the bloodstream, which is a stress on the system. So we know what stress does to blood sugar, right. But as a stressor, if it impacts insulin use as if, as if it's reducing it by about 50%. So let's say your bazel overnight is running at 1.0 units an hour, and it works beautiful, you've tested it, you know that it does what it's supposed to do. But in the effect of pizza or anything high fat, nachos and cheese or whatever it you know, the whole bucket of chocolate, whatever, you essentially have a bazel now that's functioning almost at like point five instead of one. And so you are not getting the impact of all the bazel you need your blood sugar climbs because of the fat and it stays high because of the fat and it can be long duration. So I mean, you know, we typically recommend people accommodate for a high fat meal or something, you know, high fat in nature, like the whole hog and does sundae bar or whatever. 50% increase in bazel at the end of the meal. And you extend it out over eight hours.

Scott Benner 12:52
Wow. 50% bazel increase over eight hours for a ton. Yep,

Jennifer Smith, CDE 12:56
see a ton of fat.

Scott Benner 12:59
That's where it's a Jenny. So there's a couple of things in there. But the one thing she just said was how the the impact of the food sort of gives the appearance that your bazel is only at half power. Because Because now your body needs so much more insulin. It's funny, because that stuff we say I've been saying for years, but I never thought it that way. Right? I never considered Wait, you just said it. I always say right, the by like, you know, in high carb situations, you need more bazel. That just makes sense. If you know if one unit keeps you stable when you're not, you know, when you're not putting the body through through the paces, then when you're out then when you're attacking it with ice cream or pizza or something like that, it stands to reason that you would need more in that situation, right to meet the need. But it's interesting the way you put it, I hope that maybe that'll find a strike other people maybe at the core of their thinking, because that's a neat idea. Like when when you're using that kind of food, it's as if you don't have enough bazel by half rats, they have something to like measure with even the idea of eight hours. I think the genius behind the extended, you know, the Temp Basal increase over that much time is if you do start to trend down at some point, you can just make a the foods out of my system. Now I can shut it off. Maybe I'll have to re correct this a tiny bit, too, you know, but that's it.

Jennifer Smith, CDE 14:15
Right? Right. And or maybe you got enough temping increase for quite a while. And now it's going to navigate down as you turn it off, and you may not necessarily get 100% back to target, but you're certainly going to navigate down to a much lower number than you would have been had you not done that at all.

Scott Benner 14:32
Yeah, yeah. I mean, and you have to know by now, if you've been listening this long, that you would rather stop a lower falling blood sugar than a fight with a high one. That's it. It's simple. How much truth is in the way my brain thinks about, like, more dense carby stuff like a soft pretzel or pizza or something like that, in that it sits in my stomach and it breaks down slower so that it has more opportunity to run. So my blood sugar being impacted by over a longer period of time sometimes passed when the impact of my Bolus is there. Mm hmm. Do I think about that correctly? Or is that just the cart? Yeah, that

Jennifer Smith, CDE 15:10
works. No, it's, it's a great way to kind of think about it and also plan to Bolus for it. And some of that also takes experience, right? It takes experience seeing, well, gosh, whenever I eat this soft pretzel, it's all carb. And unless you're like dipping into the cheese sauce, or something high fat that kind of comes along with it, the vat of butter, if you're just eating the soft pretzel, it's all carb. But the dense nature of it, maybe what requires a little bit more drawn out, because you don't necessarily need that quick impact all up front, you may need some, but then you're going to need it for a little bit longer in the aftermath. And the same is true for some of those, like more wholegrain hardy types of starchy foods, things like wild rice, or qinhuai, or you know, those kinds of things, they've got better fiber complex to them, they've not been processed, they're going to break down slower, and they're going to have a lower glycemic impact. So you may need to draw out the Bolus a little bit in order to prevent having a low before it kind of impacts or hits you later.

Scott Benner 16:19
Right, you have to stop thinking about the food goes in, and my blood sugar tries to go up right away. So I'll get that's not that's why your timings messed up. Like you have to understand a little bit how the food makes its way through your system. Mm hmm. high carb, low carb, high fat, low fat, you know, an in between there, the, the, you know, I used to tell people, like try to imagine an overlay machine like but then that got like an old idea, you know, like, you're in school and they do the, you know, the somebody would write on a piece of plastic and it would they'd shine up on the board. Say take two pieces of plastic instead and make one like a line of the impact of where your insolence pitting and one a line of where the food's hitting the goal is you have to slide those like those pieces of plastic left and right and make a me Italy match up? Yeah, you absolutely can't. You can't just throw in all the insulin now and just hope it hits because you hear people all the time, like, Oh, I bolus and I got low. And then I got high later. Now this makes sense, diabetes. And I'm like, No, you're so close to you. It's interesting. Jenny, earlier you said that I look at a plate. And I just know from experience and everything. I also think I just know, I don't know why I know. It's important to understand, like, I can't quantify it for you. Sometimes I can just look at a plate and go that's this much insulin, I know it. And it is obviously from something but at the same time, I have privately for the one person who called me an egomaniac in a recent review. This is not me being egotistical. I'm just telling a story. But I I fixed two kids bazel rates this week, mm remotely. And they sent me a graph. And as soon as I looked at the graph, I thought, Oh, I know what's wrong with this. But I couldn't explain it to you. Like, do you know what I mean? Like I couldn't write a manual about why this graph right points to what it points to. But I knew as soon as I saw it, I think everybody can get to that. Because I know who I am. I know what I got in school is for grades I can't possibly be smart. Right? So, you so seriously, like I think time just teaches but and please, guys, this is not an invitation for everybody to send me their thing. But But I am By the way, it did make me think, Jenny, I think there's got to be a way to start a service where you take people's graphs and make bazel recommendations back from the graphs. Because once you get people moving in the right direction with their bazel, they start to see it. And then they can then they can dial it in on there. And then they don't need you this this person this lovely person's texted me. You have to let me send you something cuz I'm going to be bugging you for the rest of my life. And I laughed and I said, Hey, you can't send me anything. And I don't, I don't want anything. And and but but be you're not going to need me for like, ever, like three days right? Now, this is gonna just make all the kind of sense in the world to you. It just starts to you start to see it, you know, right? Right? Which the matrix movie because it's such a great reference. But things start to slow down.

Jennifer Smith, CDE 19:26
You know, they do and they start to they start to come together in a way like like Neo sort of all of a sudden, all of those images that are flooding the screen in the matrix. Like he said, that's a great movie to bring up in context here. Because it just it comes together and his brain is like, I can see it all. It's clear. And I mean, diabetes, life with diabetes changes, variables come up, and there are always going to be new avenues to explore and figure out but the intuition of the day to day management, the intuition gets easier, and I think that That's what you kind of you manage off of a lot of really good built in intuition of, it's this, this feeling and you can't, you can't often I think other people would agree, you can't often put that down in writing, you can't say, I know how I know how this is wrong, I can't tell you why. But I know this is how to fix it. I know this needs to be adjusted here, you need something else here or whatever. Now, some of it can be, you know, some of that intuition can be simplified. If you do do some, you know, we're talking all about like food and the impact carbs, and fats and proteins and some of that, if you know, I've gotten a little bit into the science of why there's impact there from these foods that we don't really ever talk about fats and proteins are kind of like, swept under the table, when Diabetes Education comes, you know, comes up, it's usually all carbs, right? We focus on carbs, we learn how to carb count. And I mean, the basics of carb counting are pretty easy with a label, you look at the label for the serving size, you look down the label for the total carb amount. Next down, you might look at fiber, if there's enough of it, you might need, you know, deduct a little bit of it. But that's what we're taught. And then you're given this little ratio that's like, oh, for every 10 grams that you count from a label, you need this much insulin to take with it, right. So it's, it's a very mathematical figure. But if we take it sort of one step farther than that very simple carb counting, as you mentioned before, not all carbs are created equal, you know, you could have 10 grams of counted, you know, celery, versus 10 grams of counted watermelon, there's going to be a different impact blood sugar wise from those carbs, even though the carb count is exactly the same. And so that it kind of brings in, can you be precise in carb counting to a degree, you can look at labels, you can measure, you can use weighted scales and all of that kind of thing, you can get precise, but from the standpoint of then understanding why blood sugar did this versus did this, you know, upswing stable flat drop down, that actually it takes it a step further into glycemic index, and the nature of that food and glycemic index also in it encompasses the components of a meal to not just the carb at the meal. But like I said before, with the pizza, you could have just the flat old pizza crust and Bolus for that with just all the carb that's there. Your Aftermath blood sugar is going to look very different than when you eat it as like a meat lover or an all over cheese pizza. There are different components. They're impacting how those carbs are going to change your blood sugar.

Scott Benner 22:54
In case you missed it Episode 255 is a defining diabetes episode with Jenny, where we go over a glycemic index and load. Kelly and I went to the movies this weekend with Arden and her friend, we went to the snack stand and Arden chose a box of cookie dough bites day slushie I don't know if that's something that translates all over the country, but just imagine pulverized ice with sugar water through it. Now, I'm not scared, right? I've got all the rules in this podcast and I've got Dexcom I feel comfortable. Flip over the box with a cookie dough bites. 76 carbs for the whole box. I say Darden Are you gonna eat the whole box. She says, I don't know, the Slurpee, you're gonna drink the whole thing. She says I don't know. I look at the lady at the stand. I went any chance you got a carb count for this slushy thing. She looks at me and says carb What? I say Don't worry everybody because we have a dexcom g six continuous glucose monitor. I know what I'm going to do. So I just ballpark the carbs. Right? I use the 76 carbs for the candy thinking there's no way she's gonna eat all the candy. But, you know, the slushy obviously has a ton of carbs in it that I can't even begin to guess we're just going to start with 76 carbs, boom, insulin goes in. Now we wait for the dexcom to tell us that Arden starts trending above you know 120 as soon as she does Janga more insulin. Throughout the hour and a half of the movie we put on a number of different smaller boluses which kept Arden's blood sugar around 170 and then we got her back down as soon as the slushy cookie dough concoction stop going in. You know what I call that success? Arden Sala movie she had a snack, there was an unknowable amount of carbs that impacted her in all different crazy ways. She did not get terribly high and she never got low later, we accomplished that the dexcom g six continuous glucose monitor, head over to dexcom.com forward slash juice box to find out more. Results are mine and yours may vary. And when those variables are invisible to you, it causes you to say oh, that's Diabetes, I can't do anything about that. That's just nice. But there is like I've, I've been saying forever Jenny's just put it into specific words, which is beautiful. But I've been saying forever. If your blood sugar is getting really high or really low, you're not using the insulin correctly. I know that doesn't help you figure out how to use insulin, but it should help you to know that there's still an answer. And right, because you don't see it in the moment doesn't mean it doesn't exist. It would be no different than if I sat down and looked at multivariable calculus. And then, and then I said, you there's no answer to this. Well, a person who understands multivariable calculus would say, of course there is, you just, you just don't understand calculus. And so the trick is with diabetes, how do you find the ideas that help you get through this stuff without everything turning into a calculus problem? Right? Like, how does it just become day to day super simple and easy. And the reason you need to listen to Jenny is not only because she, you know, teaches this stuff and integrated diabetes, not just because she's been living with Type One Diabetes for a very long time, not just because she's a CD, or a nutritionist, all that stuff, but she lives in a part of the country where food literally tries to kill people. So that wow, I my brother and Jenny live reasonably near each other and the things my brother describes his food. When he got there, I was like, Brian, that's not food, don't eat that. And it's like,

Jennifer Smith, CDE 26:27
man, I would have to say Madison is sort of a little bit of an island in the state of Wisconsin. So Madison is a little bit a little we're a little beyond what the typical wisconsinite but yes,

Scott Benner 26:39
I'm just saying if you're rolling into a moment with a you know, bratwurst on a roll with a beer with some popcorn,

Unknown Speaker 26:45
curd,

Scott Benner 26:47
cheese curds, deep fried like you, boy, you you need to know what you're doing, you know?

Jennifer Smith, CDE 26:51
Right? Absolutely. And that's, you know, that's where understanding and learning things like, hey, fat, and protein and all of these factors, they can have an impact for you. It's not all cut and dry. Count the carbs, take the insulin and you've got it made it it's not and i i hate saying that because it sounds like well, gosh, I'm never gonna get a handle on this if I have to start being a mathematician and you know, figuring it all

Scott Benner 27:17
out. But you will if you just, if you think beyond what you were told. So somebody like Jenny said, they'll flip the box over a half a cup of this is 10 carbs, you know, you get sick, you know, you get a unit for every 10 carbs. So that's a unit like that. But then once that doesn't work, you know, you guys have heard me say it a million times. It's insane to go back the next day recount the same 10 carbs and go Okay, unit, because that's what the math The doctor told me. No, no, I used the unit, my blood sugar went up. It took me three quarters Veena to correct it next time. Let's try a unit and a half. Or, you know, yeah, let's try more because more it took more, you know, correct. You just have to, like, do some evaluation is that Yeah, you have to I'm following you for the people that I speak to over and over and over again, there's a moment where you just have to trust your gut. Like, you have to trust that what you're seeing is actually happening, which is why I made one of the tenants of the podcast, you know, trust that what you know is going to happen is going to happen, you know, and that's just that's simple. Like, it's not, I say all the time, like it's not stalking if you need it. And somebody I got a private message of the day it said that sentence unlocked my world, just, you know, change my life. And I thought, I'm glad I randomly said it because I didn't think of it ahead of time. I you guys have been listening for a long time you realize there's no notes in front of me. I've planned none of this is a matter of fact, Jenny and I start recording I go hey, we're gonna do like the fat and protein today. Okay, and she goes, Okay. It's, it's about unlocking your mind from what, you know, the confines that you are giving at diagnosis. And it's really it's, it's energizing to see it happen to people early in their diagnosis, because then you know, they're not going to live their whole life like this, but it's rewarding to see someone who's lived with diabetes for a long time. Have like the light turned back on for them. Yeah, I mean, the messages you guys send Are you guys owe me tissues? You know what I mean? No. It's really something. Okay, so I did we do we did carb counting basic site, like flip the box over, take a look,

Jennifer Smith, CDE 29:22
you'll buy box over? Yeah, I mean, if you wanted to go beyond the carb counting basics and get more into a little bit, I mean, taking it beyond would really be looking at the glycemic index, but then one beyond would be glycemic load. You know what that is Scott.

Scott Benner 29:38
Those are gonna be defining diabetes things we're going to do after we stop recording this journey.

Unknown Speaker 29:42
Okay, awesome.

Scott Benner 29:44
All right. Okay. We did well with this, I think.

Jennifer Smith, CDE 29:46
Yeah, I think so.

Scott Benner 29:49
Okay, don't forget that defining diabetes episode about glycemic index and load is back in Episode 255. Let your podcast player keep running because Episode 264 is the next episode. And it's with Vicki who will tell us how she handles a meal on a ketogenic diet. keto, right, here's the great thing. Even if you're not on a keto diet, even if you're not doing low carb, the information is amazing because it shows you the timing of when proteins and fats hit a person. Try to imagine that Vicki's gonna explain a meal to you, that includes no carbs. And she's going to show you where the fat and protein comes into play. So you can kind of in your head separate out when the carbs head to where the protein hits. Trust me, this is the capper for the episode with Jenny, I promise you go right from this one into 264. Thank you so much to the sponsors Dexcom on the pod and dancing for diabetes, you can go to my omnipod.com forward slash juicebox dancing the number four diabetes.com or dexcom.com forward slash juice box to get started today, we're gonna find out about the answer for diabetes. Don't worry if all that confuses you. You can find links in the show notes of your podcast player or at Juicebox podcast.com.

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#256 Diabetes Pro Tip: Exercise

Diabetes Pro Tip: Exercise

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 0:00
It's time for another pro tip episode with Jenny Smith. Hello everyone, and welcome to Episode 256 of the Juicebox Podcast sponsored by Omni pod Dexcom. And dancing for diabetes, you can go to dancing the number four diabetes.com dexcom.com, forward slash juicebox, or my omnipod.com forward slash juice box to find out more about the sponsors. Jenny is a certified diabetes educator. She's like a nutrition thing. Like she does a whole bunch of like technical stuff that she's got degrees for, she works at integrated diabetes, if you'd like to hire her for yourself, you know, have these conversations with her one on one, you go to integrated diabetes.com where you can go into the show notes of your podcast player where I have Jenny's email address, email her directly, all different ways to get hold of Jenny Smith. All these links, of course are at Juicebox podcast.com. If you get confused, and you need to find them somewhere, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And to always consult a physician before making any changes to your medical plan or becoming bold with insulin. I liked your idea, a lot of beginning ideas around blood sugar management with exercise because I hear from people constantly. And I always think that my answer to them is incomplete. Because it's one of those things that I think I just know how to do. And I don't know why I know how to do it or why it works sometimes. You know, I everyone who listens knows that Arden played really competitive softball for years and years and years. Mm hmm. And that that means at this part of the country, that means being outside in incredible heat. weekend after weekend, sometimes from 8am till 5pm playing 234 softball games, you know,

Unknown Speaker 1:45
right?

Scott Benner 1:46
And I strive for a nice blood sugar around 90 or I don't change my goals because of what she's doing. Right. And I also am not much of a pre planner, but I do I have spoken to people who are like, Look, you know, I'm an adult, I'm going to go to the gym at five o'clock after work, I need my blood sugar not to fall at five o'clock when I start working out or later sooner. And how do I do that? And I have to tell you, I know it's around bazel insulin and pre, you know, basically like setting Basil's up ahead of time or afterwards to catch lows and stuff. But I'm so reactive. I don't think about it that way. So how do you talk to people about it?

Jennifer Smith, CDE 2:23
Yeah, you don't really have a I mean, as you've done for a long time, you're sort of like, you're surfing the wave of what's happening for art. And you're managing very well doing that, because you've intuitively learned how she reacts to things for the most part, right. But to teach people in a general sense, I think one, you said it correctly. I think it's around bazel. Well, you're right in that it's around insulin. Most people

I know I was waving at him too.

So the the insulin is really a big piece. And a lot of people again, they focus on a number when they're going into exercise, but they're not focused on what's what's the causative to that number, what's affecting that number and where it may directionally go. So we talked about, you know, your person here example wise, he's going to exercise every day at 5pm. Well, for them, that's kind of a nice timeframe of the day because the goal there in a simplified way would be, you know, active insulin onboard, so no bolus insulin, you know, and they, let's say, as an adult, they only eat lunch at noon or one o'clock, tected, by five o'clock that bowl is should for the most part, unless they're looping, that should be gone. Right. And it would mean then, you know, aiming to either not have an afternoon snack, or in which there's no Bolus that would be riding into the exercise. And then the Basal component, there is a lot of debate about Should I adjust my Basal for exercise? When should I do it? How much should I do it by and that's where it comes to be an individual nature of adjustment, because it takes you have to take into consideration the intensity and the duration of the planned activity. You know, if this example, you know, guy is gonna go for an hour and a half spin class, high low, it's sort of a high intensity interval sort of workout. And if he's only going in on bazel, he could shut his bazel down, not off, but lower has bazel incrementally enough, well, before he actually starts moving, so that he shouldn't technically need much of any food at all, to continue that let's say 90 minute spin class, for example, adjustment to bazel. Most people feel like they have an idea, I turn it off, you know, I turn it down or I turned it off 30 minutes before and I still went low or I continued I was low by the end, and then I continued to be low. And the problem is that as we've talked before circulating insulin level isn't lower or higher, until about 60 minutes post adjustment. And when you're really aiming to get into a specific target, for beginning exercise, your circulating insulin level should be low enough by that point, because, as is a kind of propelled intense, intense action of the insulin on a basal level that you have now circulating, and if you're normally at a 1.0 unit per hour basal rate, and you knock it down by 50%, that 50% reduction should be started at least 90 minutes, if not two hours prior to when you jump on that spin bike.

Scott Benner 5:46
I'm checking out dancing for diabetes.com right now went to their blog, there's a lot going on over there. It's like they had a fundraiser recently a game night in Orlando, group dance auditions are now open for their annual dancing for diabetes show. Others a follow up here from when they were at friends for life, are announcing new partners in their D box program. They have this box of like great stuff that they send out to newly diagnosed people, I some actually some Juicebox Podcast stuff in there as well. But they just added sugar, medical and trialnet You can find out all this yourself, you don't need me to read it to you dancing, the number four diabetes.com check out their blog.

Jennifer Smith, CDE 6:24
So this gentleman, you know, he should really reduce his bazel by 3pm. And he should reduce it for the intensity and the duration, at least by 50%. Again, these are kind of starting places, and you'll find what adjustment works specific to you. But it's a good starting place. Now if he was just going to go for a walk for 60 minutes at a moderate pace enough to kind of bring up his heart rate a little bit but not crazy. Maybe his adjustment is a 25% basal reduction, but it still needs to be taken back by at least 90 minutes to two hours before he takes that walk.

Scott Benner 6:59
It reminds me of a number of things. One, there was a I forget what it was called. Gosh. There is a thing that happened in in I can't think of what the name of the website is it's gone now. Manny Hernandez his website that's not Oh, two diabetes. They used to do that thing every year where they they kind of challenged you to get out and do exercise, right? And yeah, your blood sugar and see where it would fall.

Jennifer Smith, CDE 7:23
So that was in November for the diabetes bump. Diabetes awareness. Yeah, check your blood sugar. Now walk or do something fun for 15 minutes of movement and check again,

Scott Benner 7:32
and people would see that their blood sugar's would come down. Yeah. So it's the same idea except with lower lower numbers and tighter tolerances for exercise your blood sugar is going to fall or try to fall because of this exercise. What can you do prior to that, to not to keep the fall from happening. And I think that what ends up happening is there's two false narratives. Well, there's a false narrative that and a problem that people build around exercise and I think about going to sleep through with diabetes. The false narrative is, if I make my blood sugar this high, that when it drops, it won't get dangerously low. Correct. If you're thinking that you are completely missing the point, right, the point should be that your blood sugar doesn't need to drop like that. Let's let's find a way to live where it's not dropping out of nowhere. Correct. And so but I see how that's the fix, right? Like, I see how that's what occurs to people. I dropped 50 points. So, you know,

Jennifer Smith, CDE 8:32
let's start 50 points

Scott Benner 8:34
higher than I really ever want to be right because the guy stuck a pencil in his pocket. And then he brought up the bank. So the pencil cause the bank robbery, like just the falls, not the the falls, the falls. God what am I trying to say? Like, like the Fall is

Jennifer Smith, CDE 8:47
the fall can be offset. If you think ahead about how insulin works, it doesn't

Scott Benner 8:51
have to happen and right and so you shouldn't be planning to stop the fall, you should be planning for a fall to never happen to begin with.

Jennifer Smith, CDE 8:59
Correct or minimal enough that you really are not in danger because of the drop, right? I mean, exercise can even you know, even people who do plan ahead might see something like a 10 or 20 point change in blood sugar during or by the end of their exercise session. That's nothing you know, if you're starting with a blood sugar of 110, and you drop 10 points. Great. You're at 100 now awesome. Nothing, you know,

Scott Benner 9:27
my expectation isn't that you can set your blood sugar at nine while you're, you know, running a marathon, it's never going to move but there are things that play while you're running that you don't think about the you know, the anaerobic style of exercise is trying to bring your blood sugar down, but you've changed your basal rate which is trying to bring bring your blood sugar up also. Maybe you have adrenaline which is trying to bring your blood sugar up. So even people who have that stability, they don't 100% know why they have it like they don't really understand all the pieces that are affecting this number moving or not moving. Right. It's interesting that the other thing that you said that feels probably To me, because I hear so many people, like, every time I speak to someone, I'll tell them the same thing. Look, just start Pre-Bolus sing and your agency is going to go down like a point. And then they inevitably say, Well, I can't really remember to do that. And I'm like, Alright, well, then your blood sugar's gonna die. What do you want from it? Right? You have to Pre-Bolus like, this is how this is what you're gonna say, this exercise thing really is no different. Okay, they're still Pre-Bolus thing, they're just Pre-Bolus thing with their their pre bazeley adjustment with it with a reverse adjustments that have a more positive adjustment. So I wonder how many people fall into that category? When they say, Look, I know I'm going to be at the gym at five. But how in God's name, do I think about it at 330? Mm hmm. You know, in that situation.

Jennifer Smith, CDE 10:47
And so some of the strategies in pumps today, you know, there are alarms or reminders that you can set, you know, even in the PDM. For Omnipod, you can set up alerts and reminders for things, I used to have one set up for reminding me to Pre-Bolus, so that I had enough time between that and actually starting to eat my dinner. I also had a reminder to check my blood sugar at bedtime. Not that I needed the reminder. But it was there in case I had a really hectic night. And I did forget before I like climbed into bed, right? So for things like a reminder, if you are pretty strategic about popping in your exercise every day at 5pm, why not just set an alert or a reminder in your pump to go off or even on your phone? If your pump doesn't do it? Or you don't want to set it there, put it in your phone and call it exercise adjustment or whatever you know. So it is that physical visual reminder, you have to turn the alert off. Oh, why did I set the alert? Oh, that's right.

Scott Benner 11:45
suicides at five o'clock, just just two days ago, someone said my child will look does not seem to be remembering to Pre-Bolus at school. And I said, Oh yeah, Arden was terrible at that. And she said, Well, what did you do? I said, I just set up an alarm on her phone for when I wanted her to Pre-Bolus it would go off and it would pop up and say Pre-Bolus. And then she you know, send me a text and be like, do you want to do this now? And we built on that. And that was years ago. And last year? She says to me, I don't need the Pre-Bolus alarm anymore. And I said okay, okay, no problem. And sure enough, like it just, it happens so many times that now it just it's muscle,

Jennifer Smith, CDE 12:22
like brushing our teeth. It's just memory. Yeah, exactly

Scott Benner 12:26
what you guys are gonna have to do, whether this is about you know, an adult for exercise a kid for exercise, or a kid playing a sport. You can't just, I mean, it sucks, right that you can't just get up and run out the door and go do it. But it's going to take a little bit of pre planning and if your health that where you're, you know, you're, you know, if that means that much to what you're gonna have to do

Jennifer Smith, CDE 12:46
like, and I do think it helps. It's important. I mean, with that statement, you can't you can't just get up and run out the door. Well, you know, what, what if you ended up sleeping in because the alarms didn't go off the right way. And you had planned to get to your kids softball tournament at 9am. And oh my gosh, it's like eight o'clock, and we're like running out the door with like, food in our hand and we're running and trying to get there. It just didn't happen to be able to plan. Well, in that instance. I mean, there are strategic management, you know, ideas, you couldn't adjust the bazel there was no way to do it, right. So in that circumstance, then food becomes your offset to potential changes in blood sugar. You know, if you got up late to go for your normal six mile run first thing in the morning, and you always like to eat ahead of time, then the strategy may very well be okay. Maybe you don't Bolus if you're going to eat and head out the door in the next 30 to 60 minutes, and you're going to take a six mile run depending on how long that takes you, you may be able to take 25% of the recommended Bolus, you may be able to take none of the recommended Bolus. And strategically then manage blood sugar well, because you're feeding the activity you're feeding to avoid a drop in blood sugar, but you're not stacking insulin into a time that it's just gonna get active.

Scott Benner 14:07
Right, I'm smiling so much because this is like the next level of thinking about all this about the manipulation of the insulin. When RM would run off the field like I and I'd have her I know what her blood sugar was. And she if she ran off i'd might say to her Hey, water, you know drink water now. And then maybe watch and then if I saw her blood sugar kind of dipping down the next time she came off the field I'd say switch to the sports drink and you know should switch to the sports drink and then I'd be like switch back to water. You know and it only happens a couple times maybe it maybe never to be perfectly honest with it. She's played softball games where a blood sugar's never moved, you've got her bazel right, your prep right going in or like you said you ate the right things before playing. And these things are sitting nice and stable in your stomach and kind of holding you know, holding the pressure back of of the activity to make your blood sugar lower. But you can reverse engineer all of these ideas like use food instead. Events like, you know, I say it here a, you know a lot and I don't know how clear it is because it's sometimes not 100% clear in my head, but we don't we always just think about how the insulin impacts the number your blood sugar, but we never think about how food impacts the insulin or how food impacts the number. There's so many different pieces to this. It's all not just a one way street, like, all right, things are affecting all these different things. And if you pick the right one, it can manipulate something, right? You ever thought was manipulatable. And it is, you know,

Jennifer Smith, CDE 15:31
and also understanding your variables and how they affect you maybe at certain times of the day is a piece of it as well. I mean, I can tell you from my, from my management, I guess toolbox. I've figured out that my morning runs, I can get up, I can Bolus for about 40 to 50%. of the normal recommended bolus, as long as I'm heading out the door within the next 30 to 60 minutes, that partial bolus for what I ate will help me keep my blood sugar nice and stable throughout. Now, in the afternoon, if I did that, my blood sugar within 1520 minutes would take it would entirely take I would need. I just know my sensitivity at times of day. And so again, on an individual level. Some of the things you know that we're talking about there a beginning piece there where to start, if you've had no strategy whatsoever, these are places to start with what you can try to, you know, I guess implement, but you're going to find that things need to be adjusted, personally for yourself. I raced a strategy knowing my like training run strategy by race day strategies completely different with the adrenaline of everything getting going on a race day morning. I mean, and I'm not a competitive like a pro runner. Right, I could only do four minute mile or something. No, I've just I'm out there, but it's a race day. And so I Bolus 100% for my breakfast on a race day morning. And if I don't my blood sugar is 300 by the time I start the race

Scott Benner 17:19
dexcom.com forward slash juicebox just got a facelift. Nice, it's fancy. Here's what it talks about zero finger sticks. That's right, the dexcom g six continuous glucose monitor is FDA permitted to allow for zero finger sticks. Of course, you can customize your alerts near alarms by setting the range and getting notified when you're heading higher low. There's smart device compatibility. What's that mean? You can see your glucose data in real time on your compatible smartphone, iOS and Android. Go check out which ones they support, sharing your data. Talking about this all the time, right being able to see a loved ones or someone's glucose levels, direction, rate of change all remotely. That could be your child at asleep over a friend that's alone for a couple of nights doesn't matter. Anybody who needs you know, someone to have their back. Dexcom even has Siri integration. I can't tell you about that right now. Or my phone will start talking to me, but you can check it out@dexcom.com Ford slash juicebox. To find out more. The CGM is also by the way indicated for use in children two years and older. It's amazing. Now to take the next step with Dexcom. Just go to my link, and fill in the tiniest bit of information patient's first name, last name, email, phone number, city state, you know, birthday, a little bit of information about what kind of diabetes you have in your insurance. You are on the way, you can do this through the links in the show notes. If your podcast that links at Juicebox podcast.com or by remembering dexcom.com forward slash juicebox. My daughter's results, of course are her own. Yours may vary. But I'm telling you that the dexcom g six is maybe the most important part of your life with Type One Diabetes, being able to see the direction and speed of your blood sugar is monumentally important.

Jennifer Smith, CDE 19:08
If I don't my blood sugar is 300 by the time I start the race, and again, it's experience it's experience of figuring it out. It kind of goes into the difference of what type of sport or what type of athlete Are you are you a an aerobic exerciser or you more the weight kind of the heavy lift or kind of you know anaerobic because those adjustments are different as well. Strategy there for many of the lifters that I work with the Find a need depending on their lifting plan, they find a need to potentially bolus to avoid a rise in blood sugar during a lifting session off at the potential rise that they see is slower with a Temp Basal increase. And again, in their standpoint, that Temp Basal increase needs to be started about an hour before they actually get to their lifting session. or it doesn't help enough and they get a major rise. So I think the biggest thing with exercise adjustment is what has happened. What have you seen? What is your problem? Right? Because if you start with the data that you've got, and you look at and you say, Okay, I just did this way. Totally didn't cut it, this did not work. Okay? adjust, look at your data and adjust and make you know, is it a timing component isn't an amount component, what do you need to change?

Scott Benner 20:33
It's funny because I see a through line from this to correcting a low so when, you know when people get when people's blood sugars get low, and they they eat because they need to, then this you know, uncertainty just allows them to they do nothing and their blood sugars come like crashing like back up again. Right now you're you've just crashed down now you're flying back up. I say all the time. Like you'll know you're like a ninja when you're bolusing. You know, after you've eaten for a low like, you know, your blood sugar is going down to 40 You're shaking, you're out of your mind. You're eating all the food. He stopped for a second go, okay. I'm okay, now I eat a

Unknown Speaker 21:11
lot of food.

Scott Benner 21:12
70 carbs worth of food. What do I do now? Well, the answer is I Bolus Now you know how much? I don't know you figure that out. But that's what I did. I mean, I the first time I did it with my daughter, I'm like I can I'm so scared. Boom, 350 blood sugar. Then next time, I was like, Okay, well maybe like for half of it and half of it didn't work. And so eventually, I could just I kind of eyeball it was usually about three quarters of the carbs. Like, right, and like when you stopped and really thought about it, you know, sure that 2025 carbs stopped the fall and got your level, the other 50 were just your body going eat more, eat more, eat more, eat more, right? If you could have stopped yourself after 25 or 30 carbs, you would have

Jennifer Smith, CDE 21:53
would need to bowl

Scott Benner 21:54
right wouldn't eat the balls. But you know, you can't stop yourself in that situation. And so it's happening. Now you got to do the next thing that makes sense. It's all really just about I hate I hate to I feel like I oversimplify sometimes. But all we're talking about in the last 10 minutes, all you really heard was right amount of insulin at the right time. You know, which is obviously overly simplified. But that's all we're talking about. the right amount might mean and I get scared to when people hear right amount that they that they think of on the positive or more like actually, the right amount might be less, it could be like bazel, right? It could be not bolusing at all, eating a banana going out the door for a run and thinking you know, this bananas, usually three units, but I know if I didn't bullish for this, my blood sugar is going to go up about 80 points because bananas Don't hit me that hard for some reason. Sure. And when I go out for a run, I fall 60 points. So boom, I'm gonna eat the banana. I'm gonna go and you've countered it. Yeah. Yep. All different ways to get in that fight. Mm hmm. I have a couple of notes. The other?

Jennifer Smith, CDE 22:57
Oh, yeah, Oh, please. Oh, I was gonna say kind of on this kind of on the same note there from the standpoint of not having enough time to adjust. Prior to, let's say, for a bazel adjustment truly, another component is you may actually have to, you may have to eat food to curb a potential drop. If you know the drop is coming, and you've only got 20 minutes before you're going to head out the door to go and exercise. And you may have to have 10 or 15 grams of carb in order to stop a potential drop from happening. And that's it's a, it's a hard thing to consider when you're also for the most part as an adult, especially considering exercise as a piece of like a weight management tool. Right? And if you feeling like, well, gosh, every time I exercise, I have to go and eat like three granola bars. And that's like, that's what's the purpose? What's the point of this? Right? I'm exercising but I'm not seeing any changes here. Well, again, some strategic planning can help. But if there's no ability to adjust anything ahead of time, because there's not enough time, you may actually have to quote unquote, eat something. And my my recommendation and most of the athletes that I work with, it's that the circumstance, simplify the carbs that you're eating, and eat in a butter jelly sandwich or a pro bar that's you know, like 300 calories, your body right before you get started moving needs the simplest form of carb you can get, it needs to get into the system to effect quickly and stop a potential drop because usually aerobic exercise drop happened within about the first 20 minutes or get started within about the first 20 minutes. So simpler. The carbs are one, you're not getting fat and protein calories. So you don't have this load of excess. And if you use something simple like the sport drinks, you know whether it's Gatorade, Powerade, vitamin water, whatever it is, make sure it's got some carbs in it and have about, you know, eight ounces which is Almost 15 grams of carb,

Scott Benner 25:02
that's a simple amount, your body is going to use it easily. It's going to help to stop an initial drop, you may need to bring it along and sip it along the way, as well. But at least it's getting used up. And it's not something that's packing away calories have a question, and I don't know the answer to it. So, which just as an indication to you guys, and sometimes I ask questions I know the answer to just so you can hear the answer. But in this situation, I don't know the answer to this question. So your body when you work out, uses up food as fuel, but that we're accustomed to putting that food in us and letting it be used up as a buoy for a blood sugar. So I don't know what my question is. But if I eat a banana, and I sit down, like because my blood sugar is 60 I eat a banana I sit down and expect this to bring my blood sugar back up to 130. And it does. But if I eat that same banana at 60, while I'm doing something that's causing my body, so is are my muscles stealing the banana that I need for the sugar? Does it still go in the blood and I use it and I get it any i do i get both benefits, or do I only get one. And all of this talk about exercise has me just super warm and fuzzy inside about the on the pod. You hear what we're talking about right? Jenny and I are discussing methods for increasing and decreasing your basal insulin in ways that will stop low blood sugars while you're exercising these tools work in a lot of other parts of life, not just for exercise. Now when you're exercising, you need your insulin, you don't need your insulin use a little more, you need a little less, you need to be able to manipulate your basal rates. If you're pumping right now and you're not using the Omni pod. This is not something you can do while you're exercising because you have to disconnect your tube pump to exercise but the Omni pod is a tubeless pump. And you can have it on not just while you're exercising. But while you're swimming or bathing, you never have to take it off. Now let's just take a second let that settle in. Right. The Omni pod is the only insulin pump that doesn't have to be the only insulin pump that you can wear while you're exercising. Because of that, it's the only insulin pump that allows you stewardship over your basal insulin during exercise a little more or a little less, a little sooner a little later. Now, here's the greatest thing about the Omni pod. And I mean this free, no obligation demo, it's a peck a pod experience kit, that on the pod is thrilled to send you an all you have to do is go to my Omni pod.com forward slash juice box for again, your free, no obligation demo pod. They'll send it to you and you can wear it, you can go out and exercise with an omni pod on and see if it's something you'd be happy and excited to do. And if you wouldn't be whatever, no harm, no foul, nobody's gonna hassle you. You don't have to get another pod if you don't want to. But the best way to find out if what I'm saying will work for you is to give it a try. There's links in your show notes at Juicebox podcast.com. Do I get both benefits? Or do I only get one

Jennifer Smith, CDE 27:52
depends where you are sort of in the exercise in early exercise, your body would get the benefit of the banana would actually bring your blood sugar up because your muscles have now are resting, you've stopped you're eating the banana you haven't been exercising for very long. So it should technically bring your blood sugar up maybe not as much as if you were just sitting and not doing anything and eating the banana and not taking insulin for it. But the longer amount of time you've been moving. And the more primed your muscles are to grab glucose and bring it into for for their benefit. right because they're trying to retain they're trying to energize essentially. And this is a really hard concept. I'm glad question wise you brought it up. Because athletes, endurance athletes, especially those who are doing long distance of anything triathletes, long distance cyclists, even kids or adults who are in long term like competition on a weekend like four or five like you said, you know, Arden might be have been in softball from 8am until 5pm. That's a long day of movement of asking your muscles to do something. And most people are like, ah, I've got my bazel dialed in. I totally I rocked it my blood sugar was nice and stable. But man, I felt like I couldn't move. My I just slogged through this whole four hour marathon and I didn't I my blood sugar was great, but I didn't feel the greatest. What's the problem? The problem is that even thinking about yourself as diabetes, a person with diabetes, right? You have to first think about yourself as an athlete. athletes, whether you have diabetes or not, you need energy of whatever source you're choosing to use, you know, even ketogenic endurance athletes use some form of fuel during long distance to maintain and be able to perform and you know, people who aren't ketogenic you need a carb source, and you need it put in strategically over that endurance time so that you can fuel your muscles, you can give it what is needed so the muscles can keep doing what you're asking them to do. Now, from a diabetes standpoint point, what you're putting into fuel your muscles also has to work well with punch for peace, right? They have to kind of balance each other out. But first and foremost, as an athlete, you have to think what am i muscles need to perform the way that I want them to perform, you're doing two different, very different thing. But they're both working on the same

Scott Benner 30:21
pool of food basically. So

Jennifer Smith, CDE 30:23
and, and thus, with insulin adjustment might be very different. I mean, when I am in training long distance like half marathon marathon, my training runs and the actual event, it's surprising, most people who've kind of dialed things in will find that their basal insulin adjustment doesn't go down a lot. For my marathons, I only reduce my bazel by 10%. And this was conventional pumping, right, I only adjusted my bazel down by 10% for the duration of time of the run, because what I expected then was the rest of the bazel to be able to encourage the food that I was taking into fuel along the way into my working muscle because insulin has to be there to propel some of that in the activity helps with the rest of it, it opens the doors on the muscle cells and lets the food in. So if I reduce my bazel too much and fueled along the way, I had these jumps in blood sugar that I didn't need. Whereas if I just kept my bazel a little bit lower, and I feel strategically, you know, every 20 minutes putting in a little bit of something along the course of time and hydration. Again, blood sugar stayed nice, but I also had energy to keep moving.

Scott Benner 31:38
I I should say that at the the other side of Arden's long tournament days. You know no problems like you just said with the blood sugar's throughout the tournament into the evening, their regular bolusing at dinnertime, but around late evening, 910 o'clock going into falling asleep time, all the food was free at that point, like she could eat without insulin like s and by the end when she goes to sleep. I know people see like one way or the other usually Arden's eyes closed blood sugar falls person, like so if something's not right with her insulin, when she goes to sleep, her blood sugar tries to go down. And so even if you gave her a juice at midnight, and turned her bazel off, that still couldn't catch a low after a full day of activity, you had to give her something to eat. That was substantial that would really stick with her in her system while she was sleeping. And even in the morning, even in the morning waking up like getting through the night, okay, and I've done it well and I've done it poorly and poorly would be like you know, three juice boxes to get through the night and a banana or something like that. I would call that poorly. And I've done it well where I've gotten her through with like a you know, something at the end of the day that stuck with her overnight some tamping down with bazel, stuff like that. But even that next morning when she woke up, her blood sugar's were like terrific. They were low, you needed the be of the mind, whatever the base amount of insulin was for the meal, like you know, sometimes you're like, this is two units, then the next day you're like, oh, how come it was more like four today? Whatever the right most minor amount was, but always the day after a softball tournament is all you need her insulin needs? Yep, very low. But that was, gosh, if that didn't kick in nine hours after she got done playing and lasted probably for nine hours after that. It's really it's really

Jennifer Smith, CDE 33:32
Yep. And that's what we call a Gary actually has coined the term dope, like Homer Simpson don't dough is d do Ah, delayed onset hypoglycemia essentially is what that is, right. And it is, again, this is where visually looking and seeing, you know, it was about nine to 10 hours later, that she started having a drop in insulin need. And it lasted for another good, let's say 10 hours. That's experience, you looked at our data, and you said over and over, this is what I see. So that's kind of where you have to go back and you have to look and see, well, gosh, after I have like a three hour run in the afternoon, or you know, a four hour softball tournament in the morning, I ended up being low from dinnertime all the way through the next morning. If that's the case, you can set temp adjustments down again in bazel at a strategic time, so you don't end up having to do a juice box and a bazel off for a certain amount of time because really there you're missing the boat. Right? Your that was your treating now when ahead of time had the bazel been adjusted down enough. The treatment shouldn't have been needed or less of it right? Yeah.

Scott Benner 34:45
No, I I made sure to characterize it that way. Like in the beginning like I didn't do a good job of it all. And you were just the whole evening was just like here, stay alive. Eat this here stay like this. Hey, why don't we just shut your bezel off for a while and see if that helps. That's all Call 911 stuff like that. That's not like, Oh, I'm really, really great job. You know, later, right later a great job was knowing that after dinner throughout the evening, she needed less bazel. Yeah, and that she should eat something reasonably substantial, like a little before bed, like that kind of stuff. But oh my gosh, the first couple times, you know, I did it once in a hotel room, where Oh, my god, it was just embarrassing. You're banging into thing, he'll know where everything is. And it's dark, you know? And I'm just like, what is happening? And then, you know, her alarm goes off. She's like, we have another game. And I'm like, Yeah, that's great. Because I've been up all night. You know? And then the next day, all the parents, all the parents, like, You look tired. I'm like, Uh huh. Yeah, you guys are all drinking all night. I was trying to fix this blood sugar thing. Not that all parents at sporting events are drunks, but most of them are and not a drinker. So I wasn't involved to begin with but they all were like they come down in the morning, like all hung over and I they must have thought I was just like, quietly privately drinking by myself, you know, I looked worse than they did some days. But no, but there's just so much so. So

Jennifer Smith, CDE 36:13
I kind of on the same on the same note not to interrupt but the aftermath sometimes to of exercise can happen right after the lower needs and insulin can be for several hours after weightlifters to may have that rise during but then the impact of lifting and their muscles sort of building repairing restructuring. And the insulin sensitivity sensitization that they get from working their muscles out, can have impact into, you know, for six, eight hours after where they actually need less insulin now.

Scott Benner 36:47
Yeah. I had that. I had that on my notes, like, What does muscle breakdown and rebuild, do? And what you know what to dehydration. I'm reminded about this again the other day, because I said this to a person. And it was like no one had ever said it to them their whole life. And they're like, you know, sometimes my insulin doesn't work as well. In the morning. I was like, you know, have you tried waking up and just banging down the glass of water? And they said, No, why? And I said, well, insulin doesn't get through your cells as well, if the cells are dehydrated, because then the insulin can't travel through, you know, like 10 it and as I'm singing, I'm like, God, you've never heard this before. You know, like three years with diabetes. Like I had never heard that before. It's like, I just Okay, that sounds great. I'll try that. When horns at school. Whenever her blood sugar gets sticky. The first thing I say to her is like, hey, drink some water. Let's see if, you know, we can find a simple, you know, answer to this question. So

Jennifer Smith, CDE 37:38
well, it's kind of like things just move slowly through your system. It's like your blood gets when you're dehydrated, your blood gets like sludge, or like molasses in winter, essentially, it doesn't move, nothing moves through the system very well. Nutrients don't get where they're supposed to go. Everything that's traveling there is slow. Whereas when you're well hydrated, and everything is nice and plump with water, it can move fast. It's like a freely flowing river, right?

Scott Benner 38:03
Yeah, that so. So I have to stay hydrated when I'm being active no matter what. But it is also helping me get a smooth baseline for what I expect out of my hands on and then at least when I see one way or the other, I know is real. And not because I'm dehydrated and or something. What does he eat? How does he impact blood sugars? Because you know, people in the warm weather states always report problems with their blood sugar's as soon as the as the summer comes, but I'm wondering, right, you heat yourself up when you're working out too. Is that similar? Or no?

Unknown Speaker 38:43
Um,

Jennifer Smith, CDE 38:44
you know, that's a good question about the workout. I guess I never thought about it that way. It's probably pretty similar. I'm in exercise, of course, your muscles are just uptaking glucose more efficiently, the doors are opening even with less insulin being there, they're just opening more efficiently exercises like free insulin, really. I mean, unfortunately, we can't live on exercise to use insulin, but it does help. But in the case of overall warm if you think about when you're warm, your vessels move closer to the surface of the skin or right and you sweat and you that's a cooling effect, right. It's your body's sort of way so that your you don't overheat. Well, when that happens, get more circulating. You get more circulation around the actual insulin pumped or injected site. So you allow that insulin to get absorbed faster. I guess is the easiest, most simple way to say it so in warm weather or worse when warm weather comes in. Many people do see an object a friend of mine, once April hits, she's always like my baseline Just need to go down, it's warmer outside, I know that I need an adjustment, nothing else has changed, my weight hasn't changed my in my food hasn't changed, and I am just outside more, it's warmer, she needs less insulin, and then it might go up again in fall and or winter. And exercise, obviously that heats you, you get a lot faster circulation, I mean, that's the benefit to your heart, your you know, circulatory system is exercise does your heart good, makes it pump harder. So with that, and the fact that you're getting warmer, you just get a faster circulation of insulin essentially. And we we

Scott Benner 40:35
haven't really said this here, either, but you have type one diabetes, or the person we're talking about does exercise is very important to you. So this is a piece you have to figure out, you can't just say, I can't figure out exercise you you need exercise, you know, everyone does, but you know, people with diabetes needed maybe a little extra because you're trying to keep your body healthy. While it's trying. While it's trying to, you know, that's trying to beat you up, you need to you need to take away as much power from that as you possibly can.

Jennifer Smith, CDE 41:03
And as a weight management strategy, sort of in the same realm of it needs to be something that happens every day. And many people with diabetes are really struggling and really trying to keep a healthy weight. If you can strategically plan your exercise in the aftermath of a meal. As I said before, you could potentially use less insulin then because you're planning the exercise in a timeframe of after insulin has been injected to influence going to work better, you're also going to enable your body to burn more of that fuel off. Right. So it's a good strategy to just all around, then workout, eat and then workout. Again, ability to reduce the amount of insulin again, prevention of lows, but also just burning calories and not having to take as much insulin. So

Scott Benner 41:57
doing what you what you wanted to what you what you intended to do. When you when you decided to get up and go exercise. I want to look right very quickly, too, because Chris Rutan was on the podcast and we talked a lot about we talked a lot about this kind of stuff, too. And I just want to be able to tell people what episode that was. Be nice if I could figure it out. I am the guy with the podcast you would think I wouldn't know. But well, there are so many of them. Well, that we are getting to that spot, aren't we? I can't figure out what should people like what episode Am I don't know any more. Let's see Where's All right, I'll have to figure it out and plug it in. Jenny's got her own life. She's got to get back though. I will figure it out. And you'll hear it edited. And right here. Chris Rutan was on episode 201. Jenny, is there any anything else that you think we should talk about here?

Jennifer Smith, CDE 42:52
We could probably go on and on with more like advanced stuff. But overall, I think those are the good basics to start with.

Scott Benner 43:00
Yeah, I think this is what we're looking for a basic invoke, we'll hit more advanced things in another episode. Let this awesome. Cool. All right. Well, thank you very much. Thank you. Some quick stuff. There's just a couple days left to enter my giveaway. It's the end of August 2019. If it's past August 2019, forget it. But right now there's a huge giveaway going on, go to Juicebox Podcast calm. There are a ton of great prizes for this giveaway. But among them is a free 30 minutes of talking with Jenny Smith. So if you love talking to Jenny here on the podcast, you know where she's talking and you're talking back to her in your car. Imagine if she could actually hear you. There's nothing to do to enter give it a shot you might want. Thank you so much to Dexcom on the pod and dancing for diabetes, for sponsoring the Juicebox Podcast. These people have been with me for a very long time. And they help keep the podcast free. So give them a shout write check them out of their links or, you know, just find a way to support them. Like for instance, dancing for diabetes has instagramming now, so does Omnipod and Dexcom. Follow them. Do something like that. When you see them online, be like Yo, thanks so much for sponsoring the Juicebox Podcast, whatever you're gonna do. Give them a little Hey, hey, you know, so let me thank you here for all the great reviews. The merchandise are buying the T shirts, I'm starting to see pictures of you guys out in your real lives. We're in shirts that say like stop the arrows and be bold. Very, very cool. All right, there'll be a new defining diabetes this Friday. And then we're going to get into the fall, run, run. My next episode with Jenny Smith will be up in a month. It's going to be about fats and proteins and how to Bolus for them. The month after that. The next episode with Jenny is called Ask Jenny. It's gonna be the first episode where your questions are what I asked Jenny

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