#1018 Pregnancy (REMASTERED Diabetes Pro Tip)

September 24, 2023Scott Benner

Scott is joined by Jennifer Smith who shares her immense knowledge on the topic of type 1 diabetes and pregnancy.

You can listen online to the entire series at DiabetesProTip.com or in your fav audio 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 0:04
Hello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right, you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CD and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisit double. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. While you're listening please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have an amazing offer for you. Right now at my link only contour next one.com forward slash juice box free meter you can get an absolutely free contour next gen starter kit that's contour next.com forward slash juice box free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries G voc hypo Penn Find out more at G Vogue glucagon.com forward slash juicebox good and fresh.

Jennifer Smith, CDE 2:25
Because I'm not gonna sing. I don't say

Scott Benner 2:28
oh no, no, because this episode is going to be basically me going uh huh. And you saying a lot of different things. So I want to if I can, yeah, do a pro tip episode about pregnancy. And I mean, like, pre planning leading up to it, what to expect out of prepare what to do, what's going to happen if this happens, what I do, and if we can, how do I do it without a glucose monitor? Is that all doable in the next hour?

Speaker 3 3:00
Without a glucose. Alright, well, let's do the winning without a continuous without physically without knowing anything.

Jennifer Smith, CDE 3:08
That's possible. But

Scott Benner 3:10
isn't it funny? I call them glucose monitors or blood glucose monitor. Why do I do that? I don't know. Anyway, without a CGM, gotcha, gotcha. Okay. Because I would like to, I want to do that as well. So anyway, I am, I'm going to be on the outside looking in here for this. But I do think that the place to start, if you agree, is understanding what the pre planning is like? Because you can't, or you shouldn't I'm guessing if you have type one diabetes, if you're the lady, you should not just if you can help it be in a situation where we got bored on Friday, and now we're going to have a kid. Right? Right. There should be some more planning to that. So how far out? Does the planning have to be in is that maybe person to person based on their situation?

Jennifer Smith, CDE 4:01
Yeah, and kind of like we always talk it is sort of person to person. Uh, you know, overall, if you've all along had pretty good management, you've put lots of play, and you know how your insulin works, you know, how food and activity and all of those things work for you. Maybe three months, maybe, you know, maybe you get married, and it's a quick turnaround. And you're like, Yeah, we're ready. And like you're, you have everything in place. And, you know, you're where it should be. And I mean, there are other parameters to check to, especially with diabetes, things like thyroid. All of those things should definitely be checked and analyzed and evaluated prior. But everything checks out. Great. If not, then yes, it could be three months, it could be six months. It could you know, if you're somebody who's starting out you, you know that you and your partner really want to have a child but you don't really have things in place to do that safely from a discussion maybe that you've had with your doctor or your OB team or whoever, then it might take a long time. I think it takes going back to really like the pro tips episodes, really, if you're trying to get things contain and that's, that's the starting place. Because while while you know where you need to maybe get, or maybe you don't glucose target range for pregnant should really be started prior to conception. Because then it's not such a big change over from saying, Okay, well, I've been aiming for a target of 80 to 180, let's say, right, while pregnancy target is, you know, fasting 65 to 95. That's when you wake up in the morning. Is

Scott Benner 5:49
that is that anyone see in the fours? Is that is that high fours to look

Jennifer Smith, CDE 5:54
for the E one C listing because what I think, Zack, they were that

Scott Benner 5:59
I think what we're talking about here is that you have to know how to manage your blood sugar's tightly and see some consistency through weeks and months. So it's not just a fluke, like one month, you're just like, Oh, I did it. And you have to be able to do it without low blood sugars that are going to be dangerous for you or the baby to write, you know. And so yeah, get it right, and then prove it over and over again, over and over again, through your period through different meals, because you also could, I just finished what I really enjoyed, I haven't, I did a four part series with a pregnant person who has type one. And we interviewed together after her first trimester after her second after a third and just yesterday, when her baby is three months old. And so I went through the whole process with her to try to understand it. And her agency was like 4.8, during her pregnancy, and she was describing needing insulin, more than double than what she normally needed. And that like swallowing that pill of like, oh my god, there's way more insulin needed here. I have to do it. And yeah, and I want to get to all that. But But yeah, to me, what you're saying is, you can't be a person who's got an A one C of nine and say I'm going to have a baby. I'll just get pregnant now. And I'll fix it. Because what could those things lead to, like what Ohio one sees in pregnancy lead to?

Jennifer Smith, CDE 7:29
So that's where the typical national standard is? A one c less than 7%. At conception, right? That's, that's the broad goal. We aim for a little tighter than that. Because as you're kind of getting to, it's easier to have things tighter to begin with. Oh, goodness, I've not really done anything, or I didn't plan it. And I also haven't done anything. And now I really have to tighten everything up. That's a lot of change all at one time, along with a load of hormones impacting things at the same time. Yeah, so it's a lot, right. So the standard center conception is really because what they've seen in research is the risks of things like early miscarriage, or many of the genetic problems that can come up from those early weeks of forming all of the different body. All of the different body organs and everything. That's what's happening in that first trimester. So the goal being under 7%, your risk is is about even with the general population who doesn't have diabetes, for those same types of problems to have, okay? Okay, the higher the agency, the more potential for early loss or or miscarriage, the more potential for the heart to not form the right way or any of the organ systems, you know, a lot of those genetic types of things. Then also a lot of things that are not specifically genetic, like they don't come from down the gene line, but they just happen because glucose levels aren't allowing the cells to divide and form into what they're supposed to do.

Scott Benner 9:23
So anywhere from a miscarriage to birth defects, correct. Okay. And is it a mortal lock that that's going to happen? I mean, you know, how you know how some people are like I smoked all through my pregnancy and he's fine like that, like it are they're dumb luck people. And I'm not that I'm saying roll the dice on that, but, but were you definitely going to see something or maybe not even know like, is it possible? You know, is it is it out of this world to think that you could have a high one C and your child could develop asthma and that even though you're never going to know it could have something to do with that? I guess that would be some speculative, but that's

Jennifer Smith, CDE 10:00
it is complete speculation, because there's really not. There's a lot of research done on later outcomes in kids who've, I guess, born from women who have had diabetes, right through pregnancy, but a lot of it is more assumption of putting information together, right? Really, no, you're never really going to know. And, you know, on the opposite of that, let's say you, you did plan to really take care, just and make changes, and, you know, things do happen, people get pregnant,

Scott Benner 10:35
and it happens. I've seen it happen personally.

Unknown Speaker 10:38
Yes.

Scott Benner 10:41
And no one's planning on it. And the next thing, you know, you're moving to a place to have more space.

Jennifer Smith, CDE 10:47
Because you're gonna need it. There's gonna be another person,

Speaker 4 10:50
someone by mistake got knocked up, because, you know, long day everybody missed each other. And the next thing you know, I gotta leave my condo. That's all.

Jennifer Smith, CDE 10:58
There you go. So you know that it happens, right. And I mean, and I've worked with a number of women through pregnancy, who that has been the case while they were planning events. Really right now, and a one C really was not where we would aim to have it be the highest I've had someone start a pregnancy, which was really not planned. It was a teen pregnancy was 11.3.

Scott Benner 11:28
Wow. And now they come to you right away. And no, it took too long. They didn't

Jennifer Smith, CDE 11:33
they, you know, they came in early second trimester it was you know, they had gotten through their first trimester, with OB TM, and some endocrine, I can't even remember how the family found integrated to, you know, get in contact and get. But I worked with her through her whole entire pregnancy. And we pretty quickly got her agency down. Yeah. And then, you know, by the end of pregnancy, her agency was 5.7. That's great. So I mean, and she has, she's a beautiful little kid now that there are no. So can things be okay? Yes, they can. But the risk increases dramatically as the a onesie. And the glucose levels are not managed

Scott Benner 12:21
it to me, for me personally, and given that you can get pregnant by you know, not on purpose. By breathing out someone, hey, that's what I was told. But I think what we're saying is, is that, you know, say you live in a nice, safe town, you don't really need to lock your door, but you do anyway, there are certain steps you take, just because why would we take the risk if we don't need to? Like if we know we're going to have a baby, why would we start with a seven a one seat and go, I bet I can get it down before something weird happens to the kid like, you know, like, let's, let's not do that if we don't need to. If we get caught in that situation, then, you know, figure it out, get it down? It's correct. It really is. It's such a it's I don't know, I just I'm thinking back now to the conversation I had, that the person who I mentioned from the, you know, the four different interviews through the pregnancy came to my attention because her first pregnancy ended in a mask a miscarriage. And so and I've been contacted by people who there's a person I'm still hoping to get on the podcast, she found out that she had diabetes, because she was pregnant. You know, like, she got pregnant, they ran a blood test. And they were like, Oh, you're not just pregnant. You have type one diabetes. And yeah, did not know prior to that. That person is doing terrific has a really cute kid. And, and I'm hoping to have her on one day. But anyway, it's just, you

Jennifer Smith, CDE 13:47
know, the other thing I wanted to mention here, too, is that all the things that you can do ahead of time, sometimes things do happen anyway. Right. I mean, I I'm I'm actually my personal is our my first pregnancy I had a miscarriage. So, you know, and I did everything ahead of time. I had been doing everything for several years. We're like, yes, we're like, finally ready to definitely have a child. Right. And I had done everything. And in fact, my my maternal fetal medicine, which is a high risk OB doctor that typically manages through high risk pregnancies. You know, she was like, this has nothing to do with she said many, many early pregnancies back she said many women, they kind of their visit late especially, they've been pretty regular. They're a little late in their in their, you know, period starting and then it starts like five, seven days late and they're kind of wondering, she said, oftentimes those are very strange where the body actually didn't even start up anything truly. Many miscarriages in terms of For a person without diabetes, and a person with diabetes who has managed well, there just because the body knows that there's not something quite right,

Scott Benner 15:08
just feels like a false start. And that's what happens. Oh, that's sad. No, of course.

Jennifer Smith, CDE 15:13
Yeah. And so, you know, I mean, it's sad in any regard. But I think if you can do the things ahead of time to prevent it, then you know that you've done everything possible,

Scott Benner 15:24
takes away from the idea of is this diabetes? Or is this something else that you can see yourself as more than having type one, you can see normal things that happen to people, I just saw someone recently who had a seizure, and thought it was because of their blood sugar, but then figured out, it wasn't, you know, but that was their first thought was, oh, I must have my blood sugar must have gotten very low. And it turned out not to be right, you need to see yourself aside of diabetes. And the best way to do that is to make diabetes a lesser impact on you so that you're not always worried about is this happening because of that, right.

Jennifer Smith, CDE 16:00
And I think that that's a good point, though, for the pre the pre conception, the pre planning stage, to know the impact of this versus, versus, you know, I do this activity, and this happens. There's a lot that goes into that, beyond just having well managed blood sugars. Yeah, there are a lot of other things to consider in that right. Nutrition is one of them. And then the other factors that are very rare autoimmune disorder is, are your other autoimmune conditions? If you do have them? Are they well controlled? Thyroid is another very big one that's really, really important to have tightly managed prior to conception. Because thyroid levels do change. They will manage and evaluate and do more blood tests and adjust your medication. But you also have chi, you have to have kind of a baseline right? To know coming in. Yes, things are good.

Scott Benner 17:02
You know, it's funny, you mentioned that because just an hour ago, I took art and to get her blood test, because we've been managing her thyroid through her endo forever. But it's always just like, well, she's in range, it's fine. It started with still having a lot of, you know, side effects of what you would consider hypothyroidism. And so I finally found an endocrinologist who doesn't care exactly what the number says they care about how you feel. And so she's doing all these other things with her and I hope to have that doctor on at some point when this process is done with Arden, but it's fascinating. She's taking so often uses terrorists and and the amount of tariffs that that her first doctor had her on is half of what the second doctor had her on. And she looked and she said, Yes, her numbers fine, but her symptoms are terrible. And she said, given her weight, I would think that this should be more medication like so she was just she's very tuned into it. I just think that I would like to do a lot more about thyroid. On the podcast, I just you have to find the right people to talk to and they're difficult to locate, you know. But yeah, so that as well. So what do I do? I've, and I don't want to skip over what Jamie just said about nutrition too, like, don't get so focused on your blood sugars, that you're like, wow, look at me, I've got a four, eight, I can eat all the Twinkies I want. I learned how to keep my blood, the kids gonna need like some greens and protein and stuff like that to grow it. But I don't want to tell you how to pray in your family. What I am wondering is I've decided, I've got some money, I found a space I can put the kid nice. The safe closet, if I want to go out maybe that break can't get hurt, you know, and moving forward. Do I make with the bangbang fun part? Or do I go find a doctor first? What's the first? Yeah.

Jennifer Smith, CDE 18:51
The other part of it is not only your management, having a team in place, prior to conception is really, really important. Because I've had a number of women that I've worked with who have thought that they would just go with who was preferred with their insurance, right plan. And a number of them have transitioned once or even twice through pregnancy because they were so unhappy with the care that they were receiving. A lot of it's specific to diabetes and the consideration of diabetes in the pregnancy. I mean, and definitely higher risk, maternal fetal medicine teams, they know pregnancy, but it really takes the right team to know pregnancy and diabetes together. And pregnancy and diabetes with type one diabetes is very different diabetes. And so if you've got a practitioner who you know says yes or there you call and you ask around to a couple of offices talk to their nurse Horses and get a bit of an idea about how the clinic runs and how appointments run and the doctor and experience and oh, we've got lots and lots of experience with diabetes. diabetes, is the question you should be asking, because they may have a good amount of gestational diabetes management experience. It's very different with type one,

Scott Benner 20:22
you don't want to get caught up in the medical equivalent of Oh, my aunt has that. Yeah, correct. Right. type one, your and as type two, it's different. Thanks for Yeah,

Jennifer Smith, CDE 20:31
so do your shopping is really, you know, the case. The other piece when you're doing your shopping essentially, for your care team is, if you've got a really great endo that you're working with already, that would be a first, like, stop to actually ask them. Are you going to be my diabetes Backup Manager through this pregnancy? Because I've had some endos who differ to the maternal fetal medicine team, which, that's okay. As long as the maternal fetal medicine team has got it, man, they understand the diabetes pieces, and they understand the diabetes pieces. Well, I've also, you know, games differ, you know, some OB is, once you get pregnant with high risk anything, they're hands off, they're like, you're going to high risk, high risk is going to manage the pregnancy for you. We won't see you. Right, we will see you until baby is born and you are post delivery time, right? Other teams, the OB sees you for the base visits just for the monitoring and that kind of stuff. You'll be shuttled away to maternal fetal medicine potentially then for the high risk types of things. Anatomy scans, fetal heart echoes all of the higher risk types of evaluations, especially in the third trimester. So it it around, it pays to even see if offices have a preconception consultation that they will do. So you can talk to the doctor and you can bring them this is how I manage I'm well managed. This is what I've done to get to the point of being ready. Because the more that any team like that what you know, and how well you're doing, the more comfortable they're going to be helping you to manage the right way. Yeah, so yeah, it takes it takes looking.

Scott Benner 22:25
Okay. So we have to do some shopping, find we find the doctor. We, we we decide to move forward. We start doing what we're doing. I ended up pregnant. Me. I don't know why I didn't see you in this scenario. Hopefully you don't pretend I'm a lady for a sec. And I'm pregnant now. And I have diabetes. So pretend everything about me is different. I'm a lady I have diabetes. I'm pregnant. Now. How soon do I start noticing like well, I noticed that my blood sugar's before I noticed in my pregnancy test.

Jennifer Smith, CDE 22:57
For the most part in the first several weeks post conception, blood sugars are going to start to look wonky. wonky and I think the easiest way to describe it is if has experienced a rise of any kind in blood sugar during their normal monthly cycle, whether it's the three to five days before the couple of days of once they get it or even around ovulation. Hormones from the start of pregnancy are significant. A big difference in blood sugar most women in about the first week to let's call it five to six weeks will experience a rise in their insulin need because of those hormones and the impact that they have. So you know if you have been trying that you've been trying as soon as you know you're done try get on the these are my diabetes pregnancy targets that I'm aiming for if you haven't been doing it you know so tightly prior to trying then definitely do it as soon as you're done try you could be pregnant.

Scott Benner 24:10
Alright, let's take a detour for a second and and let Jenny rant for a minute. Why it's might be something I know about her that she's never said here but why are there different ideas of health for pregnant people with type one diabetes and non pregnant people with type one diabetes if it's great for the baby, isn't it great for all of us.

Jennifer Smith, CDE 24:33
There you go. Yes, it opens up a whole can of worms Pandora's box, so to speak. We have

Scott Benner 24:39
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Jennifer Smith, CDE 28:00
It's a great question. And it's one that's always kind of been like in the back of my mind even before my husband and it's like, we definitely want to have a child within the next year. Right. But I had already prior to that readiness, I had already been focusing on much tighter targets than my endo ever told me to aim for. Knowing what I know the research that I've done about long term outcomes of blood sugar management and control, right. And it was several years ago actually that I worked with a woman through her pregnancy and postpartum she said to me, so my doctor wants me to loosen up my targets. And she's like, No, I'm through pregnancy, managing the way that I did. And knowing what people without diabetes, what their body manages for them. Yeah, she's like, why would I go back to loosened targets? Why would I do that? And it was, I mean, it really like brought it to the front of my head from like, love. That's what I always aim for. So I guess I didn't really think about it. But that's right. It's it's a it's a great question. Why are we not overall consistently aiming whether you're a man or a woman? Why are we not consistently aiming for blood sugars that are in the nondiabetic? Why why is that the case? Now, outside of this? There are some good reasons things like older adults, hypoglycemia unawareness. There are some medical types of conditions or certain scenarios, let's call it that could meet a range and or a higher range for safety kinds of reasons. But the general population it's a good thing to bring up because that's it's true. It why are we aiming for less than 180 after meals, and I really it should be lower.

Scott Benner 30:03
And I brought it up. Because in my sort of peripheral understanding of this, this whole time that I've been in the diabetes space, I've always thought of it as people would people with, I was gonna say people with pregnancy, people who are getting pregnant, are somehow asked to do some superhuman thing with their health. That's not even necessary. And it took me a while to realize that's not what we're really saying. What we're saying is that every Listen, there's a lot of people that have type one diabetes, and we all have different access to different technology insulins, all these different things. And so there's a, there's a blanket statement out there, like, if you're a one sees, you know, under this number, you're probably have a really great chance of being okay. As it gets lower your chances of problems get differently, you know, maybe they lesson, but then once in a while someone will put out a report, this is all there's no benefit in having a one C under this number for some reason. And I every and we've talked about on here before and I see that and I think I don't, I don't believe that that's true. And I think that that's going to be one of the things that 10 years from now someone's gonna say, oh, there was a report 10 years ago that said this was wrong. Yeah. But oops. You know, and I also think that it's a, it's an emotional idea. Like, if someone has a seven, you don't want to make them feel like a failure, because they're not five and a half. Right? Right. Because they're not, but it doesn't mean that they should stop trying for the other day not make themselves crazy, or you know, like anything, but write better goals. It's, I don't know, right? It just, you know, it's like if I went out and ran a 300 yard dash today, I think I'd finish it. And I don't know, probably an hour and a half. And so right. Now, that might be my personal best, but I saw on the Olympics, it can be done. You know, it about seconds, about 15 seconds. And so I can't just sit here and say, Oh, I did the best ever, because that's my best because it's not and it's your health or your child's health. And you can't just I mean, I think that one of the underlying concepts of this podcast is that you can't just say, oh, that's fine. It's good, or it's good enough. 300 after pizza usually go to 400. That was a huge win for that.

Jennifer Smith, CDE 32:21
Was that right? And maybe that was a win. Maybe that was a win, you know, but if it's,

Scott Benner 32:25
yeah, it's totally better. Again, try again, try it.

Jennifer Smith, CDE 32:27
Right. And that's it. So yeah, that's a very good point to bring, I think target targets in pregnancy are in a way they are tighter, because we do have certain parameters such as, in the post mealtime period, the targets are at one hour post meal, the goal is at two hours post meal, it's less than 120. Yep. And really, if meals aren't in the picture, you should be averaging somewhere around, you know, like the 65 to like, 100 ish range. That's, that's, that's what you should be aiming for. Now, the person who's not pregnant, if they're sitting at 21, great, they might feel really good at 121. In pregnancy, that's the high end of really where we would want to hover long term. So there are some parameter differences. And I think it has to do also with everything that the mother is doing to her body. Yeah, that's the impact on the developing baby then,

Scott Benner 33:30
right? And keep in mind why that is to 121 blood sugar. If if you're a person, like we've been able to see my wife's blood sugar in the past, my boys blood sugar sits at like, 75 Most of the time, right? Yeah. And so if, if, if that's what your normal is, and you're 121, I'm going to tell you some quick math tells me that's 46 points higher than what your body would have done without diabetes, which is a significant difference significant. It's a significant concentration of glucose in your blood, messing with the development of that baby. That's what I'm, or if you're not pregnant, messing with your life, you know, so

Jennifer Smith, CDE 34:11
as far as like messing with the baby, I think another piece to bring in is once the baby. I always find this concept really interesting that a pregnant woman who has diabetes type one diabetes specifically has a pancreas that's doing right, the betas are either almost completely dead or they're all gone. Right. What they have and are growing this little person that has a working pancreas inside of its body. Yeah, right. I mean, that's, it's amazing just to think of like a developing baby to begin with, but then to think of all the little parts and pieces growing and working the way that they're supposed to, in that like little being. It's amazing to me so when you consider blood sugar in pregnancy as well. Your baby has a functioning pancreas. is very early on, right? And it starts to make insulin in response to what? Telling it's blood sugar. Oh, right. So the flux of your blood sugar tells then how is it kind of it goes along with how much glucose or how much food gets funneled in to the baby, the higher your glucose levels are, the higher glucose levels will get Now, baby's glucose levels again, they're being controlled well within a normal non diabetic target, because that's what its body is doing. But the more the pancreas has to work to combat your high glucose levels, the more like swapped in glucose the to be continually. And that's why like, later on post delivery, if the baby's body has been so used to pumping out excess insulin all the time, as soon as the baby is born, and you've heard about babies have been born with really low blood sugar. Yeah, soon as that umbilical cord is cut the mother's food source to the baby, it is gone, right? And if the baby has come into delivery, with a pancreas that's spitting out excess insulin because the mother's glucose levels were so high, its blood sugars are going to plummet.

Scott Benner 36:26
Interesting. So that makes sense, obviously, but that's Yeah, interesting.

Jennifer Smith, CDE 36:31
So that's another piece of like, we talked about the tight control in pregnancy. Tight is it's, it's there for a different reason, really. And so the ranges and how long glucose should stay at that elevated like one, then be back down, really into the normal range. There. There's reason for that.

Scott Benner 36:52
Yeah. It's funny, we all talk about it. So academically, like you know, 140 in the first hour, or 120, in the second hour back down and stable until I work glucose monitor and watch my body do it. It really didn't mean as much to me as it did, saying it out loud, right? Because my understood my entire understanding of insulin is through Arden's perspective. Like I've never thought about it before about about somebody else's ever once, and there's no lie, your blood sugar just sits in the 80s, you know, and then all of a sudden, pops up a little and comes back down and comes back down and levels out. And maybe you see a protein rise or something from fat later, it comes back up a little bit, but boom, right back down again, I ate my face off and couldn't get my blood sugar to go above 145. One, you know, 130 by the cage or something, totally took in as much food as I could, and I couldn't get over 135. So, you know, so, but how do we? You know, it's interesting, right? Because this podcast works, because we talk to people honestly about stuff like this, but most people's perception of how to talk to people. So don't make anyone feel bad. And I don't want anyone to feel bad. Like, I don't want someone to hear this and think I can't do that. Because I think you can. I think that I think that it's very possible that Jenny and I could have cottoned on and said this is a diabetes pro tip episode about pregnancy, go back and listen to the other protests, and then have sex. Yeah. Right. We'll see you next time. Like it may be could have been that really. And so if you're in the scenario, right now, where you're listening to this, you're like, Oh, I can't do this, or I have a different kind of diabetes, you probably don't, you know, like, you know, a blood sugar, that's it's stable, it's 7075 80. That's Basal insulin, that's just getting your Basal right. And so it's real doable. So if you've made it this far, you must really want to have a baby. And, and it really is doable. I really do say go back to Episode 210, find the beginning of the protests, or go to diabetes pro tip.com, where they're all listed, and listen through them, I think you could change your management. Now. Here's the thing. You've been pregnant, like you said a number of times with type one, is it more difficult? And by difficult, I mean, intensive with your focus and paying attention to your diabetes while you're pregnant, or while you're not pregnant? And what's different about it, like what are people going to find once they're pregnant? So I've got my three months where I'm doing great, but now all of a sudden, there's a baby in there, what changes?

Jennifer Smith, CDE 39:35
It's more intense, I think, because of the impact of the hormones once you are pregnant, right? So you knew what you were doing? You knew let's say you had your list of 30 Awesome foods that you had figured out or three pills and you knew what to do for them and how to Bolus and you can knock out your 10 mile run, you know, twice a week and whatever you figured it out. hormones in the picture change that okay. And so and that sounds kind of scary, but it's, it's kind of a roll with it sort of. Okay, you and if you've learned things again, from the pro tips, you've learned that don't let it just sit there fix it, right? Don't wait six days to see is this really a trend? If you've got a high blood sugar in pregnancy, okay, one, it might be hormones great. Okay, but then let's get it down in the tested that you know how to get your blood sugar down, use those tools, you may need to use the tools in a in a more hyped up way, right, let's say you always knew that an angled arrow up or a straight arrow up required an extra half a unit of insulin, oh, with pregnancy hormones in the mix, maybe it requires to offset that, because those pregnancy hormones cause some insulin resistance. And in early pregnancy, it's a very quick, noticeable rise in insulin need. The end of the first trimester typically things dip off a little bit, they plateau as there's a transition, where the pregnancy hormones are made transitions from ovaries into your placenta, there's a little bit of a transition there. You see, you might run some lower blood sugar's in late first trimester, before second trimester starts. And this is where I kind of call it like, if you've ever been at a theme park, and you get on the roller coaster and you're right at the bottom just starts to get you going up and you're up and you're up. And you keep climbing and you keep climbing. That's from second trimester or about like 18 ish plus weeks, that slow steady climb and insulin resistance, thus requiring more insulin and more. And then over time, I mean, the heaviest resistance is definitely the third trimester, typically somewhere between about 30 to 32 weeks until about 36 weeks is the heaviest resistance. So you accommodate by making adjustments. And again, this is where that team to begin with should be a huge advantage to you. Because during pregnancy, pregnancy brain or mommy brain is not a myth. Yeah, it is something that is there, you might get lost in in data. And so having a team that's really, really good and willing, and frequently through pregnancy with adjustments, despite you making your own, you may need a second set or a third set of eyes looking at things and being able to say that was great, but I think we could bump this a little bit more, we could change it a little bit more here. Oh, this looks like it's happening now.

Scott Benner 42:48
That's well, I was just as you were speaking, I there's this conundrum around more insulin like, you know, my body needs more all of a sudden give it more and we call it insulin resistance. And I'm always resistant to call it insulin resistance. I'm always thinking of it as just more need. But how do you convey that to a person? Right? How does a person who believes that their Basil is one unit an hour? How can they make the leap to now believe it's two units an hour or that a meal that was three units is six units all of a sudden, like that's such a huge leap in your head? And I wonder if it wouldn't help people just to think of insulin resistance as magical carbs that just appeared inside of your body? Right? Like so, you know, like, instead of insulin resistance, pushing your fasting blood sugar from 85 to 150, think of, well, how many carbs would have moved me that far? Right? And how much insulin would I have used for those carbs? So that's in there, there's a math equation of how much insulin do I need. But what I realized most about the podcast is that people need a way to think about it, right? They need a way that it makes sense to them. Because otherwise, they want an equation that's going to tell them when I'm pregnant, I need this percentage more, or the food's gonna need this much more. And I don't know that anyone's gonna give you that answer the way you want it. So

Jennifer Smith, CDE 44:11
I think it is it's more but I think if you know when you're talking about like the math, as you said, if you know that your typical fasting now in pregnancy has been like 7881. And now all of a sudden, you're waking up when I was nine 110 That kind of range. How much of an insulin adjustment is needed in that overnight Basal then and where did it go up and what to adjust because again, if you've done your homework ahead of pregnancy, you have an idea of where things started. And as you changes, you're more attuned to them in pregnancy. You just you see things on a super highlighted level. Let's call it that You know, you're paying more and more and more attention you asked, you know, what's the difference between paying attention outside of pregnancy versus B? I think just the pregnancy itself drives a woman to think I'm now caring for another little being that's growing. And I have, I have the ability to let this baby develop really healthy from the get go. And I'm a big part of that, right? So you become really kind of like, hyper on evaluating what's happening to your blood sugar. I mean, I looked at my I looked at my Dexcom. More than Well, while I was pregnant, I was constantly like clicking to see, you know, what was going on? Where was it going? What was happening? Because, well, the see, is this normal, or have I gotten a new load of like pregnancy impact? And do I need to make a shift now? Oh, look, this is like, day two, that I've now had to correct my blood sugar with a little more after lunchtime. I need to obviously add more insulin to my Bolus, I need to change my

Scott Benner 46:07
did you have anxiety around that? Samantha mentioned in the episode that she sometimes felt like she was hurting the baby when her blood sugar would get high? Yeah, it was hard to deal with sometimes. And then I think

Jennifer Smith, CDE 46:18
that's a I would say, 95% of the women that I work with their pregnancy that's at at least once it's mentioned, well, my goodness, my blood sugar. Again, we we had like a baby shower, and I had like a bite of a cupcake and my blood sugar was 201. Or, you know, I got it down really Rino right away. I'm like, okay, that's that's okay. And they're, you know, they're very, I think the worry really is one they need to voice it because it was concerning to have worrying about that baby did that really high blood sugar for one hour? Cause my baby to now have three eyeballs now weigh 12 pounds? No, it's It's more understanding that the consistent lengthy, high blood sugars, that's problematic. Right off, I mean, was my blood sugar sitting at 83, the entire pregnancy dislike flat, beautiful, I actually go back to my Dexcom records from that time because I printed them out. But I have them in like my pregnancy file.

Scott Benner 47:21
Just let everybody take a second to say to themselves personally, whether they're doing chores, the House working out or your grocery shopping to go. I knew Jenny had her Dexcom grafts from her pregnancy.

Jennifer Smith, CDE 47:33
They're good. They're reference for me, as I work with people, and I was really glad having done that my first pregnancy, because we knew that we wanted more kids. Yeah. And I wanted to have a reference to be able to say, tested. So once you get through a first pregnancy, and you get an idea, yeah, I needed more around 20 weeks, I needed more, again, in Basal and in Bolus, and I needed to lengthen my Pre-Bolus. That's another big one that shifts through pregnancy, you might you know, pre pregnancy, you might do 1526, things are stable, that works really great. Once you're pregnant. As you get more pregnant, the time of Pre-Bolus gets longer and longer and longer. So by about mid pregnancy, you should be pretty minute Pre-Bolus For most meals,

Scott Benner 48:31
how much of what's happening to a pregnant person is in regards to their insulin use is that they're pregnant, that they're cooking a little person inside of them, they've got a bunch of hormones going on. And by the way, all of you have to be so impressed that I talk about this stuff so much. And I've never told that joke from the 80s. How do you make a hormone? I keep it inside every time I hear it, just so you know. And so how much of this has to do with that? And how much does it have to do with gaining weight too? Is that a part of it? So like a side of the diabetes piece or a side of the pregnancy piece you are gaining weight as well, right?

Jennifer Smith, CDE 49:08
Gaining weight and you shouldn't you should be gaining weight and that is a very big piece of it. Yes. And you know, Healthy Weight Gain if you've if you're at a really good target, happy healthy weight prior to pregnancy. You could gain somewhere between 20 to 3025 to 35. Okay, in pregnancy that would be considered normal. You have to expect or I guess you have to understand where does that wait to come from? Because in both of my pregnancies, my first pregnancy I think I gained I think it was 26 pounds. My second pregnancy I gained 21 pounds. And you have to you have an eight pound baby. That's like a third to maybe half of your week. Depending you know, that's a big chunk of that already. Now, like put on the floor plucked out at You're you delivered right? Hopefully that the floor but right, it's like not on you anymore, right? And then you have to expect development for lactation, you have a placenta, you have all the amniotic fluid, your fluid levels in your body doubles through pregnancy. That's why a lot of women experience swelling and whatnot in their legs by the end of the day at in late stages of pregnancy, your blood volume increases to pump all of that extra blood through you, pink tissue and the bat. So you've got a lot of gain that disappears, literally once you deliver the baby. So really, women end up you hear people complaining on this last five pounds, I can't seem to get rid of it after break. That's really it is that gain? Yeah, most women gain someone seven pounds of fat gain through pregnancy. And it's normal, your body should be doing that. Because if you plan to nurse or breastfeed your child, your body needs a reserve. So it's packing things away. So you can make plenty milk to supply this like never are empty baby

Scott Benner 51:11
hungry all the time, it was about to show off and say that that was for breastfeeding. But then you beat me to it. I was like, Oh, I know something. Finally that's yeah, prove it now. So it doesn't matter.

Jennifer Smith, CDE 51:22
And typically, as long as you nurse, you're usually most women are going to retain about that. Once nursing is done, depending on how long you plan to nurse, usually, as long as you return to your normal activity, and you haven't been eating bonbons crazy, just because you want to typically that weight does come off once you're through nursing.

Scott Benner 51:45
Alright, so we've gotten through the pregnancy things have gone well, the day the delivery comes, please talk to your doctors well ahead of hand and understand that just speaking to your doctors doesn't mean that the nurse that the hospital's going to know that you're taking care of your blood sugar during your during your delivery, right. And it's going to, if you've been doing such a good job thus far be really weird to hand it off to somebody, you know, in the last 50 yards, when you're like I can see the end, now you take care of my blood sugar. So you know, if you have a spouse or a family member, that you can, you know, teach how to help you or she'll be there with you right in case something gets funky and they end up putting you out or something like that, I guess obviously, if they go to a C section, you're gonna get handled like a surgery case then too. But if you're just having a regular vaginal birth, you should be able to manage your blood sugar through that time pretty well.

Jennifer Smith, CDE 52:42
potentially even a C section, you know, really? Yeah, really. And I think this is where protocol, like you said initially, it's, it's really important to have this talk with your team much sooner than delivery could possibly happen. I mean, there are always certain instances delivery at like 28 weeks, or 30 weeks or whatever. And those are really, it's not often. And that's a very feel of management, right. But for the most part with women that I work with your pregnancy, we establish and detail a labor and delivery plan, okay, and it goes through, these are the expectations of glucose management, this is where you should target through dip through every, this is how much insulin adjustment you could expect to need to make. And again, every woman responds to laboring and delivery a little bit differently. Some women's needs with the active nature of laboring, some women's needs go down by 50%, great use a Temp Basal decrease. Some woman's needs go up a little bit with the stress of all of the contractions and everything. Great. So you might need a little nudge kind of Bolus of insulin in order to get a little bit, right. A little bit extra. Whenever you're correcting in delivery, our recommendation is typically about 50% of what your pump is recommending to correct a blood sugar while you're laboring because, again, you're you're active. I mean, it's not like you're out running a marathon. But a pregnancy can take long, or a delivery can take a lot longer than marathon takes a person, right? So you can expect that that now is gonna get active pretty quick, and it's going to have a faster impact on your blood sugar. Right. So those are some of the things that we highlight. We also have a pattern established in the care plan so that the doctors know where your rates are, what your sensitivity is going in delivery. And then there's also a postpartum part of the delivery plan that notes now insulin needs are decreased considerably. This is what your postpartum pattern should look like a lot of the women I work with take it into their OB team, they get it signed off, it becomes part of their medical record. And once they go into the hospital, that's the plan of care. The nurses know the targets. They don't have to continue to explain it over and over and over and over to all of the nurses as they're rotating through their eight to 12 hour shift.

Scott Benner 55:22
Yeah, yeah, that's Samantha brought that up to that the first nursing staff was great after the pregnancy. And then when they switched over, the next group didn't know what the first group knew. And then now you're explaining about your blood sugar's and that all gets and you've just had a baby said she was wasted from having the baby, the whole thing. Okay, so I have a couple more questions. And I know we're running up on time a little bit. Oh, we're good. Okay. Make the baby baby comes out. Everybody comes to the hospital. They're like, Oh my god, the baby made a baby. It's great. You see your friends of yours who you're like, oh my god, they shouldn't even be near kids. Somehow you let them hold your baby. If you're younger, trust me that will happen. One of your 25 or 30 year old friends is going to be hold them in your like, that's probably a mistake letting Jimmy near the baby. And so that all happens. Your home now. Now, you've got to take care of a baby. Yeah, I see a lot of people say well, it's hard to take care of the baby and my blood sugar the way I was taking care of it before. But it did you find I'm using you as an example here because you're very good at handling your blood sugar. Did you have trouble after you had a baby keeping carry yourself?

Jennifer Smith, CDE 56:30
I think you know, this is where again, planning your care team kind of thing comes into play. And while your mom, your aunt, your best friend, you know your uncle's brother, who isn't really your uncle, but is a good friend that you whatever it is, whoever's going to be there anyone post delivery that you trust, not Jimmy, who

Scott Benner 56:55
like drop the delivery of the baby to get the

Jennifer Smith, CDE 56:59
baby to but somebody you're going to trust to be there once you come home from the hospital. Yeah, that is a really, and something for at least a week, maybe even two weeks for someone to really be there to help with things because one delivery in and of itself is it's a labor. Yeah, that's why they call it labor, right? It's work you you may with a vaginal delivery. Okay, you may not be in the hospital for very long. If you have a C section delivery, C sections typically are about a three to three to four nights stay. It it depends on healing and how things are going and all of that kind of stuff, right? But definitely when you get home. It's harder because you're now not taking care of just you and diabetes. Now, it's like you've got a second child, even though if this is your first real child, I always considered diabetes, kind of like a toddler that never really grows up, like constantly sort of like caring for it. So it's almost like this first child diabetes gets pushed off in the corner and you're like, Yeah, you're just gonna have to sit there for a bit, because mommy's gonna take care of

Scott Benner 58:15
it fine. He can do his homework by himself.

Jennifer Smith, CDE 58:18
That's right, right. So you know, some things to kind of along with that care person, they're beyond your spouse or your significant other, you know, somebody else that can be there. So you can focus a little bit because in that time period, especially the first month, things will change considerably with insulin sensitivity, especially if you're nursing. There are a lot of changes that will take place and blood sugars are going to look a little bit more rollercoaster we want how important

Scott Benner 58:49
our blood sugars to the breastfeeding process does that impact the milk at all?

Jennifer Smith, CDE 58:55
So there's a lot of like thoughts around it a lot of research that sort of like a 5051 of the big things is high blood sugars can actually good lactation. So if you leave your blood sugars sitting high one, as we've talked previous episodes about like hydration, your blood sugar's are sitting high, you are not well hydrated, you are in a and milk is liquid, not only more coming out as your nursing, blood sugars are drinking enough. Oh, I see. So Right. So hydration is really, really an important part of not only the blood sugar, but also continuing to be able to supply enough liquid that's going to get sucked out of your body. Your

Scott Benner 59:41
mind too. If you've never had a baby before. They don't sleep the way real people sleep. So there's a tired factor that is really hard to put into words. It's not easy. And so there's a lot going on. I mean, listen, we've gotten this far I should put I'll be telling you having kids is a huge mistake. I don't mean that having them is great. It's getting them and taking care of them and keeping them alive and being, you know, good to them and teaching them things. All that is a harsh show. But the kid itself is lovely. Like, when you walk through the room, you're like, oh, look, the kid. That's nice. Yeah, in that moment, you don't think about when they're yelling at you when they're eight, or that you paid a guy who was probably homeless to be spider man and a third birthday party or something like that, like, that's the thing she you know, they want you to have a dog. And then you get a dog because you like, oh, the kid should grow up with a dog. And then it's 630 in the morning, everyone's asleep, but you and you're outside with the damn dog. You know, I'm saying kids are great. A lot of what goes with it is hard. And hard. And especially right after a

Jennifer Smith, CDE 1:00:51
baby is hard. Especially if, again, it's your first pregnancy. Yeah, it's it's a harder time. And this is again, where help comes in the form of also, like, pre planning, for the post delivery, the time period, you know, we number of like soups, and things that I could put in the freezer, that were easy to pull out. I knew the content of them, because I knew what was in them, I either made them or my mom made them. And I froze them, it needed a heck of a lot easier. Also, some of those foods that are definite, no one foods and how are you react to them? Yeah, can be a huge help in the aftermath. So it's just not it's not more struggle, as you're already managing. Nursing a child putting a child to sleep, learning how to not like have poop all over the place as you change them.

Scott Benner 1:01:46
You could experience postpartum depression, which is incredibly common. There's a lot that could happen. And by the way, a lot of guys will eventually turn into good fathers, but it doesn't, they don't have a nature provided switch, like I'm telling you, you're going to have a baby and be like, This is the most important thing in the world I watched might happen to my wife, she almost didn't even care that I was alive. When the baby came out. She was like, the baby's here. And that guy, you know, like, it was you if you're, you know, lucky, you're gonna get a great connection, and you're gonna feel that desire to take very good care. It takes guys longer to figure out how to be fathers than it takes women to figure out how to be mothers, generally speaking, even if you've got an even if you're listening right now you're like, now my guy is a good guy. Listen, I'm a good guy. It took me like two years to figure out how to be a good dad, right? Like, you have to watch it and go, Okay, this is what I think they want. But this is what they actually need. There's a difference in there, I still struggle with to this day, I'll probably be struggling with it on my deathbed. I'll be 80 years old, just drifting off, and I'll hear someone in my family go. He did that wrong, you know, there's that there's a lot that's going to happen to you and you have a baby, and you're going to have diabetes too. And it would be very much my hope that you don't take all this wonderful stuff that you've learned pre planning for your pregnancy, through your pregnancy through your delivery, and just do that human thing of going that baby's more important than I am and so I'll let my stuff Wait.

Jennifer Smith, CDE 1:03:26
You know, I think it will also has type one, she had a son prior to our first son. And she gave me some really good advice and said, You know what? If inter we're talking about like, low blood sugar's around nursing, right, she was like, You know what? is low, and the baby is screaming, that the baby is safe. Not sitting like on the edge of the counter waiting to fall off. Right? But like, fine. I am important to take care of myself. It's important that I take care of myself. I'm important too. I have to manage. Yeah, I have to manage my high blood sugar and the baby screaming. It's okay. Yeah, maybe it's gonna be okay screaming really? I mean, you're not going to let them scream for like three hours. But yes, in the case of 510 minutes while you are taking care of you treating a low blood sugar or even just for your meal before you actually sit down to eat it. That's another piece that I we talk a lot about Pre-Bolus thing and the timing in this podcast and that's a piece that often goes out the window because depending on what your schedule is like what your significant other schedule is like, you may at times be whole your maternity leave with the baby

Scott Benner 1:04:50
yeah, I there's a part of me that believes that we should be making a sign and selling it through the podcast that just says that's a real homie. You know how like you see those beautiful signs and people's kids It's like The cook is blah, blah, blah, there should just be one that says Pre-Bolus. hung in people's homes so that it gets drilled into your head over and over again, because this is the easiest thing to mess up. Like, tip, forget, you know, I did it this morning, this morning, we got back from the blood draw. And art is like, I'm gonna have eggs and turkey bacon and toast. And I was like, does that mean I'm making it for you? And she's like, Yeah, so I'm thinking, Well, I have an hour till Jenny and I record. And I can get this done by then. And I started focusing on getting it finished. And then I turned to her and handed her a plate and thought, Oh, I didn't give her any insulin

Jennifer Smith, CDE 1:05:34
damage. And of course, she didn't think of it either.

Scott Benner 1:05:36
Nobody thought of it. No, we'd gotten up super early to go to this blood draw place. And you know, like all this stuff. So I said to her, we're going to Bolus now and please eat the toast last. That was like the best I could come up with, you know, in the moment, and we ended up having to use an extra unit to overcome that offset. Yeah. So okay. Did we miss anything? Is there something in the back of your head burning?

Jennifer Smith, CDE 1:06:00
I'm trying to think of, maybe, I guess the one last thing along with it is definitely stay connected to your care team. You know, because that's, as you mentioned, already, there is potential for postpartum there's a difference between just being a little bit like down in the aftermath of delivery. And true, like, you crawl in bed, and you're like, I don't to do anything else I, I will nurse the baby. But then the baby goes over here, it's almost like a, it's a disconnect that happens in true postpartum depression. Yeah. And so staying connected to your care team, is really, really important. Making sure you have those postpartum follow ups kind of scheduled. Leave the hospital, it's really, really important. Maybe staying connected with your diabetes educator or your endocrine doctor, whoever was also a really good advantage through pregnancy, stay connected with them so that, you know, they can even nudge you maybe to say, hey, you know, can you just pop in and upload it and I can take a peek and I can make some recommendations for you let somebody help you. Let somebody help you really? think, oh, go ahead.

Scott Benner 1:07:18
If you think it can't happen to you, my wife and I, we were just talking about this recently, she said for the first two weeks after our son was born, she had no feeling at all about having a baby. Like she just felt like we brought home a lamp. You know, like it really she's just like, I don't know, if I like this thing or not. Plug it in over there. Leave it Oh, we'll see how it goes. And she said that all of a sudden, one day, a couple of weeks in, I was at work. And she said she just was holding call and just started crying. She's like the baby is the most important thing. Like it all hit her at once. It was almost like you expect that to happen when you need it, but it didn't happen to her right away. And then she had that like, oh my god, I have a baby and I don't care. Like we're not even not care but like there hasn't been this ramping up connection connection immediately. Right? Yeah. So and that's a rabbit hole people could fall down especially if you've been depressed in the past or something like

Jennifer Smith, CDE 1:08:12
that, especially with another condition to manage like diabetes. Yeah, there's there's more to manage than just connecting with this new little person. Yeah, so

Scott Benner 1:08:22
So stay connected to somebody that can walk you through it and if you're feeling that way have to tell somebody like don't hide it. Just tell somebody just tell ya then I should say here as we finish up, if anybody wanted to buy a book about pregnancy with type one diabetes, should they buy one called pregnancy with type one diabetes your month to month guide to blood sugar management available on Amazon and written by ginger Vieira and Jennifer Smith CDE. Oh, okay. Yes,

Jennifer Smith, CDE 1:08:49
they should absolutely. I think the farthest I've heard that somebody's purchased. Our book is Bally Bali or Bali? Yeah. I'm in Bali. Yes. Bali

Scott Benner 1:09:03
place in Vegas where I can lose my money in the slot machine. Ali. Ali's Ali. Yeah, there's someone in Bali right now has a little baby a Bali baby. Yeah, she's pregnant. Oh, look at that. All right. Well, all I know is Ginger has been on the show before you obviously know, Jenny, the books only 12 bucks. It definitely is worth your while and it goes

Jennifer Smith, CDE 1:09:24
through everything kind of in a much more. What we've touched on kind of in each of the sections of print planning pregnancy, whatnot. It's, it's a good book. I'm glad that we did it.

Scott Benner 1:09:38
I want to thank assenza diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free contour next gen starter kit at contour next one.com forward slash juice box free meter while supplies last US residents only if you're enjoying the remastered Two episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org. A huge thank you to one of today's sponsors, G voc glucagon, find out more about Chivo Capo pen at G Vogue glucagon.com forward slash juicebox. You spell that g vokeglucagon.com. Forward slash juice box. If you're living with diabetes, or the caregiver of someone who is and you're looking for an online community of supportive people who understand, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, there are over 41,000 active members and we add 300 new members every week. There is a conversation happening right now that would interest you, inform you or give you the opportunity to share something that you've learned Juicebox Podcast, type one diabetes on Facebook, and it's not just for type ones, any kind of diabetes, any way you're connected to it. You are invited to join this absolutely free and welcoming community. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low Beegees in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two in Episode 1008 teen pregnancy 1009 teen explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025, we talked about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer, he'd really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning that Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active. Took me already from a decent 6.5 A one C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com If you're interested in hiring Jenny, you You can learn more about her at that link