#212 Diabetes Pro Tip: All About Insulin

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

I am thrilled to welcome Jenny Smith, CDE back to the show. Jenny will be joining us for an extended series of conversations that focus solely on the management ideas that we discuss on the podcast.

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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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 0:09
Hello, welcome to the Juicebox Podcast. I'm your host, Scott Benner. This episode is the third in a series with CD Jenny Smith. If you haven't heard the first two, go back and find them. The first one is called diabetes pro tip newly diagnosed or starting over. The second is diabetes pro tip all about MDI. And this one, of course, diabetes, pro tip all about insulin. They're designed to be listened to in order. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And always consult a physician before making any changes to your health care plan for becoming bold with insulin.

What is it about insulin that people need to understand at its core? And I'll start by telling you that it just a very simple story that that I was in my nurse practitioners office one day, you know, I like to say we're at the end. No, but honestly, I never see the end. Oh,

Jennifer Smith, CDE 1:13
right. It's always a nurse practitioner who is? Yeah, yeah. And most often they've got more time anyway. So that's a good gap. When people

Scott Benner 1:22
say who's your I know, I sometimes have to pause. I'm like, Huh, right.

Jennifer Smith, CDE 1:25
I don't really know.

Scott Benner 1:28
So this was a number of years ago back before I think I would quote unquote, say that I started to understand. And I would say that I've understood diabetes on a different plane for about the last five years or so. Okay, but the run up to understanding it was reaching out into the world and picking these little ideas and really wrapping my mind around them. And as much as I tried to understand bolusing, or understand, you know, the, the peaks and the valleys my daughter was seeing and all the problems we were having. It wasn't until the certified diabetes educator and my daughter's practice, answered a really simple question for me. I asked her if you had a magic wand, and you could change the way people do one thing around diabetes, but would it be and without hesitation, she said, I teach them not to be afraid of insulin. She said that would be the core step one. Nothing else matters if you're afraid of the insulin. And I took that to heart. So I guess let's start with why are people afraid of insulin? What do you think it is? I think

Jennifer Smith, CDE 2:40
the main reason is because the initial education includes so much about hypoglycemia. Insulin, I mean, insulin is one of the very, very few medications on the market, that doesn't have a tremendous amount, but really doesn't have any effect on anything else, you know, it's not going to cause your eyeballs to turn green or you know, your toenails to grow extra inches or anything funny, right? It's its side effect, let's call it is hypoglycemia, low blood sugar, if you don't understand how to use insulin, right, so that I mean, it's drilled into you, if you be careful of low blood sugar. This is how to treat low blood sugar. These are symptoms of low blood sugar, I mean, low blood sugar, low blood sugar, low blood sugar is drilled in. And so what are you going to get from that? I mean, if you're told every time you come to the stop sign that some car is gonna come and swipe you. You're not gonna like go into a stop sign either, are you?

Scott Benner 3:45
It's funny, I think of when you say that I thought of driving in my mind right away a little differently. I thought of when you first teach someone to drive, you teach them about the brakes. Right? Right. Right. So it's the it's the first thing you think, right? Like, even if they steer wrong, or anything, they're doing wrong, if they can stop, maybe they won't get hurt too badly. Right. And so it is really the same idea. I guess for doctors, they look at the giant picture that is type one diabetes. And they say what's, what's the thing where these people could run into a wall, they could use their insulin incorrectly cause a scary low a scary low might mean if you're an adult, loss of your own function, inability to stop that fall from continuing. Right, right. And then so let's talk about granularity for a second because I don't think we do this enough about diabetes. Insulin extracts sugar from your blood. Is that right? Yeah, yeah. And unlike my body, which knock on wood has a pancreas, it's working it my body knows when to stop. It gets me to a nice level, and it stops. manmade insulin is going to work until it's not there anymore, and work

Jennifer Smith, CDE 4:54
and work and work and work and it's going to work in an interaction setting with The food that it's meant to work with or the glucose that's in the in the bloodstream for it to work with now, there's too much insulin there, and there's not enough glucose for it to continue to work with. And it's still gotten a whole hour of action. Absolutely low blood sugar.

Scott Benner 5:14
Yeah, it's not going to cause a low blood sugar. Like you said, if there's impact of carbs impact of body function, then that's what the insulin is working against a minute, the carbs are going from your system or the adrenaline you had is gone. This insulin, if it is still there, if you've missed timed, it, is going to continue to work. So that we know what we are scared about. Let's be more more honest about it. I'm gonna test myself and you'll tell me if I'm wrong. Sugar is the energy that our brain works off of. It's the the gas for our brain, right?

Jennifer Smith, CDE 5:51
It is. Yeah.

Scott Benner 5:52
And if there's not enough sugar in our blood, our brain shuts off like a light switch. Is that correct?

Jennifer Smith, CDE 5:59
in an easy way of saying it? Yes. If our brain is not getting the that sugar? Yes, we that's why all of those strange symptoms come about with low blood sugar, your brain is being deprived of the food it needs to function to think the right way. Yes.

Scott Benner 6:19
Let's just throw it on the table, what everyone's really afraid of right. Nobody wants to die when they're sleeping. That's what everybody's concerned about. I don't want to say that that's not an issue, because if it happens to one person, it's an issue. I would say that I do think of it again, like driving like I, I think driving is incredibly dangerous. But I do it every day. If I happen to have an accident one day where I'm killed, I will not be thrilled about that, as I see the telephone pole coming for me, right. But I think that's maybe the cost of doing business for being alive, I have to get around, I have to travel. Right? I think the same thing about diabetes, you need to use the insulin in an effective way to make your life healthy, longer, happier, you know, all that stuff. So you have to learn how to do this. And then the rest of it just like driving, you throw it away, you're like, Okay, I'm going out there, and I'm going to do my best. And the first thing that happens is people get dizzy, confused, they're easily agitated. But then as your blood sugar continues to drop, you lose the ability to what, like what happens as you continue to get lower.

Jennifer Smith, CDE 7:21
And again, this is where symptoms are different for everybody. But truly what can what really continues to happen is the loss of the right way of thinking you it just continues to decline. And if it gets far enough, you could lose consciousness, you know, you could certainly no longer be awake, doesn't mean doesn't mean daft, but it does mean that you could certainly pass out, um, from a low blood sugar. Yeah, you'll

Scott Benner 7:51
hear it adults sometimes say they knew it was coming, they consumed a ton of food, then wake up on the floor, because then the food gets in and it turns things around for them. Wow. So I'm gonna I've said this before, but, you know, for context in this episode. Prior to technology, I mean, honestly, back when we were needles and little tiny like I've said before, like a diabetes bubble gum water, right. I have caused Arden to have two seizures. One right after she was diagnosed, she was only maybe a few months into it. And I had this grand idea that I had figured the whole thing out, which probably meant she was honeymooning. Right, right. And we go to the mall one day to pick up some stuff real quickly. My wife's going on a trip and we need I think another bag or something. Everybody gets hungry while we're running through the mall. And here's this like, mall Chinese food. And I thought this does no big deal, right? I'll just count the carbs and I'll shoot the insulin and she'll eat the food and she ate and it was good. And she was little two years old. She ate a little bit of food. I gave her No, not a lot of insulin for a 20 pound person. Right, bought the bag went home. She fell asleep in the car later in her crib. My wife and I are helping her. I'm getting her packed up for what she's doing. And then I hear what sounds like a wild animal in my house. grunting and snorting and like like that. And I go into the room and there's my daughter. She is having a seizure in her crib. And so I pick her up and I don't know what to do. I mean, I know the doctor told us about glucagon. But for the life of me in that moment, I couldn't. I couldn't hold my hand. Still, I couldn't reconstitute it. It was a disaster. While she's on the floor, and my then seven year old son is dialing 911 for us My wife is rubbing glucose gel in her cheeks. And as I'm fumbling with the glucagon and really messing it up, Arden is blind. If you touch her she overreacts in a way like she thinks she's being shot like right like he or she is grunting and incoherent and then it just ended. Like when the glucose gel was And she came back and the police came into the house and the rescue squad and we went to the hospital and now I look back, we didn't even have to go to the hospital. Like the hospital was nothing. By the time we got there, her blood sugar was back up, and she was fine in this whole thing.

Jennifer Smith, CDE 10:14
But it's scary. I mean, just, you know, you're saying it. Yeah. You know, I mean, and I talk with and work with so many parents with little, little little, you know, and it is, it's, it's scary when it's when it's your child, and it's not even you. You know, the worst thing now can tell the scary story to tell what I think is the funny story.

Scott Benner 10:39
Yeah, so a year and a half later, we're at Disney for the first time. So our first time outside in the heat. On a big day with diabetes like diabetes, the whole day is going great. Again, no CGM still using needles. end of the night we're walking back to the hotel and coming at us is a vendor holding these giant popsicles. Remember looking up and seeing them and thinking we're like 200 yards from the hotel, like make a left turn, what are you doing, you know, but it's hot out and it's late. And my kids see those and they're like, Can we have them? And I thought, sure, I'm gonna do what the doctor told me to do. I counted the carbs, I gave her the insulin. And of course, it turns out I know now, you know, I could have just let her eat that popsicle. It would have been It was a fast acting car but might have hit her spider a little bit and gone away. I didn't eat any of it. But there we are back in the hotel room. Packing again, always packing with seizures in my house. And so we're packing because we're leaving the next day. She's laying in a bed often another room sound asleep, and I hear that noise again. And this time instead of being confused and thrown off, I say to my wife Arden's having a seizure. Now remember, it's been a year and a half since it happened before. And my wife runs and grabs Arden brings her back, she's holding her and I have the glucose gel and this squeezy tube. Now the gel we owned, you had to screw the top off of them pull the foil thing often, I guess CalFresh

Unknown Speaker 12:08
and then you can use as a gel spoil.

Scott Benner 12:12
Cuz you never cut you know, because honestly now in the of course the ensuing 12 years later, we've never Arden's never had a seizure since then, but right, so I unscrew the cap, and I go to squirt out the gel, and I don't pull off the foil cover. And I squeeze it so hard with so much enthusiasm that a pinhole breaks on the opposite side of the thing. And I'm squeezing and I'm like what's going on and then I look up and on the ceiling of the hotel room is a kaleidoscope of gel, I'm shooting all over the ceiling. So I don't even pause I flipped the thing upside down. And now I just scored it from the pinhole into Arden's mouth, we rubbed around, she wakes up, we put you know, get everything straight, put her back to bed, we were traveling with my brother, when it was all over and to say that it might have been a four minute experience, right? When it was all over, I look in the corner and my brother is cowering in the corner, just with a look on his face. Like he can't believe what he just saw. And my wife and I look up and see the gel on the ceiling, we crack up laughing, wipe off the ceiling, clean it up and go back to packing

Jennifer Smith, CDE 13:14
experience is a good example of the fear.

Scott Benner 13:18
That's exactly right. Because no matter how much I explained it to him, and I said, Look, you know, I don't want to call this the cost of doing business. But we've never been in this situation before we're completely blind. We don't know what our blood sugar's doing. I think the point is this. My point is this. I don't think my point is this. I know my point is this. I don't want to have a seizure. But in Geez, two to 15. In 13 years of having type one diabetes, it's happened twice. It was both when she was tiny. It was both when I didn't know what I was doing. And it was well before the technology that exists now.

Jennifer Smith, CDE 13:52
And before experience of walking around. I mean, in this example, walking around a park all day and not really knowing, hey, she could probably get away with having this little bit of extra sugar, she'll climb, she'll come back down, the exercise is going to hit all night long. She doesn't need insulin, you didn't know that

Scott Benner 14:09
no idea. And now I do. And now Arden can go play softball for nine hours on 105 degree day and she doesn't get low at the end of the day. Because now I know what I'm doing. But I fear that exists exists for that reason. And so I don't know how comfortable you are talking about this because I haven't asked you ahead of time, but how real and this then we'll get off the fear and we'll move on to other stuff about insulin, but how real is the concern that I'm going to go to bed one night and not wake up the next

Jennifer Smith, CDE 14:41
day? I would say that the concern? It's a real concern. 100 Absolutely. It is. Is it a concern that it could happen? wildly out of the blue with and I bring this up With the technology we have today, I would say is that piece is, it's not going to be as common. And it's not because we have alarms and things that set now is technology always perfect. No mean, we can get alarms and alerts for blood sugars that are ultra low or look like they've dropped off the map and you do a finger stick, and it's that the sensor was not right, you know, it was a, you know, a kind of a compression low, or you could have a low alert, and you could actually be lower than the low alert already, right. However, the fear of going to bed and not waking up. While I would believe that it's there, for 90% of people with diabetes, the other percent, maybe don't even think about it or know that it's a potential again, education piece there. But I think that there is the knowing about insulin and action going into that time of the night. I think that's a piece that can really help to prevent that from happening.

Scott Benner 16:10
As we move forward, you'll hear me say a number of times that I think that highs cause lows, because highs create situations where you have unbalanced insulin. And and eventually, like we talked about earlier, body function, blood sugar will will be pushed away by the insolence they're leaving more insulin behind. And there are a lot of times that people will say to me, you know, I get low at 2am. Or, you know, it always happens. And I think well, I don't know that you get low at 2am. It's very possible it's something's happening hours before or you're using insulin hours before. And it's and this is what the residual of that. Right. And so when you use insulin more thoughtfully, I guess is the word. Right? Yeah, that's a great word. You don't have as much of it laying around later in your body that has nothing to do except for to make you low. Correct. And I'm hoping that we get to that as we speak, you've addressed fear and insulin, it's a real thing. It exists for most people. There's good reasons why you should be afraid. But how do we stop people from being afraid?

Jennifer Smith, CDE 17:16
But I think the fear too, and just to kind of clarify there, it's okay to be afraid. But it's also really important that you do something to understand and, and be able to get rid of the fear. It will be there it is certainly, but it's important to learn how to not worry so much with the fear. Let

Scott Benner 17:41
it overtake you. I think of it let it overtake you. Like they tell you with fire when you're three years old? Yes. You have to respect fire. But you can't be afraid of it. Right? Yeah, be afraid of it. Exactly. Yeah. And that that's what I do. I it was the first leap that I made that brought me to the place where I am now. And I think that I think that no matter what tools you give people, if they're afraid to use them to kind of, it's never going to work out quite right. And it's always going to become unbalanced, they're always going to end up in a situation where they go see, look, this is diabetes is unpredictable. And and this is always going to happen and then you know, and that that's that so Okay, so all right. So what's the first step to not being afraid? It's got to be understanding how to use the insulin, right? Absolutely. Okay. All right. So we're gonna get

Jennifer Smith, CDE 18:31
100% 100% Yeah,

Scott Benner 18:33
so let's understand a couple of things. First, that the insulin can do the cause issues for people and one, right people say, I started using insulin, and I started gaining weight. Okay, now, very recently, I had an interview with Chris Rutan, where Chris said, That's not as really nearly as much about the insulin is, as it is about calories. And that was his take on it. Like if you eat extra calories, you're going to gain weight. And that a lot of times we have low blood sugars that we treat with food, but we don't think of that food as we think of it as as necessary because it is not because you're alone, right. But what is the act what is the what is the the technical reason why people see weight gain with insulin. Elizabeth forest was diagnosed with Type One Diabetes. At 10 years old. Then a student in Holly recurs dance class, Elizabeth decide to start a nonprofit organization. Now this wasn't something that she had considered previously, but either was being diagnosed with type one. But after her diagnosis, she was driven to not let diabetes negatively impact her life. And she was inspired to start dancing for diabetes. She did this as a way to bring attention to the stories of the 1.2 5 million Americans who are living everyday with type one and to offer support to those who have been diagnosed and on top of all that she's raising funds to find a cure. started as a community fundraiser organized by a middle school student and a small group of trusted advisors has blossomed into a full scale theatrical production involving hundreds of local dancers and community supporters. Dancing for diabetes has been impacting people through dance for almost 20 years. It has grown from a middle school auditorium to filling Orlando's Bob Carr theater, and is well considered one of Orlando's premier charity entertainment events of the year. I spoke last year at one of their events, and had such an amazing time that I'm going back again in 2019. Elizabeth doesn't have a ton of money to do advertising, but she wants to spread the word about dancing for diabetes, which is why you hear during some of our episodes, I just pop in and say the name really quickly. They're trying to build awareness for their organization, while building a better future for people with type one. So you've heard me say before, and I'm going to say it right here. good at dancing for diabetes.com that's dancing the number four diabetes.com check out what they're doing. It'll put a smile on your face, and maybe you'll decide to get involved. Real good foods believes in making delicious foods, high in protein, low in carbs that are made from real ingredients so you can feel the goodness. You'll never find weird sounding words on their ingredients labels, nor will you find processed grains, flours or other fillers. For example, instead of flour. Their Single Serve pizza crust is made from two ingredients. All natural chicken breast and parmesan cheese. Real good foods family sized cauliflower pizza crust is made from cauliflower, egg and cheese, and all of their foods are grain free, gluten free and use natural ingredients. That includes my wife's favorite enchiladas. The poppers that I love so much the chicken crust pizza Arden adores, and the cauliflower pizza that my mom can't get enough for being a listener of the Juicebox Podcast real good foods would like to offer you 20% off of your entire order. All you have to do with Checkout is use the offer code juice box. And as if that wasn't enough, they also have free two day shipping. Let's hold up some of real good foods products against popular competitors. Their Margarita cauliflower pizza has nine grams of carbs and 20 grams of protein. That other pizza that you know about has 37 grams of carbs, and only 12 grams of protein. Real good foods enchiladas has four grams of carbs 20 grams of protein, and that other one that you know about has 18 grams of carbs and nine protein. Now on to the poppers, there must be even somewhere right? Nope, not even close three grams of carbs for real good foods 29 for the competitor, and protein 22 to four, you can use the links in your show notes or Juicebox podcast.com for both dancing for diabetes and real good foods. And don't forget when you get to real good foods calm to use the offer code juicebox at checkout to save 20% Why do some people see weight gain with insulin?

Jennifer Smith, CDE 23:04
The easy answer there is that the insulin is being it's being mismanaged the dosing of it is being mismanaged and mismanaged Why? That takes in depth analysis of what's going on in the person's individual settings. Right? The and I work with a lot of people weight management wise, type one who I you know, I just I've gained weight or I've done this my blood sugar's are no better, but I've gained weight. Now, if the start with if you're running really consistently high blood sugars, you're actually eating out calories. you're peeing out glucose, because that's how your body is trying to get rid of the excess because there's not enough insulin there to bring it into your body and utilize it. So you may be maintaining a weight that you love. Your blood sugars are high that it's that healthy. On the second side, once you do reign in control, and you're now taking insulin to contain blood sugars, you may be gaining weight, because your body is now retaining some of those calories that were being lost before that you didn't realize, right? So that comes down to the point of understanding lifestyle and the management of insulin. And I bring up a really important piece that people don't, people don't realize. Insulin insulins job is a storage hormone. Insulin job is to pack the food into different places in the body. Right? It either packs it and moves it into your muscle cells or at packs it and moves it into fat. Right? It's usable or it's going to be hopefully used later. If there's too much of it, your body has to pack it away and utilize it later. So that's a that's a lifestyle piece. That's something to look at and say okay, where's my activity? level where it is my nutrition intake need to be is my insulin matching that, am I driving my glucose values too low and like you said, am I taking in too much because of low blood sugars that are consistently happening, and then you're adding more insulin to correct the high that follows and then you're dropping and you're adding food and you're correcting and add. So it becomes this vicious cycle of management, if you don't understand how insulin works. And in a body, I think a good point is that in a body without diabetes, insulin plays a very big role in weight management. And people without diabetes aren't injecting it, their pancreas is making it. So if they're themselves not managing lifestyle, they're having to produce a heck of a lot more insulin, to bring food out of their bloodstream for their body to maintain that normal blood sugar, the way that it's meant to do, they will likely gain weight too.

Scott Benner 25:58
So do me a favor and go over that cycle for a second. I take something in through my mouth that has carbohydrates in it, it goes into my stomach, my bag, my body begins to break it down. It basically those carbs are leached out that sugar, which is the you know, sugar is carbs a sugar comes out. And the insulin actually helps it go into my blood, right it or how does it

Jennifer Smith, CDE 26:24
insulin takes insulin, you know, we take it, we inject it or we pump it into our sub q tissue, it gets absorbed and dissipates that into our bloodstream is I guess the easiest way to say how it works. Insulin in the bloodstream then matches with the glucose from the food that we've eaten in whatever form you know, it could be rice, it could be celery, it could be an apple, whatever it is, sugar in the bloodstream, the insulin and combines with the glucose, they latch on together, and insulin is then the key to the door on the cells. With insulin, the doors open, the key unlocks the door on the cell, the glucose is allowed to enter the cell muscle cells then use it for energy. fat cells, pack it away. So

Scott Benner 27:16
that's how it works. And so with so without insulin, we go into DK, right and so and DK is what is it technically, but what what is it that's happening.

Jennifer Smith, CDE 27:29
So technically, with DK a, it's a significant deficit of insulin with high blood sugars. Right now there are cases of aka at more normal blood sugars. dk however, really is it's a deficit of insulin, meaning that your body is has no way to clear the glucose out of the bloodstream and move it into the places it needs to go. Now your body tries to compensate, like I mentioned before, with the weight management piece, if it tries to compensate, you get really, really thirsty with higher blood sugars. You take in more fluids your body up because you're drinking more, and your body is trying to flush a lot of that extra glucose out. And the only way it can if it can't do that forever, though, at a deficit of insulin. And so your body at the point of not having energy from glucose, it starts to break down fats and proteins. So ketones are produced with the breakdown of fat.

Scott Benner 28:31
Is that why? When I think back on Arden's diagnosis prior to it, she was ravenously hungry at the end, because she her body was starving, and it's telling her eat, we're starving, except the food went in. And then there was no insulin to move it into the cells where it was needed.

Jennifer Smith, CDE 28:49
Correct? Correct. I mean, I could have I remember, I mean, I was older than your daughter and I very, I very much remember the two weeks leading up, especially the week leading up to my diagnosis. I very much remember it. I mean, I at the lunch table in school with my friends. I was asking them for their milk. I was so thirsty and so hungry. And so they would they would get two milks, and they would bring one for me. I mean, I was consuming probably six of those little cartons of milk at every lunch and between classes in the hallway. I needed to get to the water fountain. I mean it was it was unbelievable. The unquenchable thirst and hunger.

Scott Benner 29:35
It really is. A threw me off for a second think of it. No, I won't get back on Arden's diagnosis in it. It just it always just makes me think like how do I not see her dying because she was, you know, no insulin in her body and she was withering away. And he looked back at a two

Jennifer Smith, CDE 29:51
year old it is. I think for kids, it's hard to because kids are hungry all the time. I mean, I've got a two year old and a six year old and man, like every hour, they're like I'm home. Hungry rabbits. I am hungry. Can I have that kids are hungry? Yeah. But it's a different it's a very different ravenous

Scott Benner 30:08
in that setting. Oh my god. Yeah. And so let me ask you something when a blood sugar starts to get low with a person who's being managed, but maybe they have there's their insolence on balance and they're getting lower. Arden will say she's hungry prior to a low blood sugar. And I always tell her Hey, if you feel hungry, first thing we should think about is is Are you hungry? Hungry? Or is your blood sugar getting lower about the same function right there?

Jennifer Smith, CDE 30:33
in a in a similar way, just in an opposite, you know, high blood sugars, you're hungry because your body is starving for the energy. Right? And it's not getting it. Low blood sugars. You're hungry because again, as we talked about, initially, your brain is being deprived. Okay? Your brain is saying, hey, you're hungry. There's not enough go grab something. There's not enough food here. I there's, there's too much of this insulin, it's calling. And sometimes even that precipitous drop in blood sugar that can happen. That's why overindulgence is there with low is I mean, you could literally go to the refrigerator and eat the whole roof. I mean, there there are people who have done that, or just the whole box of cereal. And they're like, okay, where's the next box? You know?

Scott Benner 31:24
It's Yeah, and it's commonly referred to as ether kitchen. Right? Yeah. So yeah. And, and, and so but when Arden was younger, and before sensor technology, and I was staring at her trying to figure out ways to understand where her blood sugar was. One of them was if she said she was hungry at what I thought were odd times of day. I thought, ooh, she might be low. And yeah, yeah, because the looking for the bags under their eyes was not working. I'll never forget, she's diagnosed and the nurse practitioner goes, you know, dark circles under the eyes could be signs of low blood sugar. And then she paused and she goes, or high blood sugar. And I was like, Wait, what? Was that gonna help me? And by the way, it never came to fruition. I spent No, I spent the first year for diagnosis, staring at her face looking for a sign of something wrong with their blood sugar, and it doesn't exist.

Jennifer Smith, CDE 32:13
I have never heard that before Scott in that, right. Yeah. Never heard that as a symptom of high.

Scott Benner 32:21
And it makes me think of the insanity of like when the Arden will say to me, like, you know, you'll be in the middle of a CGM changeover. And I'll say, hey, look, it's been an hour since we reset the CGM, or since we put it on whatever, why don't you go ahead and test let's just make sure we are very thing. Sure. And she'll say, I feel fine. And I always go, ironically, how you feel is not the best indication of what your blood sugar. So and so she still won't wrap it, she still doesn't wrap her head around that right away? If she feels Okay, then she thinks I'm okay. You know,

Jennifer Smith, CDE 32:54
well, and there are some children that have not quite even gotten to the point of realizing what the difference of body feeling is. Right. And if they've lived with diabetes long enough, they may not necessarily know what quote unquote, normal should feel like, right? They may not know that your diagnosis at two or three, they're not even realizing outside of like an ear ache that they're like screaming in pain, or they're pointing at their mouth, because they're two hertz or whatever it might be a kid that young are not in tune with

Scott Benner 33:35
other bodies supposed to feel

Jennifer Smith, CDE 33:36
and and associating it with Oh, I'm low Mommy, or I have a high blood sugar. And so then moving on through life, because they've had diabetes, from such an early age, when you do start to make those connections. It's very difficult to translate that then into, you know, older age.

Scott Benner 33:56
So I was it's funny, you brought that up, because this was gonna be my next question for you. So I just was interacting with somebody on Instagram, who, you know, found the podcast is bringing their blood sugar down, and they have a beautiful stable 85 blood sugar where they feel dizzy. Yeah, okay, now, so I'm talking to this woman, and she says, I'm going to ignore it. I know, it's not real. Like, I know, I'm not in trouble. So I'm just gonna power through maybe I'll give myself a little bit of carbs to you know, kind of help it a little bit, but I'm gonna power through it. Because I know my body's going to adjust to this. And I spoke to a different person who said that they got to that that nice, stable, good number and they stopped themselves from eating too much. But it still they had trouble doing it. So my question is, when you've spent such a long time with an elevated blood sugar, you know, thinking 180 was a great day, you know, or your 250 for six of the hours of the day and you finally get this all under control. You keep listening to these podcast episodes, and you get to A place where you're 85 and stable. When that first happens, you feel like you're low? What's the function of that, first of all, and tell people that it's going to get better, please?

Jennifer Smith, CDE 35:11
Yeah, I mean, the function of that is because your body is having to adjust the values that it hasn't seen as the norm, you know, an average of one at an average of 200, an average of 250. While it's high, you're you may feel normal at that, because you don't know what a normal value or a target value feels like. So as you start to notch things down, your body has to readjust to that new normal value, and it does take some time. So hovering, you know, now at even 110. For somebody who is averaging 200, they may feel low, that may very well feel low, it doesn't mean it needs treatment, is it's truly not a low value, but it does feel low. And so it's hard. It's hard to work through that. I

Scott Benner 36:10
don't know. But I can imagine. Yeah,

Jennifer Smith, CDE 36:12
yeah, yeah. So I, you know, I think as far as CGM, especially I think that's, that's good technology now that at least they can also see where things are going. I mean, if they're at 110, feeling low, and they're all where, all right, they're consistently still dropping very much, especially, you know, fingerstick wise, they might be lower than that. If they're on a trend, if they're hovering nice and stable, nice horizontal line at 110.

No need to treat that fight through it.

Scott Benner 36:39
How long does it I realized it'll be different for everybody. But what's the average amount of time before stable in range, blood sugar starts feeling normal,

Jennifer Smith, CDE 36:48
usually, at least a couple weeks. I mean, from starting, you know, the end, depending on timeframe of how long things were higher, it may take a couple of weeks for that to feel normal at those lower in target values. And again, stability there, and lacking this big jump up and down and whatnot, that makes a difference for resetting those symptoms in your body.

Scott Benner 37:16
Okay. I have one last question. And then we're gonna move on to something else. Can

Jennifer Smith, CDE 37:20
I show you my line right now? Yeah, Jerry.

Scott Benner 37:22
But look at you. Okay, I'm looking at at a Jenny six, our Dexcom line that looks like it's been right at 100 it might have dipped to was that Where's your low at 60 or 70? Below that? 7070 it hit 70 for a little while, maybe for about an hour, and then it banged up at 85. This is very, pretty good for you. Are we? Are we gonna? Okay, here we go. Let me compare. So Arden has one compression low in the last 12 hours. That isn't real. But other than that, let's see if you can see that.

Jennifer Smith, CDE 37:59
Very nice. Thank you. She's even averaging lower than me right now.

Scott Benner 38:03
And we as a new it's a new pump too. So I think you've got the best day. Yeah.

Jennifer Smith, CDE 38:09
I know those pod change days are like, it's almost like magic. Well, can be almost like magic.

Scott Benner 38:17
I actually got walked through walk somebody through how to pod change without a high. And we'll talk about that when we talk about pumping. But yeah, so here's my last question about insulin. Let's get I'm gonna go back to something scary for a second. But I think it's, well, I know how impactful it was for me. So back when I had to dispense with my fear of insulin, like we talked about at the beginning. How do you do that? Right? Like how do you make a leap like that for me, and it will probably be different for a lot of people. I started thinking more about long term health, I realized that the doctor was telling me to leave Arden's blood sugar high so that she wouldn't get low. We were trading today's health for tomorrow's right, like we won't die today. But we might not live a long healthy life either. And I thought that can't be okay. But I still couldn't make the leap. And finally, I thought about it in as technical and scientific way as my brain would allow. And what I what I came to, to think about was I actually spilled some sugar out on the table, and I looked at how kind of coarse and granular and sharp it was on its edges. And I thought well at its, you know, at its microscopic, like existence, it's probably still course in sharp like this. And our bodies are built to handle a certain amount of it flowing through our blood. But if you pack that blood with too much, that must be and this was me thinking my way through when people say I he died of a heart attack, you know, because of his diabetes or he went blind because of his diabetes or he couldn't feel his foot anymore. What that really means is that the sugar has basically sandblasted you from the inside, damaging right making damage to the inside of your veins and capillaries, all the places where bloods covered, right? If you have a heart attack, and they say it was because of diabetes, it's because the flesh in your heart got rubbed thin. And it

Jennifer Smith, CDE 40:10
burst. And I mean, and beyond that, beyond that are the other the other pieces of those complications, such as heart disease that come about, and most doctors don't teach this. And I think it you know, it may be a time thing it may be that they don't want to get the in depth piece of it. I think we

Scott Benner 40:35
should I think to bring up on day three of your dying day.

Jennifer Smith, CDE 40:38
Right, exactly. I am blasting yourself. I have a good and I wish that I could show this to everybody. But this is a tube full of a glucose solution. Do you see how slowly those little they're supposed to be particles of sugar are flowing through the bloodstream, yeah, sugar or nutrients, right, I like to refer to them as nutrients. Because this is the other piece to overall Long, long health with diabetes is, as you mentioned, glucose I love your rough part of that example, because it is high glucose levels cause your cause your blood to get sick, almost like molasses in winter, okay, which means that all of the nutrients, your bloodstream are also flowing very slowly to all the places in your body that need to get those wonderful, micro macronutrients. So healing and everything gets slowed. If your glucose levels stay as high as the the roughness of that sugar that you're talking about, or the high glucose values, it is it's very damaging to vessels almost creates like rust on a car, it creates damage on the inside of the vessels, your body tries to heal itself, it's a self healing machine, your body actually makes cholesterol. It's like a band aid. So even if you never eat cholesterol, again, your liver is meant to make cholesterol and cholesterol is like it does a lot of other things. But it is also a patch, the more damage, the more patch, you see how narrow my vessel is now getting the more and more patches, those vessels that narrow, that leads to high blood pressure, high blood pressure damages your kidneys, high blood pressure puts a lot of pressure on the vessels in your eyes. So it's a it's a snowball effect, with consistently maintained high blood sugars now have a 200 blood sugar because you decided to eat the whole, you know, Disney Princess cake or whatever. And then you bring that blood sugar down. That's, that's a different story than this consistent maintenance of high glucose. That's different.

Scott Benner 42:54
Yeah, right. I think that when people when I say that ardens A once has been between five and six to four or five years, I think people imagine a steady 85 blood sugar forever, which is not the case. Right? She spikes up just like everyone else, you know, if you're gonna if you're gonna eat with diabetes, and not have, you know, you know, not not have boiled it down to low carb or no carb or something like that, right? You're gonna miss sometimes I miss on boluses. You know, insulin pump sets aren't as effective on day three as they are in day one. There's reasons why right? Yeah. So it really is. It's not a perfection you're looking for it's a it's a fluidity of fluidity, it's a consistency to how you manage that's what keeps your eight, one clo, right, as you were describing cholesterol coming in and making patches on, you know, arteries or veins. And it it thinning, you know, that's what people would commonly think of as needing a stent in their heart, right? Like, eventually, it has to open up that space again. Right. So for me back to what I started to say, I got past the fear by saying to myself, I can't let my fear of something happening to art and today affect her entire life. Right? I just can't do that. And, and if that means she's gonna have something bad happened to her or my life's gonna be a little more hectic managing insulin, then that's got to be what it's got to be. right because the alternative is I put all this effort and heart and love into my daughter and at the end of my life when I'm 65 7080 years old, and I'm looking back at my 40 year old daughter and she's in incredibly poor health. I'm gonna think like, what was this all for? Like, you know what I mean? Like what I spend my whole life doing so I'd rather get in the game now and do the best I can let the chips fall where they may a little bit. Then just to ignore it. I can't I am not across that bridge when it comes to IT person. I find I find when you think about life like that. People have heard me talk about it on the show before you get a bill. The mail you can't afford it. And you know, you can't before you open up the envelope, just open it anyway. Right? Be an adult and go, I owe the electric company $400. Like, right?

Jennifer Smith, CDE 45:09
No, that's not going to be better tomorrow, it's gonna be the same bill. Absolutely.

Scott Benner 45:13
It's the same idea with your blood sugar. Like, don't ignore it. Don't say to yourself, that's okay. I'll deal with it later, because later is going to be worse. Now Sox laters worse. So, get in the game, do it. Now.

Jennifer Smith, CDE 45:27
I've always thought about myself, personally, I've always thought about all the things that I am able to do be, because I choose to manage because I have chosen to understand how to manage. I mean, I, I've done a lot of awesome things. I've had two kids, I, you know, I want to see those kids grow up, I want to be around with them. And that, that is the biggest thing to look out to future wise. And remember every day

Scott Benner 46:01
it is, and that's why you and I are doing this like series inside of a it's a it's a series of podcast episodes inside of a podcast. Right? Right. It's because somebody is going to hear that and think, yeah, that's nice, buddy. But I don't know how to keep my kids blood sugar at 70 and blah, blah. But I'm telling you, we're going to talk about how to do that in a way where you don't have to, when you hear the idea of keeping your blood sugar stable to lower number, it doesn't make you think, well, that's impossible. We're, we're going to talk about the tools that make it possible. And I'll leave this episode with this thought. Three nights ago, a man in his 40s I saw him on Facebook, and he was basically begging people, he was at the end of his rope. And he had had diabetes for a long time. And it was just not going well. And people are all jumping in giving them giving him their best piece of advice. And I always think the same thing. When I see people on social media. I'm like, wow, that's valuable. But how do you make sense of it, you know, then somebody else say something else. And I go, Well, that's not really that valuable at all in this situation. But I say why it's well meaning. And so then the person's frazzled, to the point where they thought to reach out into the world to strangers, right. And now these strangers are throwing 20 ideas at them. None of them are cohesive, even if they're good. And so I just couldn't take it. And I, I stepped in and I said, if you want to message me, I'll see if I can help you with this. And there were very kind people who all jumped on and said, I would mesh it, Scott if I was you. So we got we got on the phone. And 45 minutes later, we got off the phone. And the next morning, he sent me his steady overnight graph. And to that day, he sent me his 30 day graph, and the next day, and the next day. And my point is, I can't talk to all of you on the phone and Jenny can't speak personally. But I think we can give you enough tools to get you to that spot. So so keep going with the with this series. And I think you're gonna be happy that you did. I hope you're enjoying the series, I want to take a moment to thank the sponsors dancing for diabetes, real good foods. And even though they weren't mentioned in this episode decks comment on the pod. There are links in your show notes, and at Juicebox podcast.com to all of the sponsors. But you can always go to dancing the number four diabetes.com real good foods.com use the offer code juicebox dexcom.com, slash juicebox. Or my omnipod.com slash juice box to find out more. And don't forget that Jenny does this for a living. And you can find out more about her services at integrated diabetes calm. This episode with Jenny Smith is of course part of a series if you missed the first two, there was diabetes pro tip newly diagnosed you're starting over and diabetes pro tip all about MDI. This, of course, was diabetes pro tip all about insulin. Now if you enjoy these episodes and found them useful, please go to iTunes and leave a rating and review. Over the next few weeks, you'll get the same interview style episodes that you've come to enjoy. And then towards the end of the month, three more episodes coming your way. All About bolusing basal rates pumping glucose monitoring the next steps in this bigger picture. And when Jenny and I finished with these 10 episodes, it's our goal for them to be a roadmap sort of a blueprint for how to use insulin and manage day to day with type one. I also imagine that there may be times during conversational episodes where you hear an idea brought up and you may be able to come back to these episodes for you know a refresher on the concept. Thank you very much for listening to the Juicebox Podcast. I'll see you next week.

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