#328 Ask Scott and Jenny: Facebook LIVE Edition

Answers to Your Diabetes Questions…

Ask Scott and Jenny, Answers to Your Diabetes Questions LIVE on Facebook.

• How do I attack meals that cause spike without crashing later? Is it with a longer pre bolus? More insulin? How to evaluate your bolus strategy.

• Any recommendations for helping with Freestyle Libre accuracy?

• What are the pros and cons of CGMs being used on patients in hospital settings?

• What is the best way to tackle losing weight for a type 1?

• Should I calibrate Dexcom on day one if off and how do you manage that if using an algorithm?

• How do you know if it’s a bad site or another variable?

• What are good tips for managing diabetes when you are trying to get pregnant?

• Is there anything physiologically wrong with a post meal spike if it comes down later without extra insulin? Should we try to master that meal?

• Let’s talk about pod changes and patterns.

• Is it possible to have the opposite of Feet on the floor?

• Let’s talk about female sex hormones.

• How do you manage the inconsistent eating pace of a toddler?

• What is honeymooning?

• Is there a cure on the horizon and near future?

• How do you manage kids and growth hormones? Finding the right amount of insulin.

• Can you explain insulin deficit?

• How do you manage unexpected diabetes variables like unplanned exercise, sudden stress?

• How do you know when to start eating when pre bolusing and looking at the Dexcom arrows?

• What factors affect the hypoglycemic risk value on the Dexcom Clarity app?

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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 0:01
Hello, everyone, and welcome to Episode 328 of the Juicebox. Podcast. Today's show is the audio from a recent ask Scott and Jenny, Facebook Live. Now the audio is super good. It's clean, clean the way you like it on a podcast. Don't worry, it's not all Facebook. It's not like Jenny's like, I think that we should do this thing with the input doesn't sound like that at all. Sounds crisp and clear. Right? Imagine Wolf Man jack and your house is like, hey, their kids. No one knows who that is. But that's not the point. The point is, it's a good recording for podcasting. And I didn't want you guys to be left out. So I was just trying to do a little live thing on Facebook if people you know, something to do during the day while they're trapped in their house. But then I wanted to get that audio right up here for you guys to listen to, in your ears the way podcasts are supposed to be heard. Anyway, Jenny and I started with one question from my ask Scott Jenny list. And then we let the viewers of the live ask the rest of the questions. I thought it went great. actually had a fun time was nice to hear from everybody. I'm giving you this episode. As a bonus this week. This is the third episode this week. So there won't be any ads on it. But it isn't going to stop me from mentioning the advertisers so that you remember that the good people at Dexcom on the pod Contour Next One blood glucose meter and touched by type one are the reason why I could be messing around yesterday doing a Facebook Live. So I'm gonna put links at the end. And they're going to be in the show notes here. If you'd like to check out any of the sponsors, clicking on the links is very helpful to me. And I appreciate when you do it. Alright, so let's get to it. This is episode one. I say 328. It's a live ask Scott and Jenny from Facebook. And you need to remember while you're listening to it 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. We're becoming bold with insulin. And just like that, you're listening to Scott and Jenny. redirecting to Facebook. Oh, there it is. I'm making a funny face. There we go. We're alive. Oh, that was easy. Okay, so obviously, it's gonna take a couple of minutes for people to get on. Gonna first say that. I'm Scott Benner. This is Jenny Smith. You may know Jenny and I from the diabetes pro tip episodes on the Juicebox Podcast. Jenny also does ask Scott and Jenny and defining diabetes. And today we thought we would do an ask Scott and Jenny live. Now we have a question to get started with that came from one of you. But we're totally willing to see some questions from other people. So first, I need somebody in the chat on Facebook. Tell me if you can hear me and Jenny Say something. See if I can hear you.

Unknown Speaker 2:53
Hello. Okay.

Scott Benner 2:55
Just somebody tell me in the comments if if you can hear us. Oh, hi, Maddie, how are you? Have you never seen Jenny live before?

We already have 18 people? Awesome. 24. We'll start right at three o'clock because you guys are on time. I like prompt.

Jennifer Smith, CDE 3:18
You got a minute or maybe less? I don't know my plaxis 150 or 259.

Scott Benner 3:23
They should definitely be everybody can hear. Cool. All right. They should definitely be rewarded for being on time that people will come later. Gonna have to watch, you know, watch the replay or hear it on the podcast. I can hear both of you. All right, Laura. Thank you. Whoo. All right. So if you guys have questions, throw them in there. And we'll see what we can do. But Jenny and I thought we would start with let's see, I have it here. I have it here. Here it is. Um, oh, you know what, before we start, did you guys know that? I'm Jenny. I'm gonna give your phone a few days here. Jenny Smith is an RD LD CDE T one day. She has a bachelor's degree in human nutrition and biology from the University of Wisconsin. She's a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes a pumps and continuous glucose monitoring systems. Jenny has had Type One Diabetes for how long journey

Jennifer Smith, CDE 4:17
on May 15. It will be 32 years. Okay, so that's a long time.

Scott Benner 4:23
And that is definitely a long time. So any of you who have heard us on the show before? No. This is basically what you know, it looks like for Jenny and I when we record and you guys just don't usually get to hear so we're gonna get started with the first question. Yeah, it's how do I attack meals or times of day that cause a huge spike, but come down eventually. If more insulin is added, I go low later, when I wait longer, like when I Pre-Bolus I go low earlier in the meal. Now by the way, guys, there's a disclaimer here. We're not healthcare professionals. This is not advice in this cause, just us talking and you hanging out so if everybody's okay with that. Cool if you're not jumping, all right, I went, we did not do any problems for you people just get it. You don't like it? Okay. All right. All right, Jenny. So I, you know, I hear this question a lot. I tried to Pre-Bolus. But I got low before I ate or, you know, I tried to shorter Pre-Bolus. And I just got high later, what are some of the reasons that can happen?

Jennifer Smith, CDE 5:23
So to begin with beginning of the question would be your bolusing getting high, and eventually, without correction, it comes down. That initially would be a bolus timing thing, right, where you need to Bolus sooner to stop the rise. It's an indication that there is enough insulin there because ultimately, the Bolus you took does get you down to where you want it to get later after the meal. There's just not enough time between taking the insulin letting it get started, and the food actually impacted blood sugar. But the further part of the question sounds more like if you add more insulin, like upfront thinking there wasn't enough to begin with or you correct, and then you end up going low in either of those scenarios. Clearly, there was too much insulin, right, you didn't need more insulin, you just did it in a different bit of timing for taking it right. The third part of it. So like little segments here. The third part of it really is, if you do take the amount based on your ratio, you end up climbing, or you Pre-Bolus with enough time, and you end up sinking within the time period after you Bolus, but then you still climb up later. That could be especially for those who are using an insulin pump. That could be not only a timing issue, but also a delivery of insulin issue. Okay, right, where you would probably need to use all the pumps have some type of extended bolus feature. Could it be combo bolus extended bolus dual or squarewave. bolus, all the pumps call it something different. But essentially, it allows you to take a certain percentage up front, potentially in this scenario to stop the bump up, gives you let's say you decided to take 50% of the Bolus now and then distribute the other 50% in the back end, what it allows is the 50%, you take now you can Pre-Bolus thus decreasing the amount at the beginning that you get. So you don't have a drop, but you also get the Pre-Bolus benefit of not having that rise up after the meal. And then the later impact is that you still get a finish of that end of insulin, which you knew was enough. You just needed to distribute it a little bit longer to impact, you know, the full content of whatever this meal, I guess, added.

Scott Benner 7:50
Okay. And I like obviously I agree with you. But what I was gonna say is that when when I see that I don't often see a Pre-Bolus It's so like heavy that she crashes before she gets low. And so I think that ends up being a situation where people are like, well, I Pre-Bolus and then I got high anyway. So I'll keep trying longer and longer and longer. But it's not at some point, the length of the Pre-Bolus is just not your issue. You know, and and I hate to I don't want to put a number on it. But you know, if your Pre-Bolus thing, 30 minutes in the future, you're probably coming out of a much higher blood sugar to begin with, and you have issues on the back end that you're not dealing with. I find myself saying a lot that diabetes, using insulin specifically is like time travel, everything you do now is for later, right, right. But everything that's happening to you now is from before. So if you're putting in a healthy Pre-Bolus, like you said on a good site that you can count on, etc. And you're you know, you're still climbing afterwards. I mean, the Pre-Bolus probably at this point isn't the question. And there's little things for CGM users, you can kind of look at the trend, the angle of the trend, right. So if you're, if you're shooting straight up like this, you've either missed, I think, huge with the amount of insulin you're using, or you know, if you just bolus and five minutes later start eating a real sugary thing. You're going to shoot straight up, if you come more on that, that kind of gentle rise that I tried to describe as the it's the minor or no, not the minor, like the the mountain climber on the prices, right? Any guy keeps like rolling back and forth like this, right? Because when you have a Dexcom and you you have that gradual lineup, everyone's done it, they stare at it, they're like it's gonna stop, it's gonna stop, it's gonna stop and then eventually that guy falls off the end and true Carrie says you can't have the money and it's all over right and your blood sugar's 280. And, and then that's sort of the end of it. So like Jenny's saying, there's just 1000 different ways. But in the end, what you're trying to do is manipulate your insulin and put it where it's needed. So you need that nice Pre-Bolus but if an hour later You started having this crazy rise, like she said, an extended bolus, or even coming back and readdressing with more insulin, at some point is the answer you get low later, when you put so much insulin up front, to control that line, that eventually when the impact of the food goes away out here in the future, the insulin still leftover and you crash low. So you've got to, you know, for the lack of a better term, you have to put the insulin where it's needed. I always say when you're about, you know, you have to address your body's need with with the right amount of insulin. So, right, that's cool. That's a really it's a great question. I appreciate that question. And people have left other questions. So dig in here, and see what I can

Unknown Speaker 10:40
love questions, right? Oh, yeah. But I'm

Scott Benner 10:43
on the wrong browser to see I got to get into it. Everybody chill out a second, this is my first time doing this. So a lot of pressure, like running the show, and

Unknown Speaker 10:52
like asking the questions.

Scott Benner 10:54
I was gonna feel under pressure here. Alright, I'm on a different browser. So one browser is sending you guys the Facebook Live? And then I'm going to look on a different one. Where am I looking at? I mean, the wrong I have too many Facebook groups.

Jennifer Smith, CDE 11:16
While you're looking, I'm going to add something extra to that comment. And question from before to it you were talking about, you know, the trend kind of even coming into the meal. And that can definitely determine things, you know, if you were if you were at an excessive insulin coming into a meal, and you are already on this slope headed down, right, and or if that's commonly happening within the same meal time, it could be that your Pre-Bolus thing with a load of extra previous insulin on board. Thus, you're consistently coming down in this time period of the day. And so any Pre-Bolus, it's going to look like that Pre-Bolus is causing you to drop within the first time period of that meal. So you're less likely to Pre-Bolus as much as you need to from previous experience. And thus you're getting this rise up that you wouldn't have if the hours leading into this meal. Again, if it was a consistent problem at this time of day, it sounds like the hours ahead in this setting, could need to be evaluated. Maybe the bazel is too high heading into this meal, okay, or maybe the insulin to carb from a snack three hours ago, is also giving you too much insulin. So you're consistently coasting down into this meal time. So you've got this excess behind the scenes insulin. So are some other things that could be evaluated to cool.

Scott Benner 12:36
Alright. And somebody said I was lower than you. So I just turned my voice up. So if I got if I'm now too loud, somebody told me. All right, Anna asks, I have been having trouble with the accuracy of my freestyle libri. Sometimes there's a big difference. I think I will change Dexcom was I finished? The my inventory I currently have at home. But do you have any recommendations in the meantime? While I'm using these?

Unknown Speaker 12:59
That's a good question.

Unknown Speaker 13:00
Yeah. Is there an answer?

Jennifer Smith, CDE 13:02
Well, is there anything to adjust? There's nothing from our, from our practice, all all of us within our practice. At integrated, we've all used the libri all got our like trial, you know, couple of sensors to try out and I try to as many people often do you make yourself the guinea pig, right, you try a couple products at one time to see what's actually Right, right. So I wore my Dexcom along with the lever a and the three sensors of the libri that I wore, they were all consistently reading lower than my actual sensed Dexcom and fingerstick values were consistently center to center they were all consistently different. And enough that from a blood sugar and a meal bolus and a correction standpoint strategy, it would have been enough of a difference to make adjustments kind of diff difficult to base off of, is there anything that you can do about it? In this setting, what we usually recommend is for the prime times that insulin is going to be dosed based on a glucose value, do a finger stick, get a finger stick and dose off the finger stick don't dose off of your libri what you can know from any sensor system that might be reading a little bit off or different than you know it should be is that while there is a difference in the number, the trend is still a good, it's still a value for you. So you can still tell whenever you're trending up or trending down, and you can use that to your advantage for future planning. Okay, so but you wouldn't necessarily dose off the value.

Scott Benner 14:43
So um, I guess what he's saying is when you find you're not trusting the device, test, but still look for I mean, I guess I've never used the library but arrows and direction and rate of change and stuff like that. And then when you really need to know I guess what we're saying? Is that if it's a pre meal, and it says you're 120, but you think you might be 150. That's important to know when you're making your Bolus, right. Okay. But Hmm, it's still important. I don't want to minimize the idea that a big a big difference is a problem, but at least you can be safe. When you're when you're putting in like more when you're

Jennifer Smith, CDE 15:19
putting in insulin. Yeah,

Unknown Speaker 15:21
yeah. Cool. So,

Jennifer Smith, CDE 15:23
to let her know that that's not uncommon. Gotcha. A lot of people find the variants,

Scott Benner 15:27
it's gonna be hard to keep. See, I want to, we only have an hour, so I need to keep Jenny movie but Jenny will talk and like, get all her knowledge out. And then we're gonna answer one of your questions if we do that. So Maddie, how do you Jenny see CGM being used in patient hospital settings now that we're seeing COVID-19 error How is going to help diabetics? And Maddie, what I'll say to you is, did you hear the episode of the podcast that went up today? Because Dr. Dan disalvo came on and talked about how decks coms are being used in hospitals right now. But so I have something to add, but you go first.

Jennifer Smith, CDE 16:00
That's pretty awesome. Because I have I've not obviously listened. I've been working with people all day. So I'm, so I have I both pro and con feelings to it. Okay, so from the standpoint that great, there's a lot more information, there's a lot more data, it can be beneficial. On the con side, however, there's a lot of data, and healthcare workers in hospital who we already know, have have little experience with type one, consistent glucose information management, they are used to doing finger sticks every several hours, to base decisions on right, whether it's dosing or whatever adjustments in doses. With all of this extra information, the trends, the alarms, the things that are going to be visible to them. Yeah. There's no, there's no quick education that can be done within 10 minutes to the thousands of health care, nurses, doctors, whoever that's looking at this information to help the person wearing it. Yeah. I feel like there's a lot of information, they're not going to know what to do with it. So that's what I feel like I feel like it's good. But it's also, I don't know,

Scott Benner 17:20
let me share with you what Dan said. Dr. salvo told me that what it was really helpful with in the moment was, it was preserving PP for nurses because they were, you know, they do finger sticks on patients a lot. And now you're asking them to go in and out and change their gear every time. So now they're, I guess, Dexcom. If I, if I heard him, right, gave the patients like Android phones. And so there's a cloud service. And now the nurses are able to look at the patients through the share and follow, right? And then they're like, okay, you know, they come down the line. And here's Mary and Mary's blood sugar's this, it seems pretty reasonable. I don't need to go in there. So that was the idea. What I heard while he was talking was a great opportunity nationwide for health care professionals to see how glucose monitoring works, right. And maybe, maybe in the future, things will go better. I told him a story of when Arden had a surgery. And you know, the nurse didn't know anything about it. I just kept talking to nurses till I found wonders like I have a friend who has diabetes, I go, you're my friend. Now come over here and explain to all these people why we need to leave the CGM honor during this procedure. But anyway, that's what I thought of it, Matty, I thought it was I think it's, um, it's great for that saving of the PP. And on the other side, I think it's a good first step in bringing the technology out to people. So

Jennifer Smith, CDE 18:35
yes, yeah. I also think, you know, in that scenario, as if they're using it based on the protocol that they would have used finger sticks, and they're only checking at certain points to see what the values are or responding to alarms. Yeah, it's absolutely valuable. I just hope that I would expect somebody has schooled them in what to pay attention to what not my, my

Scott Benner 18:57
thought was that it was, it was going to be used in a really, I don't know, like a limited way in the beginning. Just to keep you know, from being with people. I saw Donnie ask about managing weight with type one. So and he said, Thank you for being here. So thank you very much, Danny for being here as well. Yeah. Best way to tackle losing weight for type one. Why do why can people with diabetes who are using insulin have trouble with weight loss?

Jennifer Smith, CDE 19:24
The first thing is definitely insulin management. That's that's a huge piece of it. Because insulin is a storage hormone. It's meant to move food glucose out of the system into the cells, either it gets used by your muscles or it gets packed away into fat, right? So from a physiology standpoint, even if you look at a body that doesn't have diabetes, if you out eat what you really need, then overall your body can only pack away that extra calorie, right? Okay, and it does it with insulin. Right to manage the normal blood sugars that should be there. Same thing is happening though. And so person, even without diabetes can gain weight, that that's how they gain weight. Essentially, their body should packing away more than what they needed because their body is managing blood sugar the right way. In a body with diabetes, though, because insulin management is something that we control, body's no longer doing it for us. It's something that we have to, we have to adjust more precisely than people are often given tools to manage. Right. So overall, one, make sure that your baseline dose that bazel is right to begin with, it's in the right place, then the next thing to tackle is the food management, strategizing around meals timings, you're not using more insulin to cover then you actually need to, you're not covering with extra food when drops happen, because you used too much insulin that you didn't really need to have there. And then the other piece, of course, beyond that is, are you eating what your body needs to eat? You know, because if even in this case, if you've got great looking blood sugars, but you're constantly like popping food in and covering it with insulin, you could have wonderful looking blood sugar values, you could still be out eating what you need.

Scott Benner 21:17
Right? So I usually it's funny, I saw john pop in and he said, Don't feed your insulin, which is this is what I was gonna say. I think I think that when people who listen to the podcast have, there's two trains of thought, when you're learning how to use the insulin in the beginning, I will say be more aggressive, you can always have juice later. I don't mean that for the rest of time In Memoriam. I mean, while you're figuring it out, like if you continue to bolus and get low, fix the bolus, don't keep fit, you know, don't keep drinking juice. But it's a great point. Because people with type one can start to think of diabetes first. And instead of health, right, so all of a sudden, an Oreo cookie is not a bad thing, because I need it because I'm getting low, except your real issue is you need to stop yourself from getting low. So you don't have to eat an unscheduled Oreo. And by the way, don't eat Oreos, they're, they're poison. But But you know, like, I really I don't think there's any food in them whatsoever. But my point is, is that don't feed the insulin, but learn the steps so that you can do that. And Jenny, this is a wonderful place to say that diabetes pro tip calm is now open and available to find all the diabetes pro tips with Jenny and I all in one place in case you guys have had trouble finding them in the podcast player.

Jennifer Smith, CDE 22:34
Yes. And we've also gone over that weight piece in there. It's a great episode at least one if not a couple mentions.

Scott Benner 22:42
Yeah. All right. I have. I have one for you. And one for here's a quick one. Yeah, Jenny, you are g six. And so does Arden. Do you ever calibrate on day one? If it's off? No, you don't you let it go?

Unknown Speaker 22:57
Let it go.

Scott Benner 22:58
And how do you manage that with your algorithm that you're using?

Jennifer Smith, CDE 23:02
I manage it by doing finger sticks. Because I have had, as we talked about right away. I've had diabetes long enough that finger sticks have always been a norm. Even once things got approved for not having to do that anymore. I still do that. So that's my thing. And with the algorithm that I use for my insulin management, I can I can populate in my finger stick value for my algorithm to use that value rather than the CGM value. And then I get proper dose adjustment.

Scott Benner 23:41
And you have an apple iphone, right?

Unknown Speaker 23:43
I do. So you go Apple Health,

Scott Benner 23:45
you go into the health kit, and you tell it, you add your blood sugar there, and then that program you're using, yes, the loop app will see it and then it knows what your posture is. Correct. And so my my way of dealing with it is if it's close eye roll, you know to me like if and I test to their their advertisers on the show, but we use the Contour Next One meter, I find it to be incredibly accurate. And so in those first number of hours while the sensor wire still you know, baking in, I will test but I'm going to tell you that if it says she's 70 and she's really you know, and she's really 90, I might let it go a little longer to see what happens. But there are times I do calibrate to get it together. It's not a frequent thing. I probably only calibrate on day one when I calibrate but having said that we don't do it very often law we leave the finger sticks though

Jennifer Smith, CDE 24:42
and there are a There's your so many that trains of thought in terms of that that I've run into in working with people, some people who've got this like system, it works really well for them. Awesome, great, even if it's not what's recommended if it's working for you. I'm not going to tell you this Stop doing that. Right. But from the standpoint of education, you know, we recommend following the recommendations of Dexcom. Don't calibrate in the first 24 hours,

Scott Benner 25:13
you would never do anything like that. Somebody asked for links, I just put them in the comments. And honestly, Jenny and I are not used to being seen we, you know, I mean, for those of you who are new, I have a podcast called the Juicebox Podcast, and Jenny is a frequent contributor to it. And she's not on every episode. So if you really like her, and you hate me, you're gonna be pissed when you like tune in today, and she's not there. But anyway, calibration day one. Actually, that's sort of covered. The next question I had for you. If there's a person who is excited about algo, their algorithm pumping in the in the future, right, but is worried that because they don't always see their CGM rock, you know, rock solid, and they're afraid of what's gonna happen next, what I would say to that is, you know, Arden has definitely done both ways. And it's never been an issue. Like, I've never ran around the house going, like, Oh, my God, everyone's gonna die. Because you know, Dexcom was off and we're using an algorithm, it just, it's a it's a reasonable worry if you've never done it, but once you do it, I don't think it's something you'll think about again, does that strike you like that?

Jennifer Smith, CDE 26:19
No, it does. And it's actually a question that I've gotten more than a number of times from people that I work with, especially parents of kids, you know, wondering, Well, what about those? compression lows? Right? What happens if an algorithm is using that? And now it's not really low? What will have happened? Well, you know what, because the system if you're using one of these hybrid types of systems, whether it's, you know, on the market, or yet to be on the market, um, if you're using one of them, it's going to adjust based on that change in blood sugar, that's being seen, right. But most often, especially in this example, of a compression low, that writes itself pretty quickly. In fact, you can tell it's a compression low, because it looks like your blood sugar is literally like nosedived off of a cliff. Yeah. And then it comes back up very quickly. I mean, you could you can tell it's wrong. Well, yes, the system will have reacted to that drop in blood sugar, it may have taken away insulin where it was supposed to, but within the quick timeframe of it writing itself, that algorithms also going to write what it took away behind that, right. So I've personally, I've had sensors that have been off, thankfully, not very many, my Dexcom, thankfully, has been very accurate for me. In all the years, I've used it. But I have had compression lows. And since I've been using, you know, this algorithm, I haven't noticed that that's honestly been an issue. I've never had any problems of excessive high blood sugars or no problems with like, strange, odd low blood sugars that shouldn't have been there because of this sensor. You know, okay, she being off.

Scott Benner 28:00
Yeah. I hear you. I'm, I'm down. I think it's, it works. I mean, I've I'm not gonna tell you I haven't gone Norton's room been like, She's like, the first thing I do if she's laying on her side, because she wears hers on her, like her body, her hips. So I'll touch her hip that she's not laying on. And if it's not there, I'm like rollover. Just kind of like shutter and, and then you'll wait a minute, it comes back. interesting side note about a compression low with a CGM. The number it's reading is actually correct still, although not indicative of what your blood sugar is. So it's reading your interstitial fluid, which is you know, freely running through your body. But when you press down, it disperses it. So it's dispersing some of the glucose that it's reading. So it might tell you your blood sugar's 60, all of a sudden, the truth is, the interstitial fluid around the wire, the glucose value is 60, your whole body might be 110. But that's why when you roll off of it after it gets to the algorithm gets to think a couple more times, it'll come back and tell you Oh, no, you're one time. And that's it. How does that engineer makes a great point, if that happens, the worst thing that's gonna happen is the algorithms gonna take insulin away, you might get hot, but you know, you might get a little higher, but you're not going to be in a dangerous situation. And that's a great trade off, I think, yeah, you know, Jenny, I'm gonna ask you, somebody jumped on and said that I recently said on the podcast that I don't abide a bad pump site that I get, I get away from a by a pump site pretty quickly. But she wants to know, how to, you know, it's not just your period, or, you know, and so I'll you know, because you and I deal the same way about that we don't stick around for like,

Jennifer Smith, CDE 29:39
I don't stick around. And and I guess, you know, from a female perspective, if you're like, well, gosh, is this my period? Or is it you know, a bad sight or whatever? I mean, most women, most not all, but most women have a pretty consistent timing rhythm to their cycles. Yeah, right. So if it's You know that it's probably coming into that time, or you know that it's that time and your high blood sugars are usually associated with that. You wouldn't necessarily think that this is unless you, you haven't changed your, let's say, your settings or your insulin doses as you needed to for this time period. And if you forgot to do that, obviously the high could likely be associated with that. The best way to tell though I mean, because even in your period, you could certainly have a bad sight. Like two things hitting you at one time. That's not fun, either. It's

Unknown Speaker 30:31
okay, hit from both ends. Right? That's not

Jennifer Smith, CDE 30:33
that's not joyful at all. So, you know, if that's the case, I think, regardless, for anybody, whether you're male or female, if you've got an odd looking high blood sugar,

Unknown Speaker 30:45
yeah, that

Jennifer Smith, CDE 30:46
shouldn't be there. Right? You know, you've done everything you would normally have done. And this is just a weird, all of a sudden, you're like, double arrow up and you're to something. You take a correction, right? In my case, and what I recommend, if it's not coming down within the next 30 to 60 minutes, that's it's done. Yeah, it is done. I don't play with it, even if I pull it off. And I'm like, well, it doesn't look like I don't know, whatever the problem was, that the candle is not bent. It's not bloody, it doesn't look weird. Sometimes it might look a little bit wet, or mediawiki. So maybe for some reason, the site was like leaking up along the canula. And you didn't really get as much insulin as you should have. Yeah, um, but yeah, I don't, I don't play with like numbers that aren't where they want to be. Right. And

Scott Benner 31:32
there's a couple of ways that the way I taught myself so the answer to a lot of these questions ends up being repetition, you do something over and over again. And one day, it just makes sense to you, right? And you don't you lose that checklist in your head, like, well, I said, this is it, this, like you stopped doing that. You just see it, you recognize it, and you go, so before I could recognize it, I would inject with a needle. So if the pump didn't act the way I expected it to, I'd come back with a syringe. Now if there was no reaction after that, then I was pretty sure that my site was over also, last day of a sight, you know, or you just put it on and it just never ends up working. Because I know some people switch their pumps and they, they they'll experience a little bit of a high when they put it on. There's a lot of you know, talk about why that is I part of me thinks in children that it's anxiety. It's the you know, it's the that whole thing kind of gets you jacked up a little bit. That could be it. That's what it used to be for Arden. She's obviously much more relaxed around it now. But we've changed upon this morning, it went on and we did a more aggressive bazel rate for the next hour to try to her blood sugar was good at like 110 but to try to mitigate any kind of arise you know, same thing on the other side, if you think it's not working anymore, once you get it back on, you have to really think about for a second How long has this like not been working? And now I'm just going to slap on a new site and go oh, everything's fine now because the insulin deliveries back it's not because everything for now is for later and everything that's happening to you now is from before I get insolence always from before, go back to the beginning if you're falling late, but that's really it. Now the next one is more for you. Although people are asking follow up questions, so hold on. This is great info inside. Oh, great. Okay. Oh. By the way, there are people in the comments helping each other somebody was like, what's the compression level before we could explain it they jumped in You guys are awesome. Jenny, I drew a picture of a lady with a big belly to remind me that someone asked about good tips for thinking about getting

Unknown Speaker 33:41
everywhere just didn't write down pregnant. But anyway, I'm not showing anybody it's not a good drawing but

Jennifer Smith, CDE 33:47
good tips for getting pregnant. So preconception time. Um, we we kind of define preconception time, the three to six months, potentially even a year up to when you want to start trying to conceive. And the goal there is to aim to get glucose values into the pregnancy target. If you think about and or don't know what the targets are for pregnancy. The goal is to be under 7%. And then in pregnancy and even see more around 6%. Within the fives if lows aren't the big reason for being in the fives. But typically, most practices will say under 6.5%. through pregnancy more around six is the preferred just from the standpoint of health of you and the developing baby. For the preconception time then it's really focusing in quite a lot on what are the variables that you can learn and manage better in your life. And if some of the variables like every Friday night you eat the whole box of chocolate, you know ice cream bonbons And you can't manage around that. You know what, for nine months, you can manage not eating your bonbons on Friday night? Yeah, I mean, that's, you know, those are the things those are the strategies that you sort of learn in that preconception time. I mean, the beginning tips really are, look at what preconception or look at what pregnancy targets for blood sugar should be. Because aiming to get those as close preconception will make it so much easier. Once you're pregnant, as you don't have to shift this whole mental. Oh my gosh, now my blood sugar has to be 90, and it's been riding at 150.

Scott Benner 35:36
Just count on, I'm going to get knocked up, and then I'll do this better. Right, right, just and that probably wasn't the right way to say that. But you know what I mean, thoughtfully and through love, make a baby and then trying to get better at your blood sugar, get better first, prove it to yourself that you can do it over and over again, Jenny, if you had to say to somebody, how a way they could get better at this, what would you tell them to do?

Unknown Speaker 35:57
What would I tell them to do? Like a web address? Yes, well, they can call me

Scott Benner 36:03
just put Jenny's email address in the comments.

Jennifer Smith, CDE 36:05
They could. They could also i we've got, I wrote a book with a good friend of mine, Ginger Vieira, who's written a couple of her own books. It's, it's pregnancy management for type one diabetes. You can find it on Amazon. And we actually have a big preconception, month to month guide for pregnancy management, postpartum lactation, we've got all of the information in the books, I would

Scott Benner 36:31
also bet that sometime later this year, there might be a pro tip episode about being pregnant with somebody too, because that just sounds like a good idea. And I typed it into our running list of ideas for the podcast. Awesome. Yeah. Okay, that's a great answer. I wanted to just say that.

Unknown Speaker 36:48
I think

Scott Benner 36:50
I think that once you figure this all out, you get pregnant, you keep your blood sugar, super stable, and you're a onesies nice and low forever. It's gonna be difficult, but try not to lose track of it after the baby comes. Like, just you can do it. If you did it, then you could do it forever. You know what I mean? Like, you know, it's interesting, as I interview more and more people over the years, to see that some people who have trouble managing their diabetes, for themselves, don't have trouble managing it for someone else, you have no idea how many people have come on and said, I met somebody and I fell in love. And I got married, and I wanted to be healthier, so that our relationship or I had a baby, and I realized I wanted to do more. That's not specific to diabetes, by that it's a very human idea. But yeah, keep putting yourself at the top of your list of things to worry and be concerned and

Jennifer Smith, CDE 37:38
he can take care of you. You can take care of other people.

Scott Benner 37:40
100% I think and Wait, do you see having a baby? It's It's wonderful. Nothing like having a kid my wife and I were just sitting on the other night going, we think having these babies was really, really good idea. No, we were choking, because they were both being annoying at the same time. People are thanking us, which is very lovely. Thank you very much. We really appreciate that. You guys listen. evany asks a question back about bolusing. That I feel like I have something to say he said, Is there anything physiologically wrong with a post meal spike? If it comes down later, without extra insulin? Would you try to master that meal? I think you probably can. I mean, unless it was, like you said, Well, you know, I can't even say unless it's cereal, because I can get cereal, right? Sometimes, too. So yeah, I have an In my opinion, if you're going up, hanging up, coming back and leveling out again, and never getting low, there is a way to get more insulin up front. And you know that and we talked about it earlier that really Evan should go back to the beginning of the live, right.

Jennifer Smith, CDE 38:44
Yeah. And I also think, you know, from the standpoint of that kind of management, what it also leads into longer term, if you consider, for the most part, you're looking at your day, let's say you're using a CGM, and you can see how much of the time you're in range and where you want to be. And you're only, let's call them problematic times are these spikes above where you really would want to be after a meal. Yeah, but the end result is that you're back in target. And that looks awesome to you. Right then, one managing the timing, again, it's all about timing the insulin right, but to that peak is still leading into your overall a one C, okay, it's still leading into time out of range. And those post meal spikes also lead towards things like some of those many things people don't want to talk about, but the complications, more of those microvascular complications with these peaks that come into play, the more you can minimize and have more gentle roles, the better long term, so right.

Scott Benner 39:57
To do your best and keep messing around little sooner, a little later. Little more or a little less in there somewhere is the answer. It sounds like he's got the amount right and the timings off. Listen, even if you don't listen to podcasts, I maintain that most of managing insulin is timing and amount, it's just about getting the right amount in the right place where the need comes in. If you can get more up front to stop that initial spike, it might not have to be that much more, you'd be surprised it could end up being a couple more minutes of a Pre-Bolus or another half a unit of insulin or something random like that. That's still because that momentum from the food is so great. At that moment, it'll eat up that insulin, it won't leave you extra on the back end that will make you low. Right, hopefully. Julia asked, What do you consider a gentle roll? Did you just use the words gentle roll? Okay. Do you mean like one of those little Pillsbury things with the?

Unknown Speaker 40:47
Oh, no, no, no.

Scott Benner 40:48
Julia, I can I can talk Jenny as a matter of fact of Jenny's husband ever leaves her we're perfect for each other. what she means is not like, not like sharp, sharp down. She means like, it's cool if you go like this a little bit. By the way, this. So much of what we do is, is easier when people can see our hands moving Jenny and my hands move a lot while we're talking.

Jennifer Smith, CDE 41:11
And the funny thing is, nobody can ever see like our expressions or anything because it's just all voice. There are times when Jenny goes, I wish

Scott Benner 41:17
people could see what we're doing right. And I'm like, Yeah, they can't so Oh, Rachel, it is the best podcast ever. Thank you for saying though. I asked if the group earlier forgot. I would ask here. I had been pumping on the pod for six months. And I've just noticed the pattern. Day one runs high. Day two, good day three low. Any ideas how to combat this? More or less insulin? She's heard of the opposite problem. Brittany has a day three being a little higher. I would say that's if I see anything. It's day three higher Ardennes pumps either work, right out to 80 hours, or right around

Unknown Speaker 41:55
two and a half days.

Scott Benner 41:56
Yeah. 70. I was gonna say right at 70 hours ish, then I have to start paying attention more.

Jennifer Smith, CDE 42:01
I've actually personally noticed that when it does, it's not a time factor. It's more of a when my pod gets to about the 20 unit mark, I can almost guaranteed if I continue to use it after that for boluses or anything. Yeah, I will ride higher. Even though the pump tells me I've delivered the insulin. And it's the same way it's the same factors ratio is everything that I've used. It's it's a, it's a dose amount from what I and I've used Omnipod since 2006. So I got a lot of experience of yours.

Unknown Speaker 42:35
Yeah.

Scott Benner 42:37
I was telling Jenny the other day Arden's been using it since 2006. And it's, it's amazing. Like, I have nothing bad to say, uh, you know, a number of people asked, they said, they have the opposite of the feet on the floor up, they have a feed on they wake up in the morning and their blood sugar drops pretty drastically. Have you heard about that? from anybody?

Unknown Speaker 42:57
I've actually not.

Scott Benner 42:58
So so then would we consider maybe that the bazel leading up to their wakeup time is too strong?

Jennifer Smith, CDE 43:05
The question would be first, which is always my question to people are is your wakeup time the same? Please, it is the same. And you're noticing that drop, as soon as you get out of bed in the morning, okay, then the next thing to do would be try to sleep in and see if the drop happens. Because my guess would be the drop is there. Because you're getting up at the same time you think it's because you're getting out of bed. But it's because as you just said, the bazel in the hours preceding that are probably too high, and the drop was going to happen anyway. Um, so If, however, you find that when you wake up in the morning, and or sleep in completely different, let's say the sleep in stays totally stable. And when you wake up and get out, that's when the drop happens. Yeah, that's it. I mean, it's the complete opposite of what a good majority of people see. I'm not saying that it's not your personal experience. I've got friends who have a drop in their blood sugar with adrenaline rather than the typical peak in blood sugar because of adrenaline. So it could be the case, it, I would say that it's going to be a little bit, it'll be a little bit harder to maybe manage a drop. Because if it's related to when you get out of bed and not really wanting to like eat glucose tablets, or drink some juice just to stop the drop, though only a couple of options would be, well, if you can get up at about the same time, you could technically decrease the bazel leading into that time. So the drop doesn't happen. The only thing there is if you if you get up later, then you're not really going to need that

Scott Benner 44:48
decrease higher than listen because of this whole Corona thing Arden has been she shifted her life drastically. She's staying up way later and getting up way, way late. Yeah. And so I know if by 6am, I don't take away the power of her bazel by half, she's going to be low by eight o'clock. Like, because her daytime numbers are, you know, the insulin we use during the day is just different than what we use at night at night. She needs far less. I don't know, I hope that was helpful. Let's say I know I have a drop because I'm not waking up at the same time. Every day when I had a normal work schedule. There was no drop when I wake up. So then Laura, look is did you do you have a stronger basal rate in the time you're supposed to be awake? Because if so then that's it. Your bazel is just building up and building up and you have nothing going on inside of your body that needs resistance from extra insulin, then, at that point, a bazel. could act like a bolus eventually. Yeah, right. Okay, cool. I like the way I said that. Well, Melinda, thank you for loving the podcast. Thank you. This morning, I was 111. Justin says when I woke up later in bed and read the news got up 45 minutes later and went to 72. Hmm. And that's not Justin, it's tough. I can't have a conversation. But was that not bazel related. Somebody here said they have a new bazel program that's called pandemic. So that's a good point, too. Don't just change your settings, you can make a new program so that when this is all over, you can switch back to the way it was. I've had to you know what, I have a question for you, Jenny. This happens sometimes when we do the podcast. Let's do it now. And then I'm going to get to a question about kids and growth hormone. I was interviewing someone today who talked about when they got pregnant, they suddenly needed much less insulin. And I was saying to them, it's interesting, because for three days before Arden's period, she almost needs no insulin to and I'm wondering what hormone we're going to figure this out, I know this isn't going to something you're going to know now. But we're gonna figure this out and talk about later in the podcast, there must be some hormone that's released. For oscillation. That must also exist while you're pregnant. And maybe I'm wrong. But I'm going to find out if that's true. Because those two things like a bell went off my head as Ooh, maybe this is it. Because Arden Will you know, Jenny and I've talked about it privately, Arden will use like almost no insulin for a number of days before some of her periods. Not all of them, you know, just to keep things interesting. But do you think? Did I just say something you've never thought of before?

Jennifer Smith, CDE 47:25
No, it's well, and typically, oops, some reason went off my screen. There you are. Hi, hi, sorry. Um, I was gonna see the horrible and that's present in the lead up to your cycle, as well as the horrible and that's present very heavily prevalent in the first part of your pregnancy in that first trimester up to about like, six weeks is progesterone. Your body is having this ramp up, almost up a hill climb. And when you get your period, because your body's like, hey, you're not pregnant. So then the progesterone kind of like falls off the cliff, right? You come back down to this normal level. So most women, not Arden, but most women have a right up in blood sugar in the days before their cycle starts. And then it calms down. Same thing in those early weeks of pregnancy. Typically, women will actually see a heightened need for insulin in the first about six to seven ish weeks. And then around eight weeks of pregnancy, there is a bit of a dip off for a couple of reasons. Um, you know, hormonal II and what the body is doing, why there would be a dipped in blood sugar prior to the first day of a cycle, or maybe in the first part of pregnancy, when normally most women are experiencing a rise, the hormone, hormone drive there, I can't say that it's different. I would have to research let me give

Scott Benner 48:56
you a number another variable for this story. And I guess this is me ruining an upcoming episode. But what if the pregnancy didn't last much longer than eight weeks? Maybe there was something else going on? Sure. Yeah.

Jennifer Smith, CDE 49:09
In fact, that is if you've had a normal increase in insulin in early pregnancy, and if prior to that eight to 10 ish week point where usually your insulin needs at least stabilize and or dip down a little bit. If that dip happens sooner. Oftentimes, it can potentially be an indication of like miscarriage only because the hormones are not staying steadily, you know, there's not a steady climb. There's also you know, an early pregnancy. If you've ever had miscarriage before and or you're just worried. You can always get this the HCG hormone tested, which is the early pregnancy hormone that's released that actually gives you that positive result in your pregnancy home pregnancy test. So that hormone should add Actually, mostly double, sometimes triple in those early weeks of pregnancy, which is, it tells you is that your pregnancy is progressing the way that it's supposed to. Okay. Um, so those hormones, you know, that might have some indicative factor too. But that would be something I'd had, that's a great way to look into

Scott Benner 50:20
a little more research sound like there's more in there for to understand, hey, I want to go back to Justin for a second talking about getting up and getting low. Justin, I just had a thought maybe you should do a bazel test day, maybe you're eating enough to feed a basal rate that's too strong. And that way you sat in bed, you looked at the news and everything, maybe that is what's happening, maybe it's not, but if you bazel test and find out you're always low, maybe, you know, like, when I talk about, like, you know, manipulating bazel rates, sometimes when you manipulate them too much, Justin, you're in some belong somewhere else. So you can you might be I could be wrong. But you could be in a situation that a lot of MDI people find themselves in where when they switch to a pump, and they realize that their basals way wrong. But you know, people are like, Oh, I switched to a pump, my blood sugar started going up. Well, it's possible, your bazel, you know, before was too strong or too weak, you know, one way or the other. And so, I guess the way I like to talk about it is, so then what's happening? You can't draw a parallel to the things you think they're attached to. So I don't know, Justin, that's maybe worth a shot. Somebody here said I've been diabetic for 31 years, Melanie. Hi. And you guys have changed my life. That's lovely. Isn't that nice? Thanks, Jenny. I feel nice.

Jennifer Smith, CDE 51:33
And they can see a smile.

Scott Benner 51:35
Yeah, because we really do smile. Yeah, cuz I read those two jenine. And you probably think we're just all like, just jaded and like a doesn't matter. But no, it makes everybody really happy. It does. Sabo. Can Type One Diabetes go into remission, I can answer that one. No. That it definitely can't. Oh, what's the proper way to bazel? test? Caroline? In my opinion, that's a long conversation. It's not an easy conversation to have. But Jenny and I have had it in the pro tip episodes. So find the link, go to diabetes pro tip comm and look for the Basal testing episode. I listened to all of them If I was you, but at least to get to that one. Justin says, like, maybe we're onto something. All right. You're good to go for a little longer. Yeah, Caitlin. My toddler has decided to wait, we're gonna go somebody else said something about Caitlyn disappeared, my toddlers decided to pace himself differently during meals resulting in dipping down into the 60s mid meal. I'm concerned about our low percentage has hiked to 6%. and wondering if we should make changes.

Jennifer Smith, CDE 52:43
So if your toddler is now decided to like, pick it things like he'd rather he or she graze like over the next one and a half hours instead of like slamming it all down within 15 minutes. That was the case. You know, kids are different. I've got a three year old, they sort of roll and change without telling you they're going to Gee, sounds like the dose is probably not wrong. It would be again, the timing of the insulin distribution. So if the picking of the food he he or she ends up eating everything, but it's in a slower timeframe. If you're on a pole and extended bolus,

Scott Benner 53:27
yeah, so extended bolus you could do two different boluses if you wanted if that's get that idea scared you. Kenny says try to get them to eat the carbs first or the shorter to help it there's a you can manipulate the food. You know now you're going to get me into my my coma when I'm on stage and I start talking. Too often with diabetes, we think of just one thing, how does the insulin impact the number, but you should be wondering about how the food impacts the insulin, how the food impacts the number, how the insulin impacts the food, like there's all different sort of perspectives you can use to think about it and one of them in there is the answer. And Marcel makes a good point. Maybe the person who asked if diabetes could go into remission maybe they were asking about honeymooning and, and so, so back to that some people really can. Maybe we should go over honeymooning real quick, but honeymooning is a spot where you have Type One Diabetes you have this insulin need. And then sometimes for a day, three days, three months I've spoken to people it's gone on for years for suddenly it feels like their pancreas is shouldering the burden a little more again, and then they call that a honeymoon. Well, I think that's a fairly good explanation of what honeymooning is so it does eventually for most people go away.

Jennifer Smith, CDE 54:45
Right and you're eventually you will return to using insulin completely

Scott Benner 54:50
right for right. If I go away, I mean, your pancreas is gonna, it's gonna give up finally poop out go down like Bugs Bunny eventually. And then for those

Jennifer Smith, CDE 54:57
who are diagnosed as adults or What we call often call ladder. Some adults, it can actually have a very long honeymoon Yeah, where they may very well be able to control even without insulin for months at a time after they're initially diagnosed with just lifestyle changes before they actually start to need to use a basal insulin and eventually a bolus insulin, etc. So

Scott Benner 55:27
let me address this one question. Then there's another one here. I like that I want to go to back to Sabah because he's asking, Is there a cure on the horizon and near future? I don't know that there's any cure on the in the near future. I have a very simple concept around this. I live with a lot of hope for advancements, but I make decisions day to day like they're never coming. Because far too many people I see ignored thinking, Oh, this will be over soon. I can my body can take bad management for a little while. I that's how I feel about it. I act like it's not gonna happen. I hope I'm hopeful. But, you know, somewhere in the middle there i think is the answer. And Jenny, do you know of any cures on the horizon?

Jennifer Smith, CDE 56:08
I don't there's, as there have been long term, there's a lot of research, there's a lot of animal based studies that show some warrants some benefit. But you know, 32 years with diabetes, I explicitly remember my doctor telling my parents not to worry that within seven years, it was seven years when I was diagnosed within seven years, right? You won't have to worry about this anymore. And, you know, even into my teen years, then my team brain even started to tell me, this is like lifelong, right? Just the hope has always continued to be there that maybe there will be some grand discovery, and it'll get through and everybody will benefit from it. You know, I am, I'm hopeful more in technology, and where the technology piece is going for helping management. But I am hopeful, but I don't see it.

Scott Benner 57:06
I agree. I hate saying that. I know it sucks to say it, but I'm on the same page with you. And not for any nefarious reason, just that if you really if you go look, I think as a species, we've cured like eight things. And a few of them are just inoculations. They're not even really cure. So I'd live like, I'd live like it's not gonna happen with my actions around diabetes, but I'm always hopeful. I and here's another thing not to make light of it, though. But somebody said on the podcast recently, no one's going to cure diabetes, and you're not going to know about it. It'll be on the news. You know, you'll figure it out or turn yourself into a mouse because it seems super easy to cure them from type one diabetes. Maybe that's what we should be doing. Looking how to turn people into mice. Hmm, now we're getting somewhere. Yeah, I'm sorry. I feel bad about that. But all right, Mallory says, No, wait, Mallory. I'm sorry. That's not the one I was gonna read. And I'm like, Damn, they almost got the mind. A Kelly said nearly every night after my son falls asleep, he shoots the 300. I've increased bazel by as much as 95%. But once he's there, I can't bring him down. When he wakes up, can I answer first?

Unknown Speaker 58:13
Sure.

Scott Benner 58:16
Hold your thought, I'm just gonna put something on that you can come through with Trust me. Just because your kids bazel rate is I'm going to make up a number here, a half unit an hour and 95% puts into a unit an hour doesn't mean that's how much insulin he needs in that time. So you may have to extend on your pump, the amount of bazel you're allowed to use to get to the point where you can keep him down because there is an amount of insulin that will stop that kid's blood sugar from going up and hold him steady. What were you gonna say?

Unknown Speaker 58:46
What I said, You're so funny. So

Jennifer Smith, CDE 58:48
pretty much along that line? Yeah. One is, you've got data that shows you that this is happening every night, right? You're not like, Oh, this is only two days. And now it's not happening anymore. This is it sounds like it's every night. So one, you know, insulin needs to change to right along with what you said. It's in very low level bazel rates, especially in many kids. If you're turning Bayes a lot by 95% at a bazel. That's point one. You're not hitting the mark, by any means.

Scott Benner 59:21
Remember, you're not going to

Jennifer Smith, CDE 59:23
write it. That's that's not hitting them. You can even look at it a little further if you take into consideration. What what's the climb in blood sugar. Let's say the child is starting at a blood sugar of 91 at bedtime and climbing up to 303. Right? That's a huge increase in blood sugar. You can also take a look at Well, what is your correction factor? Most little kids have correction factor somewhere around like one unit changes their blood sugar by 150 points or by 200 points. If your kid is climbing 200 points, that little notch up 2.2 When your kid really needs a whole unit to correct a 200 blood sugar climb, right? That's how much you need to change the base and why

Scott Benner 1:00:08
Yeah, here's the thing, you'll hear me say this a lot. If you listen to the podcast, you need more insulin. That's it. If you have more insulin, it wouldn't happen. And by the way, for the person who asked about the group, and by the way, too, for a little kid, that could be growth overnight. Right? And for the person who jumped in and said, their kids in the teens and going through growth, and they can't keep their blood sugar down. Here's my answer to that to use more insulin. Because there is an amount that will stop it. Trust me, there's an amount like, now the question is, how do you get to that amount in a way that doesn't feel frightening? Especially for somebody who's now talking about Look, it's supposed to be point five, I made it one, how am I possibly going to go higher than that? That feels frightening. I've told the story in the pious, long time, so I'm not going to waste it here. But there's an amount you can do just find yourself being more aggressive cover with a fast acting is used if you've gotten too much, but the truth is Peters bazel up a little too high. He's not going to go from 300 to negative 10. Out of nowhere, you know, and keep in mind too, that if you see arise at midnight, that doesn't mean change the bazel at midnight, it could mean change the Basal at 11 o'clock even or it could be a little earlier a little sooner, depending on how his body or her body reacts to the increase of bazel. Just like you putting in a bolus doesn't start working right away. Putting in a bazel doesn't start working right away. There are more thank yous in here. Those are nice. Thank you. Jen, do you have to go at the top of the hour?

Unknown Speaker 1:01:34
Oh, no. I've got about 15 minutes.

Scott Benner 1:01:37
Jenny's giving you her personal time. That's lovely. The takeaways more instant mirror it always is. Kara? I'm glad you think this is awesome. Okay, so she got correction factors thinking about it so that way. Jeff is saying protein and fat that are hitting around dinnertime. Okay, Scott. Jamie said, Scott, I've heard you say things about being an insulin deficit. From overnight, I'm pretty sure I understand what you mean, I suspect it's a reason why some people go higher than expected in the morning. It was a lightbulb moment for me. So I'm sure others may find it helpful. Anyways, I love you guys to explain what you meant here. I'll let Jenny explain what I meant. So I can drink something.

Unknown Speaker 1:02:27
Yeah,

Scott Benner 1:02:28
I see what I mean, afterwards, just you go first, relax.

Jennifer Smith, CDE 1:02:32
So if you're at a bazel deficit, essentially, you're coming in to a time period when first thing in the morning most people are trying to put food in right away, right. And if you're coming in at a deficit of insulin behind the scenes, then the impact of that food even with potentially a Pre-Bolus, it, you're still going to rise because there wasn't enough behind it in the hours leading up to that meal time. If you're at a deficit of insulin as well, you're likely seeing that you're writing in at a blood sugar that's higher than you want to be or it's higher than the target, you've had your your pump set to keep you at. And that's a telltale sign right there. And that's only then going to lead into that real time, also causing more of a rise up than you want. Because you're already starting higher than you wanted to begin with.

Scott Benner 1:03:26
I would and I think of it, if you want a different way to think about it, it's like eating a meal without a Pre-Bolus. Right, because there's just you, if you don't Pre-Bolus a meal, you start eating that foods gonna win way before the before the insulin starts working. Same idea, like Jenny said, people jump out of bed and they eat. And you know, we just explained to the last person that you turn, you put a basal rate on at, you know, not at midnight for a jump up at midnight. So if you're getting up at seven in the morning and beginning to eat right away, your blood sugar's jumping up, it's possible your basal needs to be stronger, starting at 6am. And you still have to Pre-Bolus it's not all the base, or you're gonna have to Pre-Bolus and you're gonna have to have the base. All right, it's all just the timing and amount. Everything you see with Type One Diabetes, in my opinion, is about the balance of insulin and using it when it's needed. And you have to be able to step back sometimes to see the bigger picture. People get hyper focused on what's happening in the moment. I get up in the morning and my blood sugar gets high. That's it then they stop there. It's not about that. It's about before I've now this is going to be the third time I send everything. Everything you do now with insulin is for later, but remember now is always some other times later. Ah, that's how Arnold Schwarzenegger tried to kill those people in that movie. Right. Time travel time travel.

Unknown Speaker 1:04:47
Okay. Yeah, that's all. I think

Jennifer Smith, CDE 1:04:50
the other part of it too is that there is a very there's a very emotional level to managing your diabetes. Managing somebody that you love. Diabetes, yeah, right. And so, as hard as it can be, sometimes you have to step outside of yourself. And you have to kind of say, especially for the person who's managing their own diabetes, you kind of have to step back, take the emotion out and say, Okay, um, hi. I love being high, but I'm high. Let's, let's look at the information and see what I can do to fix it. Right? Um, sometimes taking that emotional piece out of it also makes you think a lot clearer about what you want to do. I mean, that's, that's the big reason for baseball maker.

Scott Benner 1:05:40
I maintain, I maintain that I'm as good at this as I am, because it's not happening to me. If I had type one diabetes, I wouldn't have this podcast, I'd be a mess. I'd be on the floor with my 10 a one See, God, I gotta know what's happening. You know, but it was for my daughter, right? Like, no, I don't know, like I you know, it's for her. So that I'm able to, I'm able to be more aggressive because I have a bigger fear of letting her down than I would have letting myself down. I think. So a lot of the things you'll hear about on the podcast, which by the way, you can listen to on any podcast app, absolutely. For free, just search for Juicebox Podcast, there's over 325 episodes, the podcast has been up for almost six years. You know, if you don't have a podcast app, they should be free. If you can't find one, go to Juicebox podcast.com. Scroll to the bottom there are links to all your different phones to get you on. And someone just asked a question here, how to manage unexpected activity, but a bunch of people just jumped in and said have a snack. decrease your bazel Yeah, that's it. Now listen, something somebody said was amazing. I'm gonna assume it was me and we'll just move on.

Unknown Speaker 1:06:50
I don't really know what she's talking about.

Scott Benner 1:06:53
Yet, so they're talking about that they're talking about activity around all this. Also, I want to bring up around you know, a lot of people stress, anxiety, or all of a sudden sedentary lifestyle because you're not going to work anymore. All those ideas somebody in here asked about they said their blood sugar's jumping up at night, not always, since the pandemic has started. And I wonder if when your brain slows down after your days over, do not find yourself thinking or worrying about Coronavirus because stress, anxiety, pain, there are a lot of things that can make your blood sugar go up. So I would I would look into that a little bit.

Jennifer Smith, CDE 1:07:30
In fact, there's it's really funny that you bring that up because, uh, somebody that I work with, she actually just emailed me. It has nothing to do with diabetes, but my brain was right away, like bringing diabetes into the picture reading it, it's all about dreams, since Coronavirus became the thing that it is, yeah. And the fact that dreams are, they are the way that our our mental self kind of manages through things. And we can learn some things, you know, if your dreams are kind of scary, or if they're really scary, or if they're just sort of like hinting at weird things. You know, I mean, it's the way that your body manages to sort of work through some of the thoughts that it didn't have in the daytime, right? Or that were sort of in the background. And with diabetes in the picture. Some of those can be very stress inducing in the overnight time period. So you know, if you're looking at, you know, many of your overnight values and you're thinking Whoa, why is this weird? This night was really weird. I had this strange rise and I woke up high and that's usually not happening for you. Maybe you had a horrible dream about

Unknown Speaker 1:08:37
something that you know, and it's not about never hugging another person again.

Jennifer Smith, CDE 1:08:44
Could be I had a I had after all this started I had a horrible dream about zombies. Did you? Horrible like I woke up in like a panic. And I usually I don't remember many of my dreams. I usually see sleep pretty soundly. Yes. Dream had me like, I was like all levels.

Scott Benner 1:09:03
When Natalie just jumped in and said playing video games makes her teenage son's levels go up. That's adrenaline, I would imagine. And Natalie I bet you they come back down again. Right? And because that's that's another thing. So stress, anxiety, those sorts of things are always going to well always have the ability to impact I'm sure there's some people get stressed out in their blood sugar's don't go up. But it does happen to a number of people enough that it's worth paying attention to.

Unknown Speaker 1:09:27
Yeah, and

Jennifer Smith, CDE 1:09:28
sometimes you can address the rise. If you know that it's not going to come down sometimes sometimes you have to correct for it. Many times adrenaline rises, though. We often don't have to touch oftentimes once that stress factor or the adrenaline like surge sort of passes. You'll see things come back down.

Scott Benner 1:09:46
You know it's funny somebody jumped in as you were making this and said a bedroom could make your blood sugar go up at night, mira said and there people my daughter's goes up with Xbox so if you know, listen, it's not the easiest thing to to Guess schedule. But if you know, Xbox time is going to be in a certain place, you probably could do with Temp Basal increase. Right. And that would

Jennifer Smith, CDE 1:10:08
that would definitely kind of like weightlifters if you know, you've watched enough to know how much blood sugar typically rises during Xbox use, you could technically take an amount of insulin as a bolus to offset the typical rise that you see based on what your correction factor is.

Scott Benner 1:10:23
Let's see if we can get one more thing in, because we have to go so somebody asked about their Dexcom user, and they're talking about Pre-Bolus. And when do you know when to start eating. So for my daughter, in a perfect situation, I like to see a diagnose Down Arrow before she starts eating. And you also have to get right in your head what's high and what's low, too, you know, for me, I don't want my daughter, I try very hard for our not to go under 70. That's my goal. And I try for not to go over 120 do we always do that we do not always do that a number of times a day, she ends up higher, it just happens sometimes. Okay, all the things that you just heard about happened to us to my daughter's a one C has been between five two and six, two for almost six years. But she got out of bed didn't have enough insulin going because she slept in try to eat something with a lot of carbs and her blood sugar's 200 right now. And it's and we're going to get it back down as fast as we can without it getting well it's not you're not shooting for perfection. You're just shooting for as much time and range you can get in there. But back to the initial question, I like to see a diagonal down arrow. But now I know how fast the food is going to hit or just you just have to practice right like, started 100 put in the blood sugar when you get to 91. Diagonal down, eat, see what happens? Did you go up to 150? But then level back out? Cool. Maybe you could have waited till 85 diagonal down. Maybe that would have taken you do 130 c? It's just trial and error. You have to go over and over again.

Jennifer Smith, CDE 1:11:53
Experience teaches you? Yeah, a fair amount.

Scott Benner 1:11:57
JOHN, I don't know that. Jenny knows this answer. But I'll ask before she goes john wants to know if you know what factor? What factors affect the hypest hypoglycemic risk value on the dexcom clarity app, you know what it takes into account to come up with that? I don't,

Jennifer Smith, CDE 1:12:13
it I don't, but my assumption is that it calculates the percentage of time that you've been low, within the timeframe that you're looking at, to classify what your risk is, you know, if you're, you know, 1% of the time low, I guarantee that your risk factor for most is not high. Whereas if you're pretty consistently at 10%, low, even if it's not really red low, it's just that pink low, right? Because there's a different designation. There's a 55, red low, right? But I mean, if you're really low, pretty consistently, that risk factor obviously goes up. I don't know exactly what parameters they're using to establish that percentage value for you. Um, but

Scott Benner 1:13:09
Alright, so let's roll through these last three, Jamie brought up that if she waits for a diagonal Down Arrow for her credit goes lower, so it's gonna be different for everybody. Yeah. Lisa is saying hello to us from Sweden and said, we've both been very helpful in her first six months of being a type one mom. Hi, Sweden. That's cool. And Sue asks, do we recommend the in pen which I think we both though?

Unknown Speaker 1:13:29
Yes,

Scott Benner 1:13:30
yeah. If you can't pump, you can get a lot of the knowledge that a pump has from in pen pairing with their in pen app and your your glucose monitor and even a meter. Not as much luck and Jenny's holding one right there.

Jennifer Smith, CDE 1:13:42
I've got the pink. You can get them in different colors.

Scott Benner 1:13:44
Yeah, I've got blue in here somewhere. But it's a demo. So. Yeah. Okay, so listen, Jenny was only supposed to be here for an hour. It's 409. She got to go back to her life. I want to say that at one point. This was up to 120 people and it never got below 80 even 15 minutes after it was supposed to be over. So awesome. Really appreciate all you guys. Thank you so much for listening to the podcast. If you enjoy the podcast, please share it with somebody else. It's the only way it can grow. I do not have money to to do any kind of meaningful. You know, advertising for the show in the last comment here again is Jenny's email address. You can hire Jenny. She works at integrated diabetes services. You can have one on one calls just like this with her. Check it out. See if your insurance has covered it or if you want to pay cash, whatever you want to do. Jenny is very cool. She is 100% my diabetes spirit animal. I've never heard her say one thing that I was like that's wrong. But as I've mentioned on the podcast before, that might just be my narcissism because she agrees with me. I think she's terrific. But who knows exactly, you know, this will be available on the podcast soon. And it will be running on Juicebox podcast.com as well. And it stays here on Facebook. So thank you everybody very much and Hope you guys have a great day. And Jenny, I really appreciate you doing this. Thank you.

Jennifer Smith, CDE 1:15:02
Yeah, no, this was great. Thanks to everybody who commented back and forth to each other as we were answering. It's a great way to help each other. Yeah.

Scott Benner 1:15:10
Very cool. All right, guys. Wash your hands. Stay safe.

Unknown Speaker 1:15:15
I why.

Scott Benner 1:15:19
Don't forget even though this episode was not sponsored, the podcast does have sponsors like Dexcom. The Contour Next One blood glucose meter, touched by type one and Omni pod. There are links to those sponsors in the show notes of this episode, and at Juicebox podcast.com. If you're not looking for those types of things, go into your podcast app and leave a glowing review of the podcast. It would make my day and Jenny would smile about it too. Alright, let's turn off the music and we'll dance our way out of this

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This is a bonus episode and was not sponsored. That said, these are the show sponsors.

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About Jenny Smith

Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com

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#321 Ask Scott and Jenny: Chapter Twelve

Answers to Your Diabetes Questions…

Ask Scott and Jenny, Answers to Your Diabetes Questions

• How long can you safely turn off basal?

• Let’s talk about ‘extreme’ management tactics and controversial lower A1c results.

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Pandora - Spotify - Amazon Alexa - Google Play/Android - iHeart Radio -  Radio Public or their favorite podcast app.

+ Click for EPISODE TRANSCRIPT

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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, everyone. Welcome to Episode 321 of the Juicebox Podcast. Today's show is an ask Scott and Jenny. And in just a moment, I'm going to tell you what the topics are and who the sponsors are. But first, I'd like to spend a brief second, discussing how I'm programming the show with consideration to the Coronavirus and what's going on in the world. So my family and I'm sure many of you have been held up in your homes. My family's been here at home for almost a month now. And in that time, I've been paying attention to the Coronavirus maybe more acutely than some parts of the country because I live in the New York Philadelphia metropolitan area. And it struck here pretty quickly. Now, some of you may live in places where it might not reach anywhere near that it has in New York. And I hope that for all of you. And some of you may just be a little behind where New York is right now. One way or the other. I felt like it was important for people to understand what Corona or COVID-19 is. So you know, back in mid March I had Adam Edelman Come on. He's a doctor we discussed Coronavirus, kind of in a broad way. Jenny Smith and I talked about Corona The following episode. So these are episodes 314 315 There were a couple other episodes came up. And before I knew it, Sarah who's listening to the show, reached out and said she's a nurse in New York City. And she's got Corona very mild case of Corona, she came on and told us about what a mild case of Corona was like. Adam came back on Dr. Needleman came back on again, just recently did a little bit of an update. And in that time, I was able to interview a gentleman named Justin, who's become kind of famous online for being one of the first people to put a picture of themselves up with a mask on saying that they had Coronavirus and asking everyone to be careful and, and follow the rules. Because it was serious. Justin happens to have type one diabetes, so I couldn't pass him up. Even though I thought I don't want too much Corona stuff on the podcast. Now Justin had a more significant more severe case of Corona, and I interviewed him just the other day, his episodes going to be out after this one. So what I'm gonna do this week is put an extra episode out, I'm gonna try to strike a balance, I don't want people who aren't interested or maybe are having anxiety around Corona to feel like they're not getting content. And for those of you who are interested, I don't want to stop providing the content. Now I can see the downloads and the corona episodes are very popular. And so I'm going to kind of override my inner voice that's telling me too much Corona. And I'm just going to try to continue to provide good solid information that's not click Beatty, and not meant to make you upset, you know, so that you'll come back and get more, which I think is what a lot of media does just want to offer you good information. You can do with it what you want. But there'll be three episodes this week, so that everybody gets what they're looking for. This episode of The Juicebox Podcast is sponsored by Omni pod makers of the tubeless insulin pump that my daughter has been wearing now for a very long time. Now, since she let's think, already got an insulin pump around the time she was four and she's gone. And she's 15. She's going to be 16 this summer. That seems like 12 or 13 years, it's hard to know because my math skills are limited. Anyway, Arden has been working on the pod every day for that time. She's also been wearing a Dexcom CGM. Currently Arden wears the Dexcom G six continuous glucose monitor. And we absolutely love it, you can tell that if you listen to the podcast, that's sort of a no brainer, I don't really need to tell you her meter the Contour Next One blood glucose meter super small, super convenient, lovely and accurate, like they talk about and of course you know near and dear to my heart touched by type one. And I asked you to check them out at touched by type one.org. There are links in the show notes of your podcast player to all of the sponsors. Or you can type their links in yourself. My omnipod.com forward slash juicebox dexcom.com forward slash juicebox. Contour next one.com And of course, touched by type one.org. Let's play the music and then talk about some stuff with Jennifer Smith.

In today's Ask Scott and Jenny, we answer 123 questions. Wait. Yeah, three questions couple more bigger. I asked me a question. We chat a little bit about the Zoom meetups I've been doing on Thursdays come on out and check them if you want. There's one In the Facebook page, this Thursday is going to be at 7pm. Eastern time, I guess I should tell you that Thursday's date will be April 9 2020. In this episode, Jenny and I are going to answer a question about shutting off Basal, and how long you can do it safely. I'm going to tell a quick story about meeting some fans in public. I Muse a little bit with Jenny about the social meetups and whether or not they're valuable ways to help people make improvements. And I'll talk a little bit about that at the end of the podcast as well. And then we talked about extreme management. I put extreme in quotes here. Because is being healthy extreme. And why do people think of it that way? Sometimes. I'm going to want you to remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And to please Always consult a physician before making any changes to your health care plan are becoming bold with insulin. Helen says, I hear Scott say he turns Basal off. If Arden is running low, we started to do this for my daughter, Ella. And it works amazingly well. However, we only dare do it for about 30 minutes. We were told ketones develop quickly if she doesn't have background insulin. How long is safe to do? I have my answer. Let me go first this time. Let's see how wrong I might be sure. Well, you're not wrong. Yeah, I could be wrong, you hold tight.

Jennifer Smith, CDE 6:32
Hold tight,

Scott Benner 6:33
I'll wait. Here's my thought. If your background insulin, if your Basal insulin is dragging you that low, then taking it away for a little while. It's not really gone, because you probably have too much to begin with. Now, if you take it away for a long while, and create an absolute black hole where no background insulin exists, then I think DK can come on very quickly, depending on a lot of other physiological implications. How was that?

Jennifer Smith, CDE 7:07
I was actually pretty, pretty good. Not bad. Not bad. Not bad at all.

Scott Benner 7:11
I gotta get you know how some people are like online ministers. I just need one like company to start online CDE. And I think I could get one wouldn't be like real, like, you know that while you're being married by a minister of the like, bah, bah, bah, live charge that got something by filling out a form online. It's not really a minister but it's legal. It's legal. I think if somebody would start that around diabetes, I'd be okay. Go ahead.

Jennifer Smith, CDE 7:38
Yeah, no, but you're I think that's a really good like baseline, and even a little bit more. It's a little more in depth than baseline even because you did go into the fact that if you're on Basal alone, there's little, literally nothing else left such as like an overnight, you go into bed, your last meal in Bolus was around six o'clock, it's three o'clock in the morning. And you can see that, like you said, before Arden's friend, she had a bad pump, or a bad pod site, or whatever it was, and she was middle of the night, you could see blood sugar was rising. There was no other reason for it to be rising. None at all. It was a bad site. So that kind of a deficit of insulin was likely started a couple of hours prior to the rise starting Yeah, right. Because anytime you're at a deficit of Basal, you can shut a Basal off right now, you still have circulating Basal insulin going for at least another hour, perhaps hour to two hours, right. So you're really not at that complete, utter zero level of Basal yet. So a 30 minute shut off, is really it's nothing, it's, I'm glad it's helping for the reason that you're using it for, but that 30 minutes is really like a drop in the bucket of nothing, as far as impact for causing decay a right. And the other, you know, piece that kind of goes into that as well. In this scenario. For example, let's say this low is happening during the daytime, and you shut the Basal off for just 30 minutes. And it helps for whatever reason that 30 minutes is really stabilizing things, evening things out into the next hour or two. So you don't stay low or go lower. Great. But you also have to look back and say if this was during the day, the low was probably as long as you've got Basal figured out. It was probably not from Basal. It was probably from insulin on board from a Bolus that drove things too low. Yeah, with whatever other variables in the mix that caused it to happen, right. So just that 30 minute deficit again, of only Basal it's not deleting any insulin on board from a Bolus that might still be in the picture. So again, the risk of decay a while it is higher on a pump than it is with multiple daily injections. Because once you take your injection of Basal it's there, you know it's there, you're never at a base at a deficit of it. With a pump though, you do have to be careful. And our baseline is when it usually comes in and discussions in summer when kids are going to the beach and using their pool a lot or you know, whatever it might be, they disconnect from a lot of pumps that are tubed. We usually say do not disconnect for more than a two hour time period, come back check blood sugar, take a Bolus of at least 50% of the missed Basal amount in that disconnected time period so that you don't have problems with a deficit leading to potential decay in the next several hours. So So yeah, so there's my long explanation.

Scott Benner 10:45
Oh, that's a great explanation. And and it brings up you know, what it reminded me of, you reminded me of how proud I am of the podcast, and how we can have long conversations about stuff like this, because 15 years ago, in the diabetes space, this was the message, you're more likely to go into decay with a pump. Because what if something happens and you stopped getting your insulin, and then that became the rule pumps are dangerous. And then people thought that for years, until people got other people bought pumps, and wore them and proved everybody hey, look, I'm still alive. I have a pump. So saying something, and it's not a wasn't a, an incorrect statement, right? You could be sleeping and Rick, rip out your site. And now you're not getting insulin. And that is a

Jennifer Smith, CDE 11:29
danger that could chew the to but you don't know it. I wish I could name this

Scott Benner 11:33
episode, the cat that chewed the tube, but no one would listen to it. But but but the point is, is that we used to say these very basic things, because that's what communication allowed. And then people were allowed in their minds to take the scariest part of that and run wild with it in their own imagination. Yeah, so I like that we can talk more about this. I like that. Helen can now think if I give a Bolus at noon, and I need to make it more aggressive upfront because of the nature of the food, but I know that at three o'clock, my kid's going to get low. I can still make that Bolus at noon. Turn Basal off at two o'clock, create a deficit of Basal at three when the Bolus from noon peaks and balance those things out. That is so cool that we can talk about that like that.

Jennifer Smith, CDE 12:24
That's great. Yeah. So I appreciate your tools, more tools for the toolbox.

Scott Benner 12:27
It's just more stuff to understand. I saw Jeremy in the Facebook group. He's being helpful and making fun of me at the same time, which I appreciate. Oh, because when people sometimes people are like, I don't know, like, how am I supposed to get to this place where a lot of you are what Scott's talking about? And my answer always is, you got to listen to the podcast. Like just listen through it because these things will build it's not it's not a checklist of five things you just do. And it all of a sudden works. There's you know, variability and, and nuance and everything. And Jeremy's like Scott's gonna say to listen to the podcast and, and he's like, but try this year. And he's both right in making fun of me. And he's right about what he said, too. Because this is not a quick fix. And it's not information that your brain just learns. Hearing it one time, you know. And

Jennifer Smith, CDE 13:23
when you since we've got some time now

Scott Benner 13:27
turn it up here.

Jennifer Smith, CDE 13:29
On those headphones, go for a walk with your dog, push your stroller, listen to it while your kids are running around in the backyard and whatnot. Actually, somebody yesterday that I talked to she and their family, they had come down to Atlanta for the JDRF conference to hear you, which was great. But all the way there and all the way back. They actually listened to the podcast to the podcast, because they had like I think she told me it was like an eight hour drive there an eight hour drive home. So they drove there and back listening to the pod.

Scott Benner 14:02
That's really nice. I thought was really cool on my way to Atlanta. I was I had to park my car to an airport, and I got a little shuttle bus to get to the airport. And there was this woman and her like 17 year old ish son sitting next to me, and we start driving out of the lot. And she just stands up and like goes way, way, way, way way. And like everybody's like, Oh, you know, what's this? She was I still have my key. So she was valet parking. So her car still running somewhere. But she left with her key, right? So she the driver stops, she runs out takes the key to the valet. And I turn to the boy and I say is that your mom? And he goes yeah, I said, my wife and I embarrassed our kids all the time. And he looks at me really strange, to the point where I thought Ooh, did I just offend this kid? Right and I felt bad. So I kind of withdrew back into myself and stopped talking to him. She gets back on the bus and begins to very kindly apologize to everybody on the bus. Oh, I hope I'm not making you late. Meanwhile, it was 30 seconds. You know, she just I hope I'm not making you late, Bob, I'm sorry, but and I looked up at her and I said, I just did something really stupid with my key two weeks ago. If you sit down, I'll tell you about it. It'll make you feel much better about this. She looks at me and goes, Are you Scott from the Juicebox Podcast? And I went, what? Because you know, we're on a bus at an airport with only eight other people. And I said, I am. And she goes, Oh, I saw you speak at this thing. And we listened to the show. And just as that happens, the kids CGM beeps, and I turned to him and I go, Oh, hey, and he looks at me. And he goes, I thought your voice sounded familiar, but I couldn't place it. My mom and I listened to the show together. And I was like, just think he wasn't mad at me. He was like, oh, man, why is this guy's voice seem familiar to me, you know, and it was just absolutely crazy. And then days later in Atlanta, I literally walked into them in a hotel lobby. I was like, they're there again. Funny, it was very, very strange. But, but nice. It was it was lovely, actually. So it might be different. You're being kind, but I appreciate that those it was very strange. It happened two weeks after I was recognized in an airport in Dallas. And that threw me for a loop. That was a woman approached me. He told me about Yeah, you're just sitting. Like, I was getting ready to get on a plane trying to decide when I was going to change my shirt, my sneakers, you know, like, and a person I have music on. And this lovely woman comes up to me, she kind of puts her hand out. And you know, you're just like, what's about to happen? You don't I mean? So I'm like, Hi, how are you? And she goes, good. I'm like, Can I help you? And she goes, Sure. Are you Scott? And I'm like, Uh huh.

Jennifer Smith, CDE 16:56
And who are you?

Scott Benner 16:57
And I was like, Were you just at my talk? And she goes, No, I'm in town. My daughter's running a marathon. And we're here to support her. And I was just like, wait, what? Like you weren't just at the thing I spoke at? And she's like, No, she says, My husband and I were sitting over there. 10 minutes looking at pictures of you online trying to decide that he's finally I think that's him. Go say hello. That kind of stuff. I gotta be honest with you. From diabetes podcast, I never thought and now it sticks in my head when I'm in public now. Now I'm like, Hmm, is there?

Jennifer Smith, CDE 17:27
Anybody knows what I look like?

Scott Benner 17:31
You just got to keep a lower profile. Because Because now I find myself thinking like, do I have to be nicer in public? Not that I'm not but like, am I gonna be judged by? Like, is there gonna be a story online one day, we're like, I saw this guy from this podcast, and he was being so he was being rude to a lady, you know, which I'm not. But now I'm worried about it. Right. So silly. Absolutely. So So I said, Jenny, let me ask you a question. I haven't asked Jenny question. I have. I'm doing that thing tomorrow on tomorrow, the first, you know, kind of group meet up for people. And I was thinking during this Coronavirus thing of starting like some sort of a challenge to lower your a one, see your deviation, your variability, like all that stuff, like we're all just sort of sitting around. Like, I wonder if we shouldn't, like try to help people like, right, like, I'm wondering if when everybody comes on this, this zoom later, if I'm not just gonna go through one by one and be like, Alright, everybody hold up your 24 hour graphs. Let's look at your Basal insulin. And then, and then talk about getting Basal adjusted for people, and then maybe see if we can't get back together once a week and see what we could do about like, I do a cool thing to do I do it with single, like people by themselves. Like, I think I could do it with a group.

Jennifer Smith, CDE 18:52
I not do it together and teach a big group. Right? Yeah,

Scott Benner 18:55
that might be fun. I think that would work.

Jennifer Smith, CDE 18:59
I do. And I think from the standpoint of looking, you know, I, in terms of looking at data, when you look at so much data, as I do, every day, lots and lots of data, lots of people's different kinds of data, you actually start to notice more things, right. And from a teaching tool, sometimes when it's only your own data that you're looking at, you can kind of get lost in it. Right, right. But when you bring together a big group, kind of like, like a kids for diabetes camp, or kids with diabetes kind of camp, you know, they they do a lot of things that are interactive like that, and they bring the information together and that sort of camaraderie. in a setting like this, yeah. where everybody's showing a graph. Somebody might be like, Hey, that looks like this is happening, right? Or, Hey, that looks like this is happening. And not only is it like a learning experience, you're also helping other people. You don't necessarily know.

Scott Benner 20:01
I just, I see it in the private Facebook group. So if you go on Facebook and search juicebox discussion group, I think that's what it's called. I named it, I should probably know what it's called. But it's a private group where people talk, and there's times people put graphs up. And I'll like jump in to say what I want to say, and somebody will have settled already, like, oh, great, you know, and I'll like, like, somebody comment and put a finger under it, like pointing to it. Like, this is what I would have said, Yeah. And then there are other times where somebody makes an explanation. I think that's better than what I was gonna say. And, you know, terrific. So I'm thinking like, maybe we can do it. Like, again, a mass like, you can get 100 people together and bring everyone's blood sugar down, Louis, Zoom call. I'm like, I'm like people. Yeah, I think I can. It's so and then like, yeah, I hope so. I really hope it works out. So I'm gonna even have

Jennifer Smith, CDE 20:51
like, focuses, like you said, kind of like Basal or like, even like a challenge of, okay, your challenge today is to go home and just Pre-Bolus for all of your meals. Right? And let's look at what that did from today. Compared to tomorrow. What did that do?

Scott Benner 21:06
That's what I was thinking. Alright, I like that you are doing. Jenny makes me feel better about myself. Sometimes. Like you said, one, though. Seriously, you said one time, I forget how you put it. But you said something about, like, you could do this for a living. I know you don't have the credentials, but you could. And that made me feel really nice. I just I never told you that. So thank you. Okay, let's see. How are we an hour and a half today?

Jennifer Smith, CDE 21:38
I set up for about an hour, hour and 15 hours.

Scott Benner 21:41
Okay, so let's do we'll do one more. Um, ah, Kelsey, I'd be curious to hear Jenny's thoughts from a clinical perspective on the post from earlier regarding extreme she without in quotes, management tactics versus being bold. And what her take is on lower a one sees and the pushback in the medical and sometimes social community based on available studies showing no benefit. Also thoughts on lag time of published studies and the advances made in the last decade? Have we talked about this? I brought this up in passing with you once. I just mentioned it as an article. I don't know if you've seen it or not. Right. But so I guess what Kelsey wants to know if I'm, by the way, that's a very well written question, Kelsey. It is no, so many smart people are listening to this podcast.

Jennifer Smith, CDE 22:34
They're all smart. Everybody's smart in different ways.

Scott Benner 22:36
Yeah, no kidding. But I'm saying this is a really well written question. Usually people's writing doesn't read. Well, Kelsey can write is what I'm saying. So, but but to boil down what she's asking. I think what she's saying is that there's a way that you know, the medical community generally talks about this, right? Like, oh, a seven a one C is fine. And then you see somebody say, Well, you know, me or somebody else. My kids got a five five and I just handle that by stopping spikes you know, making sure her blood sugar's Well, I don't think anything I'm saying is crazy, right? Like it's and, but to the, the masses, it seems like over management to them, because they've been given such a baseline of like, just do this, and whatever happens is fine, and go live your life. Right? So is her question really? Well, her, you know, let's ask answer a question first, like, what's your take on doing what you want, you do what I do with art, and with a lot of people listening to this do and what happens when those poor people then go into their doctor's office and then get sometimes really chastised for it? Like, like, I know, that's a hard thing to wrap your head around you and I talk about this privately, sometimes, but a lot of people that listen to this podcast, their next leap to make is to then talk their doctor out of being upset about it. Correct?

Jennifer Smith, CDE 24:03
Correct. And he we even get, sometimes not often, but again, a lot of the people that end up coming to us to work with us is because with all the information that is out there now and is so available online, we can not only see what other people are doing, but we're also reading such as she refers to, you know, these studies about lower isn't necessarily proving to be better in the long run, etc, etc, whatnot. But people want to do better, and they want to do better from the standpoint of understanding and I know that we addressed this somewhat in another podcast, there was a brief talk about this because I had referenced the fact that a one C for the population of people without diabetes is under 5.7%. Yeah, Why are we not aiming for that in a safe in in safety, right? With safe constraints? I'm not saying run at a blood sugar of 55. So you can get an A one C of 4.7. By no means, however, why are we not aiming for the goals that people without diabetes already have? Because their body does it for them? Right. And I bring it in to and I think I commented before as well about like pregnancy targets. If pregnancy targets are what, what we're aiming for, which is the normal blood sugar that the population of people without diabetes already has naturally, if we're aiming for that in pregnancy, why should somebody go back to aiming for higher or loosening that up? Once they're not pregnant anymore, but the baby's healthy? I guess I can, like, you know, lighten up on everything,

Scott Benner 25:57
go back to racing to my death,

Jennifer Smith, CDE 26:00
aiming for a target, you know, under 250. Target under 140. I, I don't I mean, from my personal and my clinical perspective, I don't know why that is the recommendation other than as we've also sort of alluded to, or really commented about previously, a safety factor from the conventional system of management that we have kind of that we've had to use, because that's all there is. There is a safety component that I think many, many, many practitioners, they, they don't see the every day. And so when they see data that's showing them and they're only looking at an AE one C, somebody comes in with an A one C that's 5.7. They're thinking, Well, gosh, this person's got to have a whole bunch of lows, or there are this a one C would not be 5.7. But if they looked at the actual data, and now that a good portion of people are using CGM, we should be looking at that to go along with the actual glucose management indicator, or the a one C or the average glucose, because if they're achieving an A one c that is phenomenal, 5.56, you know, 5.1, whatever it is, and their time in range is phenomenal. And their percent low is not more I mean, we as a practice, aim for less than 5% low. So if they're achieving that, why are you? Why are you upset that they're managing something? So well, a lot of preventing problems, a lot

Scott Benner 27:43
of people that reach out to me with a story indicate that the doctors even presented with the data, it doesn't stop them from being upset. They're so pre programmed to believe if you've got a great day one, see you did it wrong. And that no one can get that. And

Jennifer Smith, CDE 28:01
I'll tell you that I've had I had one really, really, really phenomenal Endo. In, I've had a couple of really good ones. But one really phenomenal one. When I lived in DC, he was fantastic. He he could side by side power with me on the level of information that I needed to talk at. And he was like, he was like a go for it. You know, it's here, let's attack this, I see this could be a problem area, he was happy when my a one C was like 5.4%. He's like, That's phenomenal. And your lows are not in the picture causing this. I mean, he could really talk on that level. And he was comfortable about that. Because I was also and I think maybe this is also a piece too. If you have the ability to talk back to your doctor about what you're doing to get there and to manage that. I mean, if you go in being like, I don't know why I'm here, I don't know how I achieve this, or whatever they're gonna be like, well, that's this isn't this isn't safe, I don't see data that's proving that this is safe. You don't really know what you're doing, obviously, but from the standpoint of many of the listeners, and many of the people that I work with. I don't love the data that I read the report that you mentioned the research report. I don't don't love that it's kind of telling people that they should aim higher when we know and diagnose pre diabetes and diabetes at certain emergency levels. If you're pre diabetic above this level, if you're diabetic at this level, why? Why is that then healthy for somebody to maintain once they do have diabetes?

Scott Benner 29:58
I think to that anecdotal evidence is more valuable in a time where we can all talk like this. Because, you know, calcium makes the point. You know, when was the study even done? You know, and just because data collaborate, right didn't look right, that study could be years old, just to get it out the way that's, that's and I'm not saying that the scientific community shouldn't do their studies the way they do. But the problem is you do a study with, you know, the proficiency of starting a fire with matches. And five years later, when you put your your data out, there's a flame thrower Now, that doesn't match up anymore. You know, you mean, I've got a flame thrower. I'm not using matches. Your dad is 100%, right about the thing that you thought I started thinking about four years ago, except we are in a different world now. So you're using CGM, and pumps, and you know, algorithms and everything else. And they're giving you you know, they're giving you advice from five years ago? Correct? I think too, it's important to remember. Not everybody's a bad student. Sometimes there's bad teachers. And so if you're failing, with bad information, are you failing? Or are they failing you? Right. And so if you start with a person who Jenny mentions having a great endo in Washington, right, so she met a person through happenstance, who really wanted to be a hands on endocrinologist, and sunk in and found out things and learn things, and was good at sharing them with other people. For every person like that, there's going to be a handful of people who, you know, we're coming out of high school and going, what should I do for a living, I'm good at math and science, I'd like to have some money, I'll be a doctor, my doctor goes on vacation twice a year, this is perfect. You don't just like there are some people who really want to teach children. And there are some people who just want to have off in the summer, they both end up being teachers. You don't I mean, and so not everybody's the great doctor from Washington. So if I'm just giving you look, I read the articles, this is what it says to tell people with type one diabetes. So this is what I say to them. And if they're failing, that's their fault, because I gave them the directions. You didn't tell them how to use the directions you didn't you left out all these other things. And so again, I used to talk about this a lot more in the podcast years ago, you have to just believe in yourself a little bit and what you're seeing, you know what I mean? Like you can't keep having outcomes that you know, are bad. And then turning back to the guy in the white coat. And he says, No, you're doing great. And then you swallow on that big fat pill and just going okay, I guess it's alright, the guy said, It's okay.

Jennifer Smith, CDE 32:37
And I think sometimes it's also hard. I mean, I've heard from many people, not many, but some people who've actually said, Well, if I, you know, if I choose, I choose to work with you or your practice, my endo doesn't want to see me anymore. Or if I do all of these things, and make my own adjustments, I get hand slapped every time and that doesn't change. Well, you know, in our healthcare system here in the United States. Thankfully, many of us with our providers, we've got the ability to change providers, we can look at our network, we can see who else could I go to, with social, you know, connections and whatnot. Now we can even ask, Hey, in your community, who has a really good Endo, who's a really good pediatric Endo, who do you love? What do you love about them? I mean, we can like network that way and actually make some different connections. I mean, I got an email from a woman in Canada, actually, probably at least a month ago, who she was asking how they could work with us, because she said, our endo makes all the pump adjustments. We literally get hand slapped. When we come to the office, if we made any adjustments. She's like, I even like, I save the adjustments My My doctor gave, I go home, and I make my own adjustments. And we go back to the office, I make them to back to what the doctor recommended. She's like, I know, he's also not really looking at the data, because otherwise the doctor would see that clearly. We weren't running on the profile that they told me to run on. I made my own adjustments or no, but they're also being told that a glucose value, you know, that's in United States milligrams per deciliter term was like a blood sugar of 105. They were being told overnight, was too low, to run their child at overnight. And so from that standpoint, you have to say, you do you have to say enough is enough, but I can't work with this practitioner. They're not willing to expand and allow me to manage something that's 24/7. It's not every three months of management that I come in, and I get your feedback. I look at this every single day. Every hour of the day. There is no shut off.

Scott Benner 34:55
Yeah. And at some point, you just have to The, you just have to say I can't change this person's mind. And the reasons why are unimportant. Like what it be, maybe the doctor doesn't understand, maybe the doctor is lazy, maybe, maybe, maybe, maybe who cares why it's happening to you just, you know, you have to remove yourself from a bad situation. And it's tough because some people will say, Look, I don't live near that many doctors, I need these prescriptions. And, listen, I don't know what to say about that. If you've got to suffer a fool to get your prescriptions, then you're gonna have to find a way around it. But stop trying to stop trying to make it. What do I want to say here? I have my example popped into my head, but it's too personal to share, because it's not about me. Not everybody does the right thing. And a lot of people want people to do the right thing. You can't make the fight, teaching someone else what's right, sometimes you just have to get through it on your own. And so if you've got some chucklehead, but they've got a prescription pad, then you've got to put yourself in that mindset, I'm going to go play a part for 15 minutes, and then I'm going to get out of here, and I'm not going to worry that he's wrong. I'm not going to worry, I'm just going to do what I need to do for myself. And I'm sorry, if you find yourself in that situation, but if you do still got to protect yourself. Yeah.

Jennifer Smith, CDE 36:16
And I think from the standpoint of even, you know, her question going further into like the research part of it, I think, if this is the kind of information that doctors are looking at and saying, Well, gosh, you know, running with an A one C of 5.5, doesn't seem to be any better than running with an A one C of 7.2. So why why would my patient want to get down here? I'm going to just tell them that that seven 7.2 is just as good? Well, again, we don't know necessarily where and when was the data collected? From what kind of information? What was the lifestyle of these people, etc, etc. I mean, we do know that glucose values that are well controlled, decrease, and for the most part, do limit potential complications down the road. We know that right? Now, is that to say, you're never going to get a complication, even if you did this sweet management your entire life. No, of course not. Now, sometimes things they they happen, right? We don't know necessarily everything because we we don't know 100% of how the body functions, right?

Scott Benner 37:24
We don't, don't you find that most questions around management are probably at the very core of their question. Hey, Scott, Hey, Jenny, how do I stop from anything bad ever happened to me or my kid because I have diabetes. And it's such a sad thing. But you have to, you just have to say to yourself, I can, this is my situation. And I'm going to do the best I can with it. And put myself in the best position to hopefully thrive for as long as possible. And that's sort of it you know, the rest is sort of out of your hands. Right. But the part you can control. That's the part you should focus on, I think. All right, Jenny, I'm gonna let you go live your life. Okay. This was excellent. You do? Yeah. Thank you. Oh, I'm gonna record again in 45 minutes with somebody.

Jennifer Smith, CDE 38:09
Oh, good. That's fun. Yeah,

Scott Benner 38:10
I'm doing today. Jenny Smith works for Integrated diabetes calm. She's also lived with type one diabetes for over 30 years. Jenny holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She's a registered and licensed dietitian, a certified diabetes educator and certified trainer on most makes and models of insulin pumps, and continuous glucose monitors. She's also pretty damn lovely. Check her out at Integrated diabetes that com if you'd like to hire her to help you with your type one, diabetes management. I have more to say you want to chill out for a minute. Okay. So we did a meet up? Two weeks ago, there's been two already. There'll be a third one this week. As I told you on April knife that I say the knife. Yes, April knife. It's a Thursday going to be 7pm Eastern time, not the point. Point is did the first 175 People rolled in very cool. And I thought people would just hold up their graphs or ask their questions and we'd roll through their answers and their answers may help may help other people and other people may have helped for them. And it did mostly go like that. But there was something that happened. I didn't expect. And I don't know why I didn't expect it. Because now in hindsight, of course, it seems obvious. But some people were very quiet. And they were not wanting to hold up their graphs. As a matter of fact, the amount of notes that I got out that I got afterwards. That said I was embarrassed or ashamed or nervous or a lot of different words to describe how people felt to talk during the thing but could you help me now? That piece makes me feel like that what you heard me say to Jenny about like we should all just come together and do a challenge. Like it would be, you know, I maybe that doesn't make that reasonable. Perhaps most people aren't interested in sharing that much. And I get that. So in the second meetup, I just realized, let's make it informative. Some people will speak up, some people will be willing to share their data, and some will learn from watching. So while I like the idea of a challenge, I don't think it's reasonable. But what I found afterwards was that getting together is hugely beneficial for everyone there, no matter how they choose to participate. So I hope you come out. Like I said, there'll be links in the Facebook page for bold with insulin. I'll try to put something up on Instagram to remind you there, but here's a reminder right here. I think it holds 100 people. So it's kind of first come. The two we've done so far have been in the afternoon. So I'm going to shift it to the early evening to help accommodate other people. So 7pm April 9, it's on Zoom. Anybody can come and hang out. Just look for companionship, meet new people. There's a chat people can go off and chat on their own. Listen to the conversation. It's just a nice way to distract yourself during this time of crisis. Today's Juicebox Podcast was sponsored by Omni pod makers of the tubeless insulin pump that my daughter has been using for most of her life. You can get an absolutely free, no obligation demo of the Omni pod sent to your home by going to my Omni pod.com forward slash juice box and filling out a little bit of information. You can learn about the Dexcom G six continuous glucose monitor@dexcom.com forward slash juice box and to see if you're eligible for a free Contour Next One blood glucose meter go to contour next one.com Learn more about touched by type one at touched by type one.org 10 second dance party

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About Jenny Smith

Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com

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#317 Ask Scott and Jenny: Chapter Eleven

Answers to Your Diabetes Questions…

Ask Scott and Jenny, Answers to Your Diabetes Questions

• When do you change basal rates? Basal versus temp basal adjustments.

• What are the most meaningful measures of successful diabetes management?

• What is a good standard deviation?

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Pandora - Spotify - Amazon Alexa - Google Play/Android - iHeart Radio -  Radio Public or their favorite podcast app.

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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 and welcome to Episode 317 of the Juicebox Podcast. I'm your host Scott Benner. Today, Jenny Smith and I will be answering questions that you the listeners have sent it. Three questions today. The questions three. As you can tell, I've been locked in my house for a number of weeks now, I'm getting a little weird. This episode of The Juicebox Podcast is sponsored by the Contour Next One blood glucose meter. And by touched by type one, you can go to touched by type one.org or Contour Next one.com to find out about these wonderful sponsors. My friend Jenny Smith has had Type One Diabetes for over 30 years. She's also a certified diabetes educator. She has a bachelor's degree in human nutrition and biology from the University of Wisconsin. Jenny's a registered and licensed dietitian, a certified trainer on most makes and models of insulin pumps, and continuous glucose monitors. And as you'll find out later, very well may be a person who can talk to wildlife. But one thing Jenny definitely is, is a person who would want to to know that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, she'd want you to always consult a physician before making any changes to your health care plan. We're becoming bold with insulin, and he's just good like that. She's rock solid, you know what I mean? She wants what's best for you. In today's show, Jenny and I are going to talk about when to change bazel rates you know when to do with Temp Basal, and when to put, you know, a firm change into place. We're going to talk about the measurement for success in diabetes management. And what a good standard deviation might be not just for you. But for everybody. Bum Bum, bum bum bum, bum, bum, bum, bum, bum, bum, bum, bum bum bum. The highlight of my entire week has been that the Costco near me had paper towels.

Hey, sorry, I was moving my microphone stand a little.

Unknown Speaker 2:18
That's okay.

Jennifer Smith, CDE 2:21
I think I have a like, I think I have like a problem with like, I did a finger stick. Okay. And my finger really hurts. really hurts. Like, like, and it's kind of like, puffy. Like, can you see that? It's like puffy and red again.

Scott Benner 2:42
We're on the top. It's puffy, but you didn't stick yourself?

Jennifer Smith, CDE 2:46
No, I stuck it on the side where I always does do and yeah, like I can't see anything from it. I also need like bifocals, because I have to go like this every time I have to like see something up close. My son brings me like the directions for a game. And I'm like, like, seriously, who wrote these directions? Like, come on.

Scott Benner 3:09
You have no idea how many times because Arden's a side stick like she sticks on the sides of her fingers, too. Yeah, you have no idea how many times like in the middle of the night when I do it. I'm so close to a cuticle. I'm like, how did I miss that? Yeah, and I looked down at her and she's not awake, and I go ooh, she's never gonna know about this.

Jennifer Smith, CDE 3:30
never happened before like, and it's it like it hurts it physically. Yeah. I'm like, I can't there's like no hole. I can't tell if there's like gross underneath or anything. But who knows? I don't know. Maybe there's like an alien growing underneath

Scott Benner 3:45
there. Listen, if it's too fast for you to get an infection, obviously. So it's not that I did you maybe just hit a nerve. I just

Jennifer Smith, CDE 3:54
responding must have just hit something that was just a much more sensitive spot. Or maybe I hit a spot that I had already hit. It's wrong. It's time it's kind of a favorite thing. Like

Scott Benner 4:07
Yeah, her sleep. Right. This is fascinating. In in Arden sleep, I will try I will go to fingers that she doesn't use figuring she's asleep. She won't know in her sleep. She'll pull the finger back and give me a different finger. That I'm always impressed by because sometimes I'll be like Arden and she's not awake. Right? she just she feels you in her sleep. Take the wrong finger. She's like, No, no, no, this one. Or she'll do two of them. She'll like either one of these is fine, but not like I try to use her thumbs when she's asleep. Yanks him right back holds him up in a fist. I'm like, That's hilarious.

Jennifer Smith, CDE 4:44
That's super funny. So So how are you? How are your older older kids? I hate calling them kids because they're really not kids anymore, but like, how are they doing with everything? I've got 17 nieces in Milwaukee, and they are just like, they're like climbing the wall really learning to up brother in law says they're just like, I cannot be inside anymore. I need to be not near my parents.

Scott Benner 5:13
I'm bored. Well, we're gonna turn your question. You're very kind. How are you question into part of this episode. And here's here's why Arden's insulin needs have gone way down since she stopped going to school.

Jennifer Smith, CDE 5:27
Do they go down in the summer too?

Scott Benner 5:30
Yes, she doesn't like being at school. That's just what it is. So now this whole the the, the incarceration is actually freedom to her. She can go to bed when she wants get up when she wants handle her work when she wants to. She's much happier. I'm seeing more smiling. I don't think I should ever send her back to school.

Jennifer Smith, CDE 5:55
The reason a lot of a lot, I've got several people that I work with who homeschool their kids. One who I started working with. I was telling about her she's the pilot. Yeah. And her parents school homeschooled her. She's now like, out of college, she's actually doing an internship with one of the airlines doing wonderful, but she was homeschooled. And they didn't see the fluctuations. Like comparatively with the other kids her age that is working with who were in school. clear difference from a weekend or a holiday away to actually being physically in

Scott Benner 6:33
school. Right now. There's there's been, even the summer takes time for her to like ramp down. Sure. But this was one day, the first day, which she was unsure of how this was all gonna work, her blood sugar didn't change. And then after she got her work in on time, she was just like free and easy and really happy. So it's interesting. Now my son. He doesn't like the lack of activity. Like we were outside in the driveway throwing a baseball yesterday for half an hour. He brought us. He said, He's the my kids are both very good with money. They don't ask for a lot of stuff. And he's like, I need a squat rack. For the basement. He's like, I need to be able to like exercise. And I was like, okay, and the other end, he walked outside just sat on the front step for a while, you know, just the hate, I need to get outside, because he's also a boy. So like, he'll start playing a video game and lose a day to it if he if you let him, you know what I mean? And last night, he told me around midnight, I'm going to get a shower. And then I'm going to read for my economics class. And I was like, Oh, that's great. And he's like, it's not. I was like, why is it not? He goes, because I'm going to read for an hour to get what I could get out of a five minute explanation for my professor. And I tried to do like I did the dad thing. I was like, oh, there's nuance to the reading. You'll appreciate it later. He was looking at me like, I don't care what you're saying. And I was like, I was like, I tried not to be, you know, I just was like, you know, this is it. It's good. And, but he wants that he's also concerned about how much we pay for school. And that now he's basically learning through, you know, yeah, really fancy YouTube videos. So he's like, why are we paying for this? And I said, coal, this time is going to turn. It's one of the strange things about about the United States at least, that I've never understood. Like, why has quality distance learning not become more? I don't know, like acceptable, especially in college. Right.

Jennifer Smith, CDE 8:40
Right. Right. Yeah. I mean, I think it's getting better now. How people viewed the distance learning like the University of Phoenix or whatever it is, yeah, all the commercials for but there, there are quality programs, and my sister in law actually did an online master's degree in business management. And she she does a great job. She's a wonderful job because she did that. So there's nothing wrong with

Scott Benner 9:07
no, no, no, but why is it not more popular? Why? Why not? Yeah, it is. It just is like, his level of embarrassment. Like I went to school, like through the mail. Does it feel like that or something like that? You know what I mean? Like 1960 took a writing course from Hollywood.

Jennifer Smith, CDE 9:22
Yeah, I don't know. I think I think in today's technology world, it's getting better. Um, in fact, some colleges as I'm sure you've seen with even Cole, I'm sure he probably has some things he needs to submit online and do that way already. But I think it's such a big change from the quality of as you know, in high school and even in college. There's a lot of social networking that goes on that you you don't get that when you have it at

Scott Benner 9:53
school. You just don't and we talked about that. There's, you know, you sometimes meet guys You know, he's playing baseball with or he's met through school. He talked to them a little bit, you know, that's an impressive kid for 20. It's going to be an impressive adult. And you don't know when 10 years from now that kid or your son's going to wake up one day and go, you know, I have a position to fill, you know, who would be great for this? Yeah, yeah, that guy played baseball with 10 years ago. And so there's that piece and there's the social part of it. Like, I'm not, I'm not discounting that. But for some people, they just want their degree. They're not looking for you know,

Jennifer Smith, CDE 10:28
they could care less about sitting in class next to the guy who doodles pictures of his dog.

Scott Benner 10:32
Right? Yeah, I met the most interesting guy in college yet. No one cares. But anyway, it's just it's it's interesting that they both are, they're not happy. We spent a number of hours playing poker the other day. You know, there's, we keep talking about having a movie night, but it hasn't happened yet. Everybody said we're, I think we're kind of quietly keeping things. Activities aside for when everyone loses their mind. And we really, like need the activity. So far. Everybody's been okay. And Kelly's under the weather, but Oh, it's not um, you know, it's nothing related to all of us. Yes. Yeah. It doesn't feel well,

Jennifer Smith, CDE 11:14
just a normal thing. I know. And that's every time you hear somebody like,

Scott Benner 11:19
like, Oh, my God, get back 30 person get away.

Jennifer Smith, CDE 11:24
The cough. Maybe they were eating a granola bar that didn't go down the right way.

Scott Benner 11:28
We're doing it on purpose for comedy reasons. Oh, yeah. Yeah,

Jennifer Smith, CDE 11:31
that would be my husband.

Scott Benner 11:32
Yeah, just everybody runs out of the room. Mom's like, Don't touch her. She's like, I just I got a dry piece of wood. Like that bringing us down with you. So, and she cut caffeine out. But she did it too fast. So now she has a caffeine headache, you know, and I gave her a little tea. I'm like, here have a little that's not from soda. And this, she might

Jennifer Smith, CDE 11:55
even do better if she if she's willing to do tea. She could even do something like a matcha which has a little bit of caffeine in it and could kind of ease down

Scott Benner 12:03
help her the caffeine.

Jennifer Smith, CDE 12:05
Because it's also much smoother caffeine than coffee coffees. Like you get this big like, Whoa,

Scott Benner 12:11
yeah, we don't drink coffee. Nobody here drinks coffee. Actually, I think the truth is that I don't believe Kelly ever has, but I've never had a cup of coffee in my life. So I wouldn't even know what it is. Jenny takes a large as well.

Jennifer Smith, CDE 12:26
I drink tea every morning. Usually a couple of hops, but

Scott Benner 12:30
I'm drinking Earl Grey with a little bit of honey.

Jennifer Smith, CDE 12:32
Oh, I have a very good friend in Colorado who Earl Grey. And lady grey are like her favorite.

Scott Benner 12:38
My favorite thing? It really is. Alright, so Jenny, we have a ton of ask Scott and Jenny questions. And we are going to do like three recordings in a row over the next two weeks so that we have them all set up. Yes. Before we start, let me tell you that and there's no pressure here. But tomorrow at 3pm I'm doing a like it's just a social meetup online. And if you're free and you jumped in for a couple of minutes, I bet you these people would be very excited to catch

Jennifer Smith, CDE 13:07
up on were zooms on zoom.

Scott Benner 13:10
Yeah, you could sit like this, click on a link pop up.

Jennifer Smith, CDE 13:13
What? Yeah, we zoom for our staff meetings on Wednesdays. But

Scott Benner 13:18
what at what time, three o'clock tomorrow? Three to 430 it's gonna run. It's gonna be like a free thing. Like people can come it's your

Jennifer Smith, CDE 13:24
time. So like, two to 330 my time. I should be around. Usually I'm working on emails at that time. So send me the link. I will

Unknown Speaker 13:33
even if you just popped in and you were like, yo,

Jennifer Smith, CDE 13:35
and send me a quick text while you're doing it so that I remember you

Scott Benner 13:39
will. You're gonna find out what it was like to be Elvis in the 60s.

Unknown Speaker 13:43
Ah.

Jennifer Smith, CDE 13:46
Interestingly, um, are you recording right now? Of course. Okay.

Scott Benner 13:51
I just wanted to read you want to say something private? Hold on a second. Bye, everybody. Well, Jenny, I hope nobody finds the body. I think you're gonna be okay with where you hit it. I mean, it's Wisconsin. There's so much snow on top of it. No one's ever gonna find it.

Jennifer Smith, CDE 14:10
We've got lots of bogs, too, you know?

Scott Benner 14:11
Yeah. Should we just start at the top of this list? Or do you have a favorite in here?

Jennifer Smith, CDE 14:16
No, I the one that I think we had commented briefly the last time we talked was it last week already? Um, was about there was somebody who asked about artificial sweeteners. And that one was curious to me. But there's a good list of questions. So wherever you want to start, it's totally fine to me.

Scott Benner 14:33
Okay, well

Unknown Speaker 14:38
can you like

Scott Benner 14:41
there's so many guys first of all, Rudy was so nice to send in so many questions. Yeah, let's just roll through the top. Okay. Okay. Sarah asks, please address puberty specifically. I think Sarah wants eight question answered for her specifically, but 12 year old, pre period girl spikes and drops are insane. They're on Omnipod Dexcom. So I think the question here is when to change bazel? And just Temp Basal. Okay, so she's seeing drops and spikes. And she's looking for when is this a change I make forever? And when is this just something that's happening? Well, that's interesting.

Jennifer Smith, CDE 15:22
It is. And it's a great, I mean, given the age of the preteen and and you know, her being a female, obviously, there are going to be, as I've talked with a lot of the people I work with who have girls about this age, who have not started a cycle yet. There are often about like a six to maybe 12 month time period before a cycle actually shows up. Okay, that if you start to track these resistant and sensitive times on a month to month basis, you may find anything to answer her question, you may find that it actually flows around the same time every month. And if you can catch that, then yes, you may be able to put a pattern in, you know, Omnipod, all the pumps out there allow you to actually set up different Basal profiles to turn on at certain points. So if you can track enough to say, Okay, this cyclic nature of resistance is always coming around the 15th of the month, or whatever it is, right? If you track a couple of months, and you see that, and you say, Okay, last month, we used 50% more this month, we're using 40% more, you should be able to set up a bazel profile, then that essentially is that much more at least in bazel delivery. And then just enable it for that time of the month and the duration of days that you see it typically lasts. That's you know, that's kind of then going forward into once a cycle does start, you'll be able to utilize that same kind of pattern. And once the cycle becomes regular, which is usually it takes about a year, yeah, give or take for most girls once they start their period to have kind of a consistency to it. So you should be able to use a pattern then, rather than just always employing a temporary bazel. It does take using the temporary bazel up front though, to figure out which amount extra you need to actually create a profile from

Scott Benner 17:28
okay. So last night, I learned that Arden has a name for her period and she won't tell any of us what it is. It has a human name, apparently human

Jennifer Smith, CDE 17:35
name. Yes. Awesome.

Scott Benner 17:36
I think she likes to feel like there's a person who's inflicting this on her so that she can be focused on the person doing the problem that's on the side. Yesterday I showed Arden's friend Jani, who has not been on the show yet, but will eventually she's somebody whose blood sugar on tracking. I showed her how to see that her pod site went bad. So she's rolling along great in the 90s just kind of bouncing, you know, at 996. Like all day long, three o'clock in the morning, it shoots up and levels off at like 220. And just stays that way all night till she wakes up at like four in the morning realizes that Bolus says the Bolus takes her down a little. And then she levels off and kind of rises back up again. And so I just pulled up a 12 hour graph. I showed it to her and I said just look at this. This is a bad site. And she's like, why? And I'm like, doesn't matter. It just is like look at it. Look at it. This is what a bad site looks like all the sudden, your insulin pump is not doing what you expect of it. Mm hmm. Common sense here says bad sighs it is this the last day of your set. And she goes it is and I was like, okay, change your pump. Get yourself down and start over again. The reason I bring that up where it doesn't feel like it maybe fits here is that the way I would handle Sarah's question is I would just do it over and over again until I had that feeling of like, Oh, I know what this is. And I really believe that it's not just me. I mean, I think the podcast has proven that out right? That eventually after you do something enough, you just see it. And then all the thinking goes away Jenny's what Jenny said is all perfect do that. But I think that one day, it'll just be a situation where you go Oh, this is a Temp Basal increase or Wow, this is not giving up. This is more. Right. Sorry. Exactly. long game.

Jennifer Smith, CDE 19:33
It is a lot. It's a marathon, not a sprint. Yes. entirely. And you know, in the beginning, though, when you're really trying to figure out the difference between a temporary or a true solid adjustment. Yeah. I think you know, when you make let's say you make you decide you're going to make a profile change. Oh, sorry. Ringing it shouldn't arraign I had it turned off.

Scott Benner 19:57
I didn't hear it on the sensor. You're good.

Jennifer Smith, CDE 19:59
Oh, good. Good. Good, good. So, you know, overall, you might make a bazel change. And then you're like, well, what, what gives Three days later, you're like, that's not working anymore. And now I'm way back down that might overtime again, prove, I need to maybe make a temporary adjustment, rather than a permanent kind of an adjustment, kind of similar to growth patterns and kids, you know, where you see a temporary need, because you're now fluxing up and Okay, all of a sudden, this is gone now. And I'm staying a little higher, but I wasn't at the rate of need. Like I was for three days. Yeah, it's come back down a little bit. But now it looks more stable. It's a little higher, but not quite. So. Yeah,

Scott Benner 20:41
yeah, I think that somewhere in between, stay flexible, be and reactive, not in a negative way. But in that sort of, don't wait around way, you know, like, and there's drifts Sarah that you'll start seeing on the Dexcom line. And just by the angle of it, I don't know how to explain it to you. But you'll start to look and go, this isn't going to stop, like this shouldn't be happening here. I'm going to try a Temp Basal increase right here. With Arden's period yesterday, I used a lot of temporary increases yesterday, because she was sitting stable at 190 boluses weren't moving or, and so to me, that meant, you know, bazel jacked it up, it worked a little but not enough, it was the end of her pump. So we swapped her pump, you know, we just went through the steps of you know, what it could be and, but we didn't wait around, like once you saw it, we moved on it. Well, we all have one thing for certain. And that's an abundance of Time, time that can be used in many different ways. You could perhaps spend your time at touched by type one.org. Or maybe you'd go to Contour Next one.com to find out if you can get a free Contour Next One meter by just clicking on a link and filling out some information. So here's what we're gonna do. Touch by type one.org has a mission of elevating awareness of type one diabetes, they also want to raise funds to find a cure. But mostly they're looking to inspire people to diabetes to thrive. They have these beautiful programs and services. They're helping kids all over the world with their D box program. And they put on one heck of a dance program every year in Florida. Go check them out, touched by type one.org. And once you've done that, you know what you need. You need the best blood glucose meter My daughter has ever used. And by best I mean, the most portable the handys fits well in your palm lights up nicely at night super duper accurate. And blood sugar test strips, the little strip things you get a second chance with if you mess up, you know when you go into the blood, sometimes you're like I got it, I got it, and then it doesn't beep and you're gonna throw away the test strip, not with the Contour. Next One, he does dive back in again, beep beep looking at your blood sugar. I absolutely adore this meter as much as anyone could adore a blood glucose meter. But Contour Next One is it. So head over to Contour Next one.com and see if you're eligible today for an absolutely free no obligation meter. And if you know you need a prescription, contact your doctor. They're just sitting in their living room to no one's doing a damn thing. Just throw them an email be like Yo, what's up? Let's try this new meter. send out a prescription. I've got nothing but time. Contour Next one.com touched by type one.org. Those links are in your show notes right there in the app, right that you're listening in now. And it's Juicebox Podcast comm check them out support the sponsors.

Okay, well, it's so funny. It's another Sarah but a different Sarah.

Jennifer Smith, CDE 24:17
There are lots of stairs just like Jenny. Yeah, it was a popular name. So

Scott Benner 24:24
they're even spelled the same way. It's not even helpful. What would you consider the most meaningful metric or measure of successful diabetes management?

Jennifer Smith, CDE 24:33
Oh, that's a good one. I think we've actually got we went over that a really long time ago. Any of the of the pro tips or any of those kinds of things? I think if you're looking at measurement from a site like clarity or one of your pump upload sites that gives you all of the metrics of this is your you know your average or standard deviation. This is what your glucose management indicator showing you what not what's the best indicator is time in range. That's it, I and second to that really would be that standard deviation, right? Because the lower the standard deviation, the more smooth management is rather than the jig up and down kind of Rocky Mountain. But definitely, I would say time in range. Our goal when we work with people is always new, at least 75% time in range less than 5% of the time low. pregnancies a little bit different. But

Scott Benner 25:35
yeah, so ranges, what are the ranges you give people? But is that range?

Jennifer Smith, CDE 25:40
I work with people on their target range, because everybody is individual. Mm hmm.

Scott Benner 25:45
So okay, so if Do you feel like most people are being told at 180? Something like that? 7180 Yeah,

Jennifer Smith, CDE 25:54
70 to 180. Like, if we look just at tide pool, tide pool has automatically set up as a timing range target, as 70 to 180. You can in your settings, go in and adjust that to get it tighter or make it broader or whatever. But yeah, most most practitioners, I would say, are aiming for about an 80 to 180. That's the most common that I hear. Um, so again, if you just aiming for what the standard is. That's it? Well,

Scott Benner 26:24
I think that these companies should expand this a little bit. I've been thinking about this, I need a time in range. And a time in Nirvana, like kind of mess, right? Like, I want to know,

Jennifer Smith, CDE 26:39
I want to know, the end range, but I really wanted this sweet spot. Like I'm not I'm

Scott Benner 26:43
not, I'm not upset that Arden's blood sugar's 180 for an hour, right? I'm going to get it back down again. But I want to know when I'm 70 to one to one, or, you know, at 130, once we're in there, I want to know when I'm, I even want to know, like 65 really like because if I'm because if she's 65, for a couple of minutes after Pre-Bolus? Yeah, I'm already with that, right. And so I think that everyone needs to remember that when we talk about this stuff, there's context that you need to give it. And you see all the time there's people online, or Look, I was in range 100% of the time today, and somebody will come in and say, you know, what's your range? And then suddenly, they don't come back again? Because you know, they never went over 350. And we're never under 50. I'm in range all day. And even you know, what, if that's for them a success? I'm not taking that from them. I'm just saying that when you're trying to share it out loud in public, you need to tell people what that range is, right? It lacks, you know,

Jennifer Smith, CDE 27:45
weight. And I've even seen something that goes along with it. I've even seen people then question, well, what are you eating? Because when we're looking at sharing our own information, and kind of patting ourselves on the back, what's good for us? Absolutely, it takes work. So go ahead and pat away. But you also have to, when you're putting it out there to the public, you have to give all the information that went along with that. You can't just say look at this nice flat line. Well, people then ask, Well, what are you eating? How did you get that? Because there are so many different variables that go into meeting that.

Scott Benner 28:21
So my blood sugar has been between 82 and 86. All day, I've had four hard boiled eggs yet like, like tell somebody the whole story.

Jennifer Smith, CDE 28:28
Right? Exactly, yeah, because it feels

Scott Benner 28:30
bad. Otherwise, like, otherwise you're looking at it, you're like, Oh, my gosh, you know, this person's blood sugars like this, I try to remember as much as I can to say, you know, ardency, one sees been between five, two and six, two, by the way, coming up now on six years. And she doesn't have any diet restrictions. But I always think the important thing to add is, for all of you that are imagining that her blood sugar is just at three constantly. That is not the case. You know, we just don't look at high blood sugar's very long and she's not low. So, you know, I would say that ardens deviations never where anyone would want it. Hers is usually like 40. You know, and

Jennifer Smith, CDE 29:11
but within range,

Scott Benner 29:13
it's being measured between, it's being measured between 70 and 120. Right. So, you know, and, you know, and I know, I still don't want her to spike up, but she sort of doesn't, right, you know, so. And not that she doesn't ever she does a couple of times a month or you know, a couple times a week or whatever it ends up being, but she just doesn't jump the 300 and stare at it. So I think that while the measurements are really important, the way we talk about them are is possibly even more important. So I don't see anything wrong with a one see if it's being done correctly, meaning no protracted lows that are giving you a false sense that you're a one C is lower. But what Jenny's saying is you do not want your blood sugar bouncing up and down. That is just It's not good for you, it would probably be better for you to be steady at 150 than to go from 70 to 300.

Jennifer Smith, CDE 30:07
Correct. Exactly.

Scott Benner 30:09
Right. So there you go. Actually, the funny thing here is the next question from Nicole, is, what are your thoughts on a reasonable standard deviation for a growing five and a half year old? Hmm.

Jennifer Smith, CDE 30:22
Yeah, that's an, I think you have to have a little bit of expectation that there is going to be more variability in certain periods of life, there will be I mean, kids, I mean, she's is growing five year old kids are growing considerably from birth, I would say, honestly, until about the age of like, 10 ish, things are kind of similar and patterns of growth, they really speed up, I mean, you can see the difference. You know, we've got one of those, like tree growth charts for our boys. And I usually turn every couple of months to see where are you because I know, you look like you've grown or your pants look way too short again. And I swear, I just bought new one last month, you know, but at some point that growth slows down. And certainly the teen years are a different amount of growth, not the same as far as like height or anything, although it could be for boys differently than for girls. But hormones are a bigger impact there in the teen years. for little kids like that five year old age, you can expect that eating for a standard deviation of something like 20 might not be in the cards, because you may have a lot more variability. Even if your timing range is kept very good, you still might have a little bit more variability in there. Because if your five year old is like my who is now seven, when he was five, I mean, he could be like I want to eat, I want to eat, I want to play I want to eat Nope, I'm not going to eat all of that. So when you mix diabetes in there, and you have to bolus and strategize and Okay, now I have taken a little way. And now I have to plan for this and whatever, there's going to be a lot more variability perhaps. But aiming, that's why I said that metric of time and range would be really more what to look at. Yeah, we don't want your standard deviation to be 80. But if it is going up a little bit more, you know, up and down. That's kind of par for the course with littler kids.

Scott Benner 32:30
I think that common sense is incredibly important here too. Because as you're listening to Jenny, explain this, from a clinical standpoint, you're thinking about what is or isn't said to you by the American Diabetes Association, or by your endocrinologist, all that stuff, you have to remember that they're just trying to give, they're not with you, they're not always whispering in everybody's here, right. So they're just giving a baseline like, you know, your standard deviation should be less than blah, your agency should be here, your variability shouldn't go but like, they're just giving you a place to start. I think that it's a, it's kind of incumbent upon all of us to take what looks like the rules, I'm making little quotes with my my fingers, and realizing that that's probably not the best you should be shooting for. It's not It's not the top, they're just trying to keep people. I don't know how to say this. There's a there's a way that if your own? Well, I'm struggling here, anyone, anyone who's been in a position of power in an organization knows that you're giving common denominator advice to your employees to you know, the subjects of your kingdom to like to whom ever you're talking to. And and to hear that advice and take it as gospel, I think is a mistake. Do you know what I mean? Like, you know, yeah, you ever go around a corner and the speed limits 25. But you're in a sports car, and you're like, I could go around this corner of 45. And it would be you know, that's you you're in a different car. They put the 25 there for the guy coming through in the 1975 Datsun like do you mean like his car can't handle this curve at 25?

Jennifer Smith, CDE 34:17
He will roll the car and right yeah,

Scott Benner 34:20
so for us, for instance, my standard deviation doesn't look good on Arden compared to what people say, except those people have a range between, you know, 80 and 180. While I'm shooting for a range between 70 and 120. And so, my I, I know where our standard deviation sets when I'm happy with our blood sugar, right, and I don't care what anybody else says that works well for us, right? And then people are like, oh, but then or health or health or health is going to be great. Like if you tell me that a person growing up with diabetes, who's got an eight one C and the fives constantly eat whatever they want, doesn't spike Hi, you know, maybe sees one ad twice a day for 45 minutes. If you're telling me that's a problem, I don't believe you, you're I mean, like I were, here's this, that's the best we can do. So, you know, we keep trying to tighten it down and make it better. But at some point, that's when you get to the life versus management trade off, like I got to be alive to

Jennifer Smith, CDE 35:24
weed. Right? Exactly. Right. Yeah.

Scott Benner 35:26
And so the problem with asking these questions are and getting the answers is that no one's going to give you a real answer. They're just gonna say what feels safe. Right. And so that's the most part common topic,

Jennifer Smith, CDE 35:39
what I can kind of say about standard deviation, though, even in, let's say, your timing range of whatever range you have set. Even for a five year old, for example, you know, if you're constantly having these big old climbs, and then constantly attacking then and then having a drop that you're getting into the red zone, and then you've climbing again, because of the red zone, and then you're dropping again, even if you're in range in doing that, that standard deviation, still, it requires improvement, right? You don't want this mountain peak, you know, up, down, up, down, up down all day, because even in range, it doesn't feel good for any age person. So the smoother that is, the better the person, the child to whoever feels.

Scott Benner 36:29
And if you're looking it up and down and up and down like that and worried about time and range or standard deviation, you're missing your Miss focusing your concern, your right turn should be Pre-Bolus thing and carb ratio and understanding glycemic index and stuff like that.

Jennifer Smith, CDE 36:43
And also effective insulin right duration of insulin. Yeah, understanding how long is my insulin actually working? You know, we're under I mean, that kind of takes it a step further in that variance that you see that standard deviation, because we're kind of in the understanding that our rapid insulin is rapid. And we've talked about this before, and that it also clears very rapidly. That's not actually the case, if you follow it out, right, there's actually a lingering dribble of impact. So if you are getting that up, down, up, down, up, down, it's very likely that even with using a pump, you might unknowingly be stacking insulin because your duration of insulin has been too short. And with modern day conventional pumps, what you set it at is what it uses, it doesn't know anything else beyond that, right? So it can't say okay, there's still insulin left here, make sure you take some of this off. But yeah,

Scott Benner 37:42
Chinese talking with her hands while I can hear birds outside of her window, and she looks like Snow White. I talk with my hands a lot. I don't mind the hand talking. I'm just telling you like Snow White for a second. Listen, here's what I think. Don't worry about your algebra grade worry about understanding algebra, right? You know, the grade will come if you understand the math. And with this, if you know how insulin works, the standard deviation of calm, the time and range are commonly a one seal come like you can't, don't focus on the grading focus on the work. And, you know, I don't know how many more times I can say this, I keep thinking I'm going to sync the podcast, it's timing and amount. It's understanding how insource use the right amount of insulin at the right time. And the rest of this becomes unimportant, you know, its background all of a sudden.

Jennifer Smith, CDE 38:30
And the important thing about that timing and understanding is that it is individualized right for you not to cut and dry up here. The doctor told me that this should last three hours. So that's what it should last. That might be the case for Johnny. But for Susie over here in the corner, maybe she's figured out that three hours the doctor told me Ah, it looks like it's four hours for me. So it does have to be individualized,

Scott Benner 38:52
right? I don't know where I was where I rolled up into a talk and I told people look, here's the truth. I could have flown in here, got up in the morning, got showered, jumped up on the stage, grabbed this microphone and said, Hey, everybody, it's all about timing and amount. Just understand how insulin works and you and you're going to be fine. Thank you. Good night. I could have left. You know. Well, you know what I left out some of the details about how to get to that but that's still the truth. Correct. Jennifer Smith is available to work with you. Check her out at integrated diabetes.com Thank you very much to the sponsors. Contour Next One and touched by type one. A lot of ones in there. Two ones you know you get when you add up to ones. One on One is equals to.

Unknown Speaker 39:45
I'm completely alone in this room.

Scott Benner 39:48
I just want to go outside, touch a handrail. Don't walk past somebody who sneezes and not have a stroke. Soon, probably a couple more weeks, couple months at the most, it'll be fine. I'm still wearing pants or you don't judge me. Listen, I put this up a little early. Right? Because on March 26, at 3pm going to do a big zoom meetup. And I have an idea for that I think you guys are gonna like, so if you're hearing this in the moment, check it out. And if not, the video will be running on the Facebook page, you can go back to it. But here's what my thought is, when you get a bunch of people together. And we're all going to, you know, just chit chat, see how things are going make sure nobody's like, you know, go and do it because they've been locked in their house too long. And after we all do a little Chitty, chatty like that. We're gonna talk about getting people's bays on its own right. So like a big group thing on everyone's basal insulin. And then we're gonna come back the next week, see how people are doing and then add another step. And maybe during this whole Coronavirus thing, we can bring everyone's variability and standard deviation and a one seat down, when that'd be cool. If we just all got together in a group and did something like that. I hope you think it's cool, because I'm pretty excited about it. March 26, Thursday, 3pm Eastern time. There's links right now on Facebook, I think the links on Instagram, send me a message if you don't know how to get to it, get there gonna go through people's bays or it's just like it's a private phone call. We're all gonna be there, kind of kicking in our two cents, helping everybody out. You know, if the listeners of the Juicebox Podcast can't count on each other during a time like this, then I don't know who we can count on. So while we're all busy being stressed out watching bad Netflix shows, I figured we could spend a little bit of time doing something for everybody's health. I hope to see you there. Hey, last thing if you're not a subscriber to the show, like if you just count on remembering the shows on it would help me out a lot if you hit subscribe in your podcast app would help even more if you share the show with a friend. And if you're not up to like sharing the show, maybe just share the zoom with them get together and maybe they'll see something they like and they'll check it out on their own. The podcast is growing so quickly because of you guys. It isn't even letting down during this Coronavirus thing. I'm super impressed. I thought for sure. Like oh, downloads will slow down but they haven't. And that's really very touching. Oh, by the way, last thing next week. So the next show that comes on. Let me take a look. On the 30th of March, it's going to be an after dark episode. Sexuality from a female perspective. So if your kids usually listen, don't let them listen to that one. Because there's not a lot of bad words in it. But there's a lot of clear talk. So unless you want your kids to know exactly where the round peg in the square hole are, I think you should. I think you should make sure they skip that one. I didn't believe a lot of kids listen to until recently but apparently they do. Which I think is great, but not for this one on Monday. So there's an afterdark coming up on Monday. Make sure you kids. don't hear it.

About Jenny Smith

Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com

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