Scott Benner 9/10/21 Scott Benner 9/10/21

#540 Diabetes Variables: Stress

Diabetes Variables: Stress

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 540 of the Juicebox Podcast.

Jenny's here today to do another diabetes variable with me. And today's topic is stress. While you're listening today, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please always consult a physician before making any changes to your health care plan for becoming bold with insulin, know this as well. Jenny does this for a living. If you want to check her out. Go to integrated diabetes comm you can hire her. Hey guys, please don't forget to go to T one d exchange.org. forward slash juice box and fill out the survey you'll be helping people with type one diabetes and supporting the show. If you do that, it really does just take a few minutes. It's HIPAA compliant. Absolutely anonymous, you do need to be a US resident who has type one, or is the caregiver of someone with type one. But otherwise, if you haven't done it already, please go fill out the survey just takes a few moments.

This episode of The Juicebox Podcast is sponsored by the Contour Next One blood glucose meter. Head over to Contour Next one.com Ford slash juicebox. To find out more links to Contour Next One comm forward slash juicebox as well as all the sponsors are right there in the show notes of your podcast player. We're at Juicebox podcast.com. When you support the sponsors, you're supporting the show, so allow me to thank you right now if you've used any of those links, or if you're considering using any of them. Alright, let's get to Jenni. How does stress impact blood sugar's?

Jennifer Smith, CDE 2:12
Do you want to talk or should I?

Scott Benner 2:14
Well, I mean, it seems it seems obvious, but it's not because I've spoken to people who get stressed out and their blood sugar's go down. So I'm wondering what you've seen from people on both sides of this.

Jennifer Smith, CDE 2:30
I've seen more people who have an impact of stress with a rise in blood sugar or an increase in their insulin need. It isn't to say though, and a good friend of mine, her level of stress, just like her level of like adrenaline rush causes her to need less insulin. Okay, like race morning, she is cutting her insulin down while the rest of us are like rage bolusing

Unknown Speaker 3:02
blood sugar.

Jennifer Smith, CDE 3:03
She's like, what do you guys all doing? Like you're sitting at like 82 like going down? down this high. Right? But yeah, I mean stress the same thing. For the most part stress will cause a rise in blood sugar relative to that like mental strain. It's kind of putting I mean, and then you have to determine the type of stress right? Is it a mental stress? Is it something that you're really working through? Is it a lengthy stress like several days worth of something happening? I mean, one stress I can say personally really increased my insulin needs was when my dad passed away, okay. I mean that week with going to family helping my mom out with a week and a funeral and everything in the process. I was using like a 75% temporary increase in my basil. Okay,

Scott Benner 4:00
well, it was a lot I'm looking here and long term stress can increase depression caused headaches heartburn, insomnia, weakened your immune system. Make your breathing rapid puts you at a risk for a heart attack. It can bring up your blood sugar, your blood pressure, pounding heart fertility problems, stomach aches, low sex drive, erectile dysfunction, miss your periods, tense muscles and high blood sugar. Yes. So when you're under stress, it is not healthy for you know, that's obvious, but it actually can impact your blood sugar. And I don't know if people would consider that or not.

Jennifer Smith, CDE 4:37
Yeah, and you know, in terms of that effect, you also then have to look at the length of time that the stress is going to happen for and if it's already impacted these other health pieces. If you've ever been under significant like work related stress in the past year, then you may have caused injury really too many other pieces. Have your body which until they get healed is likely causing inflammation and inflammation in and of itself also increases blood sugar increases your insulin D input increases resistance to insulin. So stress is bad.

Scott Benner 5:18
And well, I guess what I'm thinking is, like we talked in other variable episodes about, like, you know, I said, My daughter gets into the shower and her blood sugar goes down where a lot of people, you know, would say that might be heat, I kind of think that she's relaxing. Sometimes I think of it that way, like, and can you just chill out? And is that possible in our society, the way the way our days are set up, right? Like this is way more about, you know, your general health than it is about maybe blood sugar health, like sure. stressful moments can make your blood sugar rise, you should be aware of that. I've seen notes from people who have car accidents fender benders, right? And boom, you know, their blood sugar goes up, you think, well, that might be adrenaline, but then it stays like that for hours and hours. And if that's

Jennifer Smith, CDE 6:03
more that fight or flight, that's, that's

Scott Benner 6:05
okay. But yeah, I mean, I realized that this is somebody telling you be generally healthier, and you'll be generally healthier, which is obvious. But it's, um, stress can cause your liver to release extra sugar into your bloodstream, which over time puts you at risk for type two by diabetes. This is telling me here, meaning that if you're a long term stress, you're hurting yourself long term. Right? Wow. So is I have to say I use a breathing app on my phone. It's really helpful. I mean, just got one on my watch. Yeah, yeah, a couple times a day, it, it pings me, and I spend 60 or 90 seconds doing some sort of in and out breathing. It's kind of nice. I mean, I'm sure it would be better if I moved to Wyoming and lived on a hill and a cabin, I'm sure I'd be less stressed. Although I gotta be honest with you. I'd the entire time I'd be like a bear is about to kill me. I'd be incredibly stressed out by that. But you have to find a way to overall lower your stress. But in the moment, so in the moment when it happens. Do we Bolus weren't

Jennifer Smith, CDE 7:13
in the moment for stress is kind of like the adrenaline Bolus consideration, right? Do I Bolus for the stress in terms of like the car accident example. And my blood sugar's now shooting through the moon, you could Bolus at least minor amount. Because obviously, the incident as well as the skyrocketing blood sugar is not going to create anything that's more even flow. It's just gonna keep increasing your anxiety.

Scott Benner 7:45
Let me ask you a question. A personal question before we wrap this one up?

Jennifer Smith, CDE 7:49
Yeah. Do you?

Scott Benner 7:51
Are you so in tuned with yourself? That you always know because it's unfair, like you're here, like this front facing image of you is Jenny, who knows about diabetes, but you're a person to like I actually want to do and I want to interview completely about burnout just one day, like, like, away from all this, like the baby stuff. And but if you're stressed out, if your kids are struggling with something, and your husband's being a jerk, and somebody else is doing a thing, like Do you notice that? And how quickly Are you able to say to yourself, my life is more stressful right? Now I need more basil? Like does that in a real world situation? Does it work?

Jennifer Smith, CDE 8:34
in a real world situation, if you have enough awareness of everything that's happening, it can work to use a temporary increase to basil. I mean, many people I know who are using a pump, you know of whatever kind of pump you're using, have either a basil profile that may be termed stress, or they have a temporary basil kind of setting that's specific to stress increased need. I've got an override that's already programmed for stress. Thankfully, I don't use it very often right now. It has happened. I mean, in terms of like life, things happen, you know, somebody might need some additional help in the family. And beyond that you don't have time to take off of work. So now you're juggling and juggling and sleep, you might get three hours a night instead of your eight hours a night and that can definitely increase you know, but personally, yes, I've, I feel like at this point, I know myself well enough to be able to say my kids spilled the milk all over the table. That's not going to cause my blood sugar to go to 250 I'm just gonna tell him to get a cloth and clean it.

Scott Benner 9:49
I asked because I've become much more in tune with the idea that people have anxiety since I've been doing the podcast because I am a person I get up in the morning. You know what I'm thinking about nothing. I go do the thing I'm supposed to do, I do it as well as I can, if it works out great. If it doesn't, whatever, you know, and I move on, right? But I see my wife get out of bed. And she, you can like, look her in the face. And she's going through a checklist already. She knows what's happening today. And if what's happening today is something she feels like she can't keep up with. It stresses her out. And I've just talked to too many people at this point, who live in that reality. And I just wonder. I mean, it's, it's too simplifying to say to them lower your stress, because they're like, yeah, da, thanks. I can't, you know, so. I don't know. Just

Jennifer Smith, CDE 10:41
I know myself, you know, in terms of like, as you asked me, personally, I know myself enough to also say that I'm kind of like your wife in terms of like the morning time. I'm German. I'm a little bit like, like strategy, figure it out, apply it kind of you know, so in the morning, especially on the weekdays, I know my checklist of things, I have to do this, I've got this many people to talk to, I've got to attack emails, I've got a project, I've got a podcast with you. I've got, I've got this checklist of things. And I keep moving through it through the course of the day. But a stress to me, that would increase like my need for insulin overall would be something major happened to like a family member, and it's blowing all those things on my checklist, like they're now off the list. And like this is an immediate and I'm like, okay, must assess and redo and plan differently. And I

Scott Benner 11:43
only worry about my kids and my wife like that. I don't worry about anybody else. Like when I get in bed at night, I can see Kelly going through that like wind down thing she does. Like I feel terrible. Because all I'm really concerned about what is like are the blankets where I wanted to be and do I have my pillow flip the right way and is my phone on its charger. And once it is on like goodbye. And then I'm just asleep. where she's, you know, trying to decompress and trying not to think about tomorrow. And I feel terrible for anyone who's caught in that because it really is, it really seems like a place he can't get out of

Jennifer Smith, CDE 12:20
you. In terms of like overall stress that's I use that that breathing app like you talked about, I use that because especially in the evening time I really tried to stay away from like, technology itself, right within about 30 minutes of actually like getting in bed and trying to like fall asleep. Because that I found is a big impact for me. I have like one of those mindful adult coloring books.

Unknown Speaker 12:50
adult coloring book, it's just kids,

Scott Benner 12:56
let me clarify for Jenny. They're there. Because my wife actually has these two. They're very intricate, pretty pictures, not naked people having sex. I got your

Jennifer Smith, CDE 13:05
intricate pretty flowers and deer and fish. And yes, there was funny to watch you catch yourself. Anyway, but things like that to kind of do that decompress. And while my brain has an idea of what's coming in the next day, I'm really not too like focused on it until the next day, because I've found that I don't sleep.

Scott Benner 13:27
Here's an interesting question. And I will let this go after that. But say I'm pre diabetic, right? I'm like, type two diabetes is coming for me. And I'm also an incredibly anxious, stressful person. Is there a world where and I'm not pushing medication. But if a doctor prescribed like, like an SSRI or something like that, to take care of the anxiety that as the anxiety went away, and the stress went away, the blood sugar impact would go away as well, to some degree, I mean, could you get some win out of that?

Jennifer Smith, CDE 13:58
You could get some win out of that. I mean, we always try to encourage people in terms of like lifestyle change to actually make a lifestyle change rather than a medication addition. But yes, in all, whatever type of stress reduction you put into play, could have enough impact that that person on the path that they're on whatever stress management strategy they're putting into place could make them turn the road down the path that's going to prevent that now they're going to have to continue whether it's now I start taking a mile walk every morning, because it decompresses me, I think through what's coming for the day, and I'm ready, maybe they choose to start eating broccoli now rather than a handful of potato chips at lunchtime. So there might be other little things that they could do along the way that impact the stress that's on their body helps them to feel better or decreases the chance of type two or any other health condition itself, which in and of itself is a decrease for anxiety as well. Right? If you know you're doing something good to prevent something,

Scott Benner 15:05
even if it bolsters you, I have to say it would be criminal Not to mention in a even in a short conversation about stress, that activity, you know, of any kind is, is really good for your mental health, it just really is. So, okay, well, thank you very much. Friends, if you're enjoying the variable series, I'm going to list all of the available variable episodes in just a moment. But first, I need to tell you actually, I want to tell you about the Contour Next One, blood glucose meter, you know, bare bones, simple cell, it's really, really accurate. And that's incredibly important, especially in a world where sometimes we just get the meter that someone gives us, you can actually make a choice, you can choose an accurate, reliable meter. And the Contour Next One, in my opinion is exactly that. Not only is it easy to carry, easy to read, easy to see at night, but it has Second Chance test strips. So you can go in for some blood, get some but not enough and head back for the rest without impacting the accuracy. We're ruining the test trip. I don't know what else you want in a blood glucose meter. I mean, if you want it to be Bluetooth enabled so that you can launch an app on your phone and see your records. It does that. And it works fine if you don't want to use the app. So there's a lot of flexibility in there for you lets you choose. I mean, really, it's just a great meter. So why don't you check it out, it's super simple to look into Contour Next one.com, forward slash juicebox. He may be eligible for a free meter, there's a test trip savings program that you might find eligibility in. And it's possible that all of this could cost you less in cash than you're paying right now for your current meter through your insurance, I think I'm not sure. But it could work out that way. And if not let your insurance pay for Contour Next one.com forward slash juicebox. If you have to have a blood glucose meter, you might as well get a good one.

First, I want to thank Jenny for lending her expertise to the shell. Don't forget, you can find her an integrated diabetes calm. I want to thank you for listening. And I'd like to remind you that there are others in this variable series. trampolines, temperature travel, exercise, hydration, food quality, leaky sites, or tunneling video games and today's stress. There's one coming every week, this variables list is compiled by listeners just like you, we did it over on the Juicebox Podcast Type One Diabetes private Facebook page, if you're not a member, you should go check it out. We do stuff like this all the time over there. Listeners just like you made a list that is so long that there'll be variables episodes coming for ever I feel like but for now, just once a week, I'm gonna let you go in just a second. But if you're not part of that Facebook group, I wish you are. It's private. And it's full of people just like you. It's a matter of fact, I think this month, September 2021, I'll be celebrating 4 million downloads of the Juicebox Podcast. And I think I'm gonna do it with a like a q&a, I'll probably just jump on Facebook Live, or do it through zoom or something like that. And if you want to know about that, I'll be announcing it there. So I hope you'll become a member. There's you know, it's absolutely free, obviously. I mean, I hope that's obvious Juicebox Podcast, Type One Diabetes to private group, you'll have to answer a couple of questions to prove to the algorithm that you're a human being. And then after that you'll be in and talking to other listeners, just like you. Hey, thanks so much for listening, and for supporting the show. I really appreciate it. I'll be back soon with another episode of the Juicebox Podcast. Please continue to share. Subscribe in a podcast app, tell a friend. Leave great reviews wherever you listen, that kind of stuff is all very supportive and super, I mean helped it. Take the T one D exchange survey. Support the sponsors. All right, that was choppy at the end, but you get the point. I appreciate you. Thank you so much for supporting the show. I'll be back soon.

#535 Diabetes Variables: Video Games

Diabetes Variables: Video Games

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

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Scott Benner 0:00
Hello friends and welcome to Episode 535 of the Juicebox Podcast.

Jenny's here today to do another diabetes variable with me. And today's topic is video games. This is the eighth in the diabetes variable series. So far we've covered trampolines, temperature travel, exercise, hydration, food quality, leaky sites, or tunneling. And of course today, those good old video games, there's also a diabetes protest episode about variables that is Episode 231. If you haven't heard the diabetes protests, I wish you would give them a try. They begin at Episode 210 where you can find them at diabetes pro tip.com. Please remember while you're listening today that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. Today is a pretty short episode there's only one ad and I think the episodes about 15 minutes long. I hope you enjoy it. This show is sponsored today by the glucagon that my daughter carries g vo hypo pen Find out more at G Vogue glucagon.com forward slash juicebox g vo hypo pan has no visible needle and it's the first premixed auto injector of glucagon for very low blood sugar in adults and kids with diabetes ages two and above. Not only is chivo hypo pen simple to administer, but it's simple to learn more about. All you have to do is go to G Vogue glucagon.com forward slash juicebox G voke shouldn't be used in patients with insulinoma or pheochromocytoma. Visit g Vogue glucagon.com slash risk. Well, here's one that I hear from a lot of moms. I don't want to be too specific, but a lot of moms of boys usually my kids blood sugar shoots up and they don't just mean 40 or 50 points. They're talking about 202 50 when they play video games is that adrenaline? That's adrenaline. That's people should know that.

Jennifer Smith, CDE 2:43
It's and I think you're right in terms of video games and maybe the type of person who might be playing one video game versus another. I mean, I like age old like Mario Brothers I can guarantee you my blood sugar was never going up when I was playing Mario Brothers with my brother as a child okay, but I can probably say that if I could go back if I was doing some of the the Olympic ones where you were like competing against the other person like you were doing jumping and even though it wasn't an activity my brother and I were very competitive in that in terms of who did better so I would guess without knowing I didn't have achieved CGM at that point but I would guess that my blood sugar probably went up a bit

Scott Benner 3:34
I'm picturing you trash talking to your brother playing we bowling right now.

Jennifer Smith, CDE 3:39
Oh it wasn't we bowling It was like Do you remember the old like you had to do like the lock you had to like run run run and then do like the long job kind of thing like the old school Nintendo right Yeah, no

Scott Benner 3:51
kidding like can you get moved in? So that's interest but

Jennifer Smith, CDE 3:55
today's games

Scott Benner 3:57
the first person shooters and that's stuff that feels like you're really doing specially

Jennifer Smith, CDE 4:00
the virtual ones the ones where you have the visual the goggles on you are almost immersed in that setting. And many times there will be a rise especially if it's any of the what I call more violent ones. You know the games where you're really like shooting and killing or you're battling the zombies are these like demon looking creatures?

Scott Benner 4:26
I've been scared I've sorted for my son shoulder and watched it been like this is kind of Loki frightening. Yes, and I know I'm okay I'm so I wonder too. I would love to hear from somebody I wonder if it is that competition piece. coupled together with the frightening like intense nature of it like all that together just drives out of nowhere. So do you Bolus for it?

Jennifer Smith, CDE 4:57
I usually recommend paying attention too What ends up happening, because a first visual is often what parents see in activities or competitions, sport, not obviously the practices. But typically the sport on the weekend where you're doing a tournament or a game against your ATM, you know, rival or whatever it is, this spike in blood sugar, we can either see, blood sugar sits high, and you do have to take care of it, or it's just high the whole game, or it spikes. But then as the kid keeps moving things even out and they end up coming down without correcting the adrenaline rush at all. So the piece in the picture of these games is, is it a seated adrenaline rush type of game? Or is it one in which you are also moving along with the game? That may be the difference of correcting? or letting the rise happen and letting it even out?

Scott Benner 5:59
Is there an impact about what happens after the game? So if I kill the zombies, jack, my blood sugar up and then sit down? That would be different than if I did that and began to move around afterwards? Because the movement might have a blood sugar down. But if you go from a jacked up adrenaline to sedentary or into bed or into a meal, right, then you're not Yeah, then those other variables are going to keep the adrenaline from because I've seen I think there's a fairly common story that I have told on the podcast a number of times about noticing that Arden was competitive at sports, and learning to Bolus for it. But the other you know, the end of that story is, yes, it kept it down. But then she needed food later, I was basically Pre-Bolus Singh food, and the Pre-Bolus was handling the spike of adrenaline. And then afterwards, it needed to be fed.

Jennifer Smith, CDE 6:53
Or it was like the end of that insulin action had to be taken care of.

Scott Benner 6:57
Yeah, the adrenaline bump in blood sugar was not enough. How do I mean this, the the insulin, the amount of insulin I used was necessary to keep her blood sugar stable through the adrenaline. But as soon as the adrenaline was gone, there was still insulin leftover and it needed carbs.

Jennifer Smith, CDE 7:16
Right especially considering it's on the back end of exercise, which enhances insulin absorption for a couple of hours after in most cases,

Scott Benner 7:23
which is why aren't always got waffles after basketball. So it was like a nice little pre planning thing. Like I still would listen, I used to do the same trick afternoon at high school, she'd get higher 1231 3230. But she was always hungry after school. So I was aggressive through that afternoon, knowing that there was going to be food right at three o'clock. Right, you know, and then that's, that was one of the ways I was able to stay on top of that kind of blood sugar problem without causing a low later. Right. So video games, and that's just, it's confounding to people when it happens then once they see it, they're like video games make my kids blood sugar go up. I wonder. I wonder if it says frequent with girls as it is with boys.

Jennifer Smith, CDE 8:11
I would expect it's it depends on what their interest is. Yeah, you know, a lot of the girls that I work with who are sort of in that like eight to 12 range where they're sort of getting into like the dance dance type of game or whatever it is. They're excited about doing it. But that's that's like exercise they're moving and so their insulin needs actually obviously go down. I wear a lot of girls games girls specific I guess if we're terming them boy girl games, which they're not really anything. Yeah.

Scott Benner 8:49
No, I mean, like, I wonder how many people who are, you know, who are girls are into like, thrashing zombies in video games. It seems like a I mean, I don't know I'm using my

Jennifer Smith, CDE 9:02
I would guess that if there was a group of friends that was very interested in doing it all together, regardless whether they were boys and girls, they just wanted to hang out and they were all doing that. And

Scott Benner 9:13
I just wonder if like internally in their brain they have that same like, kill it, stomp it I'm amazing. Let me win feeling like I want to hear from somebody who's got a little killer for a daughter. Outside just running through things constantly.

Jennifer Smith, CDE 9:28
The warrior ninja child.

Scott Benner 9:37
A huge thank you to one of today's sponsors. g Vogue glucagon, find out more about chivo Kibo pen at G Vogue glucagon.com forward slash juice box. you spell that GVOKEGL Uc ag o n.com forward slash choose ba If you'd like to hire Jenny, she works at integrated diabetes comm go check her out. Thank you so much for listening. I'm gonna put a little bit of information after the music about the pro tip series and the defining diabetes series. But if you already know about that stuff, pace, you're done.

Alright guys, there's some series within the podcasts that are about management. I mean, you're listening to one now variables. There's also the defining diabetes series, which goes over jargon, tools, ideas, but there's also the diabetes pro tip series. And I want to read you just one piece of feedback that I got from a Facebook user just a couple of weeks ago. It said, I've been listening to the podcast since May of 2019, when my son was diagnosed, without all of your help, advice, tips, education, we wouldn't be where we are now, a one C in the fives this last year, brought it down from 11.3 diagnosis, no food restrictions. And I swear my child doesn't even know he has diabetes half of the time. That's from Christine, I could read you hundreds and hundreds more. But instead, I would just like it, if you check out the diabetes pro tip episodes, I've tried to make them easy for you to get to because I realized there's so many episodes in the podcast. So you can go to Juicebox Podcast COMM And at the top, just click on diabetes pro tip. actually gonna make sure I'm telling you the right way Juicebox Podcast calm diabetes pro tip will take you right to it. Or there's a direct link, diabetes, pro tip.com. At diabetes pro tip calm, you'll have access to all of the pro tip episodes. So you can write down the numbers and go find them in your podcast player or just listen to the mirror online doesn't matter. You'll also have access to the defining diabetes series, please just check them out. They're very worth your time. I saw a mention of the podcast and one of the Dexcom groups I follow on Facebook, the pro tip series is filled with such great information. Thank you. For someone who has been living with diabetes for 30 plus years, I wish I had been more proactive in finding this information sooner. I'm going to recommend this to my endo. I'd love it if you could be the next person to leave a review like that. And I think you could, if you just check out the pro tip series. I don't know how many episodes there are at this point, maybe 20 could listen to them at your leisure. They're absolutely free. The whole podcast is always free. I don't think it would take you that long. But I do think they'd really be valuable for you. So I hope you check them out. Thank you so much for listening, for sharing the show with others. And for downloading it in your podcast apps that I'm positive you're subscribed in. Please tell me you're subscribing to your podcast apps, please. Thank you. If you don't know what a podcast app is and you want one, go to Juicebox Podcast comm or diabetes pro tip calm there's links to the most popular ones. They're all free. You should not have to pay for a podcast app, Google podcasts, Spotify, Apple podcast, Pandora, Apple Music, Android, just there's it's an endless list of ways you can listen you can basically listen anywhere that you get audio.

#530 Diabetes Variables: Leaky Sites/Tunneling

Diabetes Variables: Leaky Sites/Tunneling

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

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Scott Benner 0:00
Friends Hello, and welcome to Episode 530 of the Juicebox Podcast.

Jenny and I are going to talk about another diabetes variable today. And today's topic is called tunneling. But you may think of it as a leaky site. So I'm still deciding at the last minute what to call the episode. But once you get in here, you know, then you'll see the whole thing. Please remember, while you're listening that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please always consult a physician before making any changes to your health care plan, or becoming bold with insulin. If you want to hire Jenny Smith, she works at integrated diabetes.com Check her out. And while I'm talking about stuff, let me remind you that I really appreciate when you share the show with other people. That's it, the show is growing incredibly fast. It is getting silly, silly amounts of downloads. And that is because of you. And I want to say thank you. So thank you very much for listening, for subscribing, and for sharing.

This episode of The Juicebox Podcast is sponsored by the Contour Next One blood glucose meter. In fact, the most accurate and easy to use blood glucose meter that I have ever used. Contour Next one.com forward slash Juicebox. Podcast is also sponsored today. By Dexcom, makers of the Dexcom g six continuous glucose monitor, you can find out more or get started today@dexcom.com forward slash juice box.

Jennifer Smith, CDE 2:05
Is the sound better? By the way? I guess you probably wouldn't be able to tell until you listened. But I I got a really long cord.

Scott Benner 2:14
Okay, and you're back in the other

Jennifer Smith, CDE 2:16
100 foot cord. And it's like out of my office down through our house down into the basement where the thing is. And so I'm back in my office small space. Right. So hopefully it won't echo is my show sound nice.

Scott Benner 2:33
Thank you. That was very nice. I would record you didn't have to buy Oh,

Unknown Speaker 2:36
god it was 20 bucks. Okay. All right. Deal. So yes, no, that's very nice. You're very kind to do that.

Scott Benner 2:44
Okay, so you brought up a topic, you sent me a note and you're like, you know, we should talk about tunneling. And I have to admit, I thought to myself, tunneling sounds like with those characters on Hogan's Heroes we're doing all the time when I was a little kid watching that show. And then I thought, well, Jenny knows I wrote it right on the list. And no lie. Four days later, I get a note, like an email, like something someone had to like, sit down and compose from a woman who said, Hey, could you and Jenny talk about tunneling? I thought, get out of here. Like, it's

Jennifer Smith, CDE 3:19
really funny. What works isn't like quite

Scott Benner 3:22
a coincidence. That's fine. So I don't know what it is. I'm just gonna be honest and say it.

Unknown Speaker 3:28
Really? Yeah. I

Scott Benner 3:29
mean, I, when you said the word, I started imagining what I think it is. I'm probably not far off. But I had never heard the phrase.

Jennifer Smith, CDE 3:38
So yeah, I mean, you're, you're probably not far off. I mean, you're a smart guy. So I'm quite sure that you can probably guess honestly, but it's most common with straight inserted Teflon infusions that's most common. It's really when the insulin that goes in through that infusion set or through the canula. And it's supposed to be get kind of dispersed under the sub q tissue absorbed, blah, blah, blah. It doesn't it sort of pools at that infusion site, and then because of that, it leaks back up. If you imagine the sides of the canula, right, it leaks back up the sides and it leaks out the top, so you're essentially losing insulin. So the most common are kind of the straight in infusion sets, especially the ones that are not very long, the shorter as well as it happens in larger doses. Typically, you're not going to see it in a dose that's like a unit. But if you've got pretty hefty donut boluses donuts, maybe I'm hungry. I don't know I ate breakfast this morning. If you've got pretty hefty boluses eight units, plus, you could potentially see more of That tunneling happening tends to be reduced in sets that are more the angled sets. Or especially for those who use the 90 degree set, if you can choose the steel canula, that goes straight in kind of like a foam tack, it doesn't tend to be as common to happen with that.

Scott Benner 5:22
So where would we see that? So I know on the pod goes in on an angle. And that's not the case. And I do know that people use like 90 degree sets that are plastic, and I've heard people say, Oh, if that one doesn't work, if the if the plastic handle doesn't work, try to steal one. Yep. Right. And well, so what you're making me feel like is, I don't know, has anyone ever, like, taken the garden hose and like, jammed it down into the mud, and then hold it there for a second, and then the water starts pouring back up like that. That's it. That's what's happening.

Jennifer Smith, CDE 5:53
That's exactly right. Yes. And, you know, it does also happen in more common, I guess, lifestyle types of activities that can be prone to like pulling, or yanking on the site, things like golfing, things like tennis, where you've got those swift movements, especially with tube pumps, that you can get that because anytime there is a yank on that tube, it Yanks the infusion set sitting under the skin. And another reason for tunneling is inflammation of that tissue underneath the skin. So as it gets inflamed, anything that gets inflamed gets puffy or swollen, right? And that creates more space. You would think if it gets swollen, it would create less space like it would squeeze the canula. It doesn't it actually creates more space expands. Yeah, right, it expands. And so the tube itself, the canula has more space to move, and insulin can leak that way as well. So

Scott Benner 6:58
we are counting on on some level. Anytime you put in an infusion set you're counting on so tenuous. Now that I'm thinking about it, you're counting on your body just sort of healing around that tube just a little bit to create a seal. Correct. And you start and so if you have a tube pump, the tubing gets pulled, that seal gets broken, if you're twisting or turning, it could get broken. And then you get what I would just call leaking. I didn't realize people called it tunneling, but like the site leaks is how I Right, right. Yeah, but that's specifically what's happening.

Jennifer Smith, CDE 7:31
It is exactly and you can tell, honestly, I mean Omnipod you can often tell because they do because there's insulin that kind of leaks around that edge. Or oftentimes you'll see liquid in that viewing window area. I mean, there should be some degree of condensation over the wear of a pod, not from me,

Scott Benner 7:53
do you know why? What do you do? What's your magic. So after I pop the little plastic, like safety tab off the Omni pod, we take a clean tissue and twist it like and we we dab the liquid

now people listening just heard of very weird diabetes like nerd that moment. Because if I take the liquid out that I can trust, if I see liquid in the window, that sounds coming from the site,

Jennifer Smith, CDE 8:27
right? Because you can usually tell liquid versus again, condensation, I mean a really hot sticky day or if you're sitting in a sauna or something like that, you may get some visible like clouding condensation in that viewing window. But it shouldn't be liquid to the degree that you can physically like see it almost if you've ever had like a bloody sight, you can see the blood sort of pooling in that area. It's the same thing with tunneling of insulin. And on the pods, I've, I've noticed more than with tube pod to tube pumps, that that adhesive that's right around that curved area. If you've got a leaking problem, it's going to be wet there too. Let's face it, it's Yeah. Um, so I mean, some ways around it are for those who are more active or have more movement to their day, or just kids who are just more prone to pulling on a tube pump, potentially. I mean, there are some tricks things like using the product called iv 3000. It's like a really thin, clear sort of bandaid, almost hypoallergenic, you put it down on the skin, you essentially put the site over that and let the canula go in and through. And then you put another one on top of it almost sandwiching the infusion site, so that what happens is you minimize like the movement, okay,

Scott Benner 9:50
so like there's no tectonic shift, sort of like that. That's correct.

Jennifer Smith, CDE 9:55
Yeah, the other one is and this is actually with and maybe Part of the reason that it's better with steel camulos is that the steel Canyon has a site. And then it has a short amount of tubing that connects to another, not a site, but almost like another little adhesive area. So you've got the site tubing, a site that holds that secure, and then the tubing that goes on from there. So another recommendation with non steel cannulas is to just take about a two to three inch section after the canula and adhere it to the skin using some type of you know skin.

Scott Benner 10:40
Okay, so if you're if you're using tubing, you go a couple inches away from your site and here the tubing to your skin. And that way pulling on the tubing pulls on the fixed site, not on the

Jennifer Smith, CDE 10:50
not so much on the actual infused area.

Scott Benner 10:53
Yes. Is this more common in certain body styles or types or older or newer sites or anything like that.

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Jennifer Smith, CDE 15:06
Definitely, I mean, you bring up a good thing about, you know, just the rotation of sites, obviously, because if that is going to be a reason for tunneling, older sites, sites that have more scar tissue, again, scar tissue is going to be less mobile or less, you know, flexible, I guess is the better word. So you're going to have the tissue that's hard, and has more ability for that canula to kind of have wiggle room.

Scott Benner 15:34
Alright. But not like I'm thinner, I'm heavier, I'm older, I'm young, none of that stuff happens.

Jennifer Smith, CDE 15:40
That doesn't seem to be it's much more the insulin amount, and then the movement itself of that particular person's lifestyle.

Scott Benner 15:50
So if I just sit perfectly still, I'll be okay. And don't eat a lot of food don't eat the Bolus. So you're saying if I could just basically get rid of diabetes, and this tunneling thing wouldn't be much of an issue at all.

Jennifer Smith, CDE 16:02
Right? I mean, in terms of in terms of the insulin doses themselves, knowing that we obviously have to use insulin. Sometimes using the fancy features on a pump can be more beneficial to dispersing insulin slower. So using things like an extended Bolus with a portion of a large Bolus, now a portion extended out a little bit more slowly. I know some of the insulin pumps. I know tandem does it. I can't remember I don't think that Medtronic allows you to change but tandem allows you to change the rate at which your insulin gets dripped and on boluses. And so slowing that process down even in a small amount can sometimes help that Bolus get absorbed. I've

Scott Benner 16:51
often used a 30 minute extended Bolus to bridge a gap like while Arden's leaving a class going to lunch like if like if her blood sugar 78. And I still want to Pre-Bolus but I'm like, Well, I don't know how we're gonna do this. Like I can't put it as much as I want, because she's going to be low before she eats, right? I would do like a 0%, upfront, and all over 3030 minutes. So you kind of get it in on time ish. But it's not all in there that seems like that might help that, hey, this is making me wonder do people with higher basil rates, Basil? How do I just miss pronounce basil to people with higher basil rates? Go through this more often. Do you think

Jennifer Smith, CDE 17:33
like we would expect? So I mean, I would say yes. In general terms, yes, mainly, because if you've got a higher basil rate to begin with, you also have much larger boluses. I mean, think about a Basal rate that's like 1.75, you're not going to have an insulin to carb ratio of one to 30. And if you do there, something's not set. Something's wrong. start over again. But you would expect that with larger basil, overall, your sensitivity to insulin is lower. So you're going to need larger Bolus as well. So another thing that kind of goes along with decreased chance of tunneling, especially with larger insulin dose, is making sure that you're changing the site more frequently, okay, you might need to change the sight, despite your pump holding 300 units of insulin, you might need to change it once you get to two full days, and nothing beyond that, regardless of the amount of insulin, you know, in that large amount, you might make it to two days. And that might be it.

Scott Benner 18:33
Could you cheat a little and split your Bolus, and inject some of it, if this was an issue,

Jennifer Smith, CDE 18:38
you're kind of getting into all the realm of what I do in pregnancy with women who've got really high resistance before they get pregnant. And we know that their insulin needs are going to be just exorbitant by that third trimester, we pull a lot of tricks out of a hat, I mean, we sometimes cover 50 or 60% of the basil with a basil injected insulin and take the basil that's pumped in way down, then we may even use you 200 insulin, which gives you two units of action per one unit of an actual dose volume. So then instead of a Basal of two, you get down to a Basal of one, but you're getting the impact of a Basal of two. What is that called?

Scott Benner 19:19
I can't think of the word all of a sudden when people only Bolus with their pumps, but they use an injected Basal insulin. They call it something

Jennifer Smith, CDE 19:28
really, I don't know the name for that. But it's

Scott Benner 19:30
right out of my How could two people who twist up a tissue and dad out the couple of drops of insulin on the pod not be able to remember that word?

Jennifer Smith, CDE 19:39
I don't know what that's called.

Scott Benner 19:40
I'm never gonna figure it out sitting here, that's for sure. But But people have a name for it.

Jennifer Smith, CDE 19:45
They do and even at smaller doses, some people find that for whatever reason, a Bolus with an injection works a lot better they get more very precise. Like dosing action. Yeah. And impact of action by just Taking a Bolus versus they love the precision of the basil coming from their pump. Okay, so I mean, there are lots of ways to attack things. Definitely. I've got someone in college right now that I work with and she knows that any Bolus that she needs to take over seven units, she will have tunnelling, if she doesn't Bolus with an injection,

Scott Benner 20:21
okay, would change into an omni pod for her make a difference? She's on Omnipod. It's still happening to her even with the FC that so some people it's funny because you hear people sometimes say, oh, if you're having trouble with that with the, the Omni pod can yell at go to a pump with a 90 degree candle. And I've heard people say, Oh, if this 90 degree candle is not working for you, you should try the army. Right? Exactly. Right. You shouldn't just sit around struggling with something that doesn't work for you.

Jennifer Smith, CDE 20:48
No, you shouldn't. And that's a that is one benefit, I think to tube pumps is that if you think it's one canula that you're using, there are multiple to choose to try. Call the company and let them know hey, I think that this set this type of set is a problem. Do you have some I'd like to try this one. This one, they'll usually send you a couple of samples to try before you order a whole big box.

Scott Benner 21:11
years ago, I interviewed Todd Hobbs, who I think at the time was the CEO of Novo Nordisk, but I don't, I don't believe he is anymore. And in his talking about what he thought people with type one diabetes needed, he was adamant that what they needed was better canula technology. Oh, yeah, that at the top of his list, you know,

Jennifer Smith, CDE 21:32
well, and there, I'm sure that you've seen, the study is about the candle that has, it's almost like a sprinkler effect, right? It's a candle, that's a tube that's got multiple holes through the tubing rather than just coming out the end. And what they find is that with more more surface area that they're covering with like a spray of insulin, rather than an injection, at one point, you get a lot better absorption, you get more precise and even absorption. And tunneling almost disappears.

Scott Benner 22:04
I wonder how hard that is then to inject the cannula because now maybe some of the rigidness of it is gone? Because you've got little holes in the side. Right? Good question. Yeah. All right. What made you want to do this? Like why you were very like, like, we talk frequently, but not that frequently. And you were like, Hey, we're doing this.

Jennifer Smith, CDE 22:26
Yeah, because I think in and I, you know, I texted you about it as like one of the variables, because we've got so many variables to talk about. And I think a lot of people call it leaking. Right? Without, and I think it helps to understand what's actually happening. And some of the reasons and the frequency if you're one person versus another, you know, one kid who's like, a swimmer maybe has no issues ever with tunneling, and they're the same body size and type of their, their little buddy next door, who is an avid golfer? Well, there might be the issue to consider, you know. So I think I think I thought it was important, because I don't see a lot of people but I see enough people that have had this issue. And just think that they've done something wrong, or their doctor isn't offering any solution. I don't know it's a leaky site, change it?

Unknown Speaker 23:21
Well, yes. But

Scott Benner 23:22
it'd be nice if I understood this a little better. It's funny, because he's, you said that, I thought, well, I'm gonna have to call the I'm gonna have to call the episode leaky site so that people even understand like, how to go, like, figure out what it is right. But that's great. I'm glad you did this.

Jennifer Smith, CDE 23:39
Awesome. Yay.

Scott Benner 23:47
Jenny and I are starting to get quite a little list of diabetes variables, episodes. You can find them right there in your podcast player. There's a lot more just search Juicebox Podcast, diabetes variables, or search diabetes variables at Juicebox. Podcast calm. When I get a couple more together, I'm going to build a list. But Ilana put it on the website. Not quite yet, though. Come come into it. All things in time, my friends. Are you looking for Jenny? She's an integrated diabetes.com. Oh, and let me thank the advertisers. Thank you Dexcom, makers of the G six continuous glucose monitor. And of course, the Contour Next One blood glucose meter.

Why I almost forgot the links. I think they pay me to say the links dexcom.com forward slash juicebox. Contour Next one.com forward slash juice box. Check out that amazing Dexcom g six, and the most accurate meter I've ever held. The Contour Next One. Thank you so much for listening. Thank you for sharing the show. Thank you for downloading it your podcast app. Oh, Thank you for subscribing in your podcast app. Thank you. Thank you. Thank you. Thank you. Thank you for making the Juicebox Podcast what it is, I really appreciate it every time you listen every time you share, every time, everything. If you're really looking for some help with all this stuff, you should check out the private Facebook group for the podcast. It's called Juicebox Podcast, type one diabetes, and there are over 14,000 members. I do my best to look in on it every day. And so should you it's an incredibly helpful Facebook group. I know that sounds kind of weird, like people like Facebook doesn't Facebook suck. Maybe it does, but not this group Juicebox Podcast, type one diabetes, go find your brethren. They're very, very kind, very helpful and excited to say hello to you.