#1447 Diabetes Pro Tip: Insulin Resistance
Jenny and Scott break down what insulin resistance and diabetes.
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Key Takeaways
- Understand True Insulin Resistance: True insulin resistance occurs when your cells (liver, muscle, fat) don't respond properly to insulin. However, increased insulin needs due to temporary variables like stress, illness, hormones, or growth spurts are not true resistance, but rather situational needs.
- The Double Diabetes Diagnosis: A "double diagnosis" (Type 1 with features of Type 2/metabolic syndrome) is increasingly recognized. If you have Type 1 but also struggle with obesity, high blood pressure, high triglycerides, or require an excessive amount of insulin per kg of body weight, you may fall into this category.
- Lifestyle is the First Line of Defense: Before adding new medications, ensure your basal and bolus settings are optimized. Consistent exercise (both aerobic and resistance training) and dietary modifications are critical tools for improving insulin sensitivity.
- The Impact of Processed Foods: Highly processed foods contain additives, refined carbs, and unhealthy fats that promote inflammation and oxidative stress, which can directly exacerbate insulin resistance. Focus on whole, unprocessed foods.
- Hydration and Sleep Matter: Poor sleep quality acts as a significant stressor on the body, increasing insulin resistance. Dehydration thickens the blood (like "moving mud"), severely impairing the efficient delivery and action of insulin and nutrients.
Resources Mentioned
- Juicebox Podcast: juiceboxpodcast.com
- Wrong Way Recording: wrongwayrecording.com
- GLP-1 Medications (Ozempic, Mounjaro)
- Metformin
- Inositol
- Omnipod 5
Introduction to Insulin Resistance
Scott BennerHere we are back together again, friends for another episode of The Juicebox Podcast. Today I'm adding to the Pro Tip series. The rest of the series runs from episode 1000 to Episode 1025 it's also available at juiceboxpodcast.com, up top in the menu, look for diabetes Pro Tip. Please don't forget 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 health care plan or becoming bold with insulin. Jenny, we're going to do something that we don't do that often. We are going to add to the Pro Tip series today. Yay. Right? We are gonna talk about insulin resistance.
Jennifer Smith, CDEOh, the fun of insulin resistance. Did you hear all
Scott Bennerthe clicking? Everyone's like, reaching for their phone. They're like, Oh, I don't notice this.
Jennifer Smith, CDETurn this off. Let's fast forward and see if they talk about something. Guys
Scott Bennersay, insulin resistance. Did she pretend to be excited about it? What's happening right now? But we think this is very important and very important to add to the Pro Tip series. So we're just going to jump in with, you know, starting at one, what is insulin resistance in type one and what drives it? Let's talk about that first, make sure we understand awesome.
Jennifer Smith, CDESo I think it's important to again, define kind of insulin resistance as what's happening in the body? Like, why are you using a ton of insulin? That's what I think most people on a very like, just low statement level, I use a lot of insulin. I must have insulin resistance. That's not necessarily true, and I think that begs definition as well. Overall, the definition of insulin resistance is the body is impaired in response by some specific tissues in the body to actually using insulin well, which then decreases glucose uptake or movement of glucose out of your bloodstream into those cells, right? And the main sort of tissue receptors for insulin that become resistant are your liver cells, your skeletal cells, and then your fat cells. You might also see them called adipose tissue, but it's just fat cells, essentially, and it really means that your body just isn't it's not allowing the insulin to open the doors on those cells and allow the glucose to come in so our body doesn't essentially dispose of glucose the right way. I mean, it's the defining piece of type two diabetes. And while we really want to talk about type one, I think that's the piece that is misunderstood, because it's happening in type one and type two in a in the same way, but potentially and potentially for some of the similar reasons, right? But type two, we may eventually get to insulin resistance by not really seeing blood sugar changes, right? Because the body is actually trying to compensate for those cells not using insulin. Well, the beta cells just put out more and put out more and put out more insulin, and eventually they kind of get pooped out, right? So in type one, I think it's important to then define we can have insulin resistance in type one, but there might also be times where insulin needs are very high. And that doesn't mean you have insulin resistance that is long term a problem, right? So to defining those time periods really insulin resistance for time specific could be puberty, your child or teenager may use an excessive amount of insulin because there is a lot of growth and a lot of stuff happening. But unless your child is also obese, has elevated blood pressure issues, has issues with low HDL levels, kind of the metabolic pieces that we're looking for that coincide with insulin resistance or metabolic syndrome, right? You may just need more insulin steroid use. You need a lot of insulin for using steroids and some other medications or other medical treatments. You may have excessive use of insulin, but there's the resistance in the picture, then, because of something that will not be long term, okay? Does that make sense? And you type, you know, pregnancy with diabetes as well, gestational diabetes, those are all instances of insulin resistance that they can be managed. And once those hormonal shifts are out of the picture, the resistance typically isn't as excessive or and, or just goes away, right? It
Scott Bennercould be language with type ones too, because, like you said, insulin resistance is a very specific thing, but you could be at times resistant to insulin. That's the feeling right, like it doesn't matter how much insulin I give myself, it's not moving. I'm resistant to the insulin. I'm insulin resistance. And then those two things just get blended right together, correct? That's just Yeah. And now it all means the same thing, but it doesn't mean the same thing. Does not again, weight gain, sedentary lifestyle, hormonal changes, medications, illness or stress, lack of sleep. These are all reasons why you might find yourself requiring more insulin than you normally do, right? Doesn't necessarily mean well, the weight gain does, though, right now weight gain is that would be insulin resistance.
Jennifer Smith, CDEIt would be especially if it's weight gain that goes well outside of a growth parameter, or expected growth, right? Kids, teenagers, we expect them to grow, and usually growth happens in weight and then height, and then weight and then height, right? It doesn't typically all happen at the same time, give or take the kid, right? But we wouldn't expect a child to grow really, really slow or not much in height, but continue to pack on the pounds. That's not what we would want to be happening. That's not normal growth. And so then if other parameters are in the picture, especially, you know, more sedentary lifestyle. I there is, you know, one of the potential risk factors when we talk about type one with insulin resistance is a family history of type two. So there's the potential, then, that the body is more from a genetic predisposition to have the potential for problems with weight management and whatever. And again, there are people that would beg to differ with that, but there's enough research out there. I've
Double Diabetes and GLP-1s
Scott Bennerhad a doctor on from Joslin. He's also on staff at Harvard, and he said that, you know, the term double diabetes is just, you know, going to take on more and more prevalence, maybe in the zeitgeist coming up, probably because of how GLPs are working. For some people with type one, which then, you know, you ever see somebody with type one, go, I tried a GLP. It didn't do anything for me. And I thought, oh, yeah, you don't have any insulin resistance, you know what I mean?
Jennifer Smith, CDEAnd or the other factors that the GLP-1s, I mean, they're, they've been used for a long time. The newer versions now are definitely like the steroid version of what we had years ago that really didnt do what the new ones are doing.
Scott BennerGLPs on steroids, right? I mean that inflammation, weight loss, it tamps down hormonal issues for some people, also just constantly high blood glucose, just chronic hyperglycemia, can increase your insulin sensitivity.
Jennifer Smith, CDEit can actually, yeah, it can increase high blood sugars. Can increase your insulin needs, not your sensitivity, but yeah, exactly, it can
Scott Bennergive you increased insulin resistance, is what I meant,
Jennifer Smith, CDEright? Absolutely. And what, what does that boil down to? It boils down to an inflammatory, you know, nature. I mean, we've talked before when we've talked about the different things that high blood sugars do in the body, right? And it is. It's kind of like, I think you've said, like a sand blaster to the outside of a painted building, right? The more sugar you have circulating, the more damage it creates inside your vessels and your tissues, thus all of the complications that we know about and have been told about, but if we leave that high, it's just chronic inflammation, and that's really hard for the body to get over. I think it's interesting that the doctor you talked to actually commented on what we kind of call now we're really aiming for the ability to have a dual diagnosis. And there is now in the ADA's, I think I brought this up before too, like an ADA standard changeover, the 2025 standards of care in diabetes does have a specific kind of statement within their document that notes that although type one is the diagnosis, some people with type one may have features that are associated with type two, things like insulin resistance, the obesity factor, metabolic abnormalities, inclusive of things like PCOS and all of those, and in terms of managing their life the best that we can, we're going to need to create a category for those people who have features of both type one and type two, almost a new diagnostic code or a new not just type one or type two or LADA or Type 3c, or, You know, any of those things, but it translates then into the ability to access medications that can be an advantage. And as of yet, we still don't have any. We don't really have anything that's type one outside of insulin. And maybe, you know,
Scott Bennermy daughter's endocrinologist gave her a double diagnosis, and it was accepted by our insurance the first time. She didn't have to argue about it.
Jennifer Smith, CDEAnd there are some specific parameters, like, if you're looking at that dual diagnosis, because you've gone through it with your doctor, it's not just your, you know, Google searching, or whatever it's you've gone through it with your doctor, and you've got at least, I think it, think it requires at least three specific areas to be check off points of determining insulin resistance. It it's based on how many units of insulin per kilogram of body weight you're using in a total daily amount of insulin. If it's over that amount, check box, right? Obesity is another indicator, right? So if you're looking at BMI from that indication, the threshold for the GLP-1s is at least a BMI of 27 and above, right? So if you've got those factors, blood pressure that's elevated more than 130 over 80, I think it's a HDL that's low, especially for for men and for women, you've got high triglycerides higher than 150 all of these are their check offs to proving that there's a metabolic condition or a metabolic piece despite the initial diagnosis of type one, that dual diagnosis can be really beneficial.
Scott BennerI know for sure, after talking to Dr. Hamdy, I'm gonna have to be digging more into what a cytokine is, because. Because he kept bringing it up a lot. He also talked about a oral GLP medication that's in the pipeline that will not only help you with weight loss, but minimize muscle loss. So very he was very excited about that, I will say, he seemed very sure that injectable GLPs are a flash in the pan, and that the oral ones will be the way it happens much sooner than you expect. So I have my fingers crossed for that. I wonder,
Jennifer Smith, CDEdid he comment anything about the reasoning? I know a lot of people have asked for a long time about, why can't we just take an insulin pill? Right? And it has relevance to what the digestive system does to that it just breaks it down, and it digests it, and you really get nothing out of it. Then, right? So either it's an injectable or it's an inhalable and then the body doesn't break it down too quickly, and you get nothing out of it, right? He
Scott Bennerdidn't mention how it's getting accomplished at this point, but if people are interested, it's episode 1411 it's called GLP essentials, with Dr. Hamdy is very thoughtful on the subject. I'll have to listen to that too. Yeah, very involved for a long time. Hey, I just want to say that if you have type one and you're not experiencing what seems like actual insulin resistance, some reasons might be genetics. You may have, like Jenny said, not be in one of those hormonal impact signs. You could be younger because, for reasons, you know, younger people don't experience it always as as frequently as older people, and you might just be more active, like, you know, we talk about that all the time the Pro Tip series and other places. Why do people struggle with AID systems? Sometimes, because I'm super active on the weekend, but not during the week or vice versa. And you're like, oh, this thing can't keep up with me. But the truth is, is that your lifestyle is greatly impacting your insulin needs, correct? Yeah. So that's another way to think about it,
Jennifer Smith, CDEand therein lies a you then don't really, you're not really classifying that as insulin resistance. That's a lifestyle impact or unlike chronic inflammation, which can also come from other health conditions, they could be impacting your body's ability to use insulin the right way or efficiently. And so then inflammation is more of a long duration, and you are likely to then have true insulin resistance, whereas high blood sugar is from a really stressful job. I have so many you know now working with a lot of women who are kind of moving past menopause, moving into sort of retirement stages, right? What we see is really high stress, high energy jobs. They retire, and come January, they're like, I don't know, I'm low all the time, like, well, let's take a look.
Stress, Algorithms, and the Liver
Scott BennerI would curse right now and tell you that Arden's been off of school for a number of weeks. Might be six, eight weeks, she takes a GLP medication that helps with her insulin. You know, resistance, because she probably has PCOS. And you know, her settings are much lower right now than they were back in college. And today, she went back for just a day, like, to go back for a day to do this thing. And since she woke up, and now three hours later, her blood sugar is 175 like the algorithm, can't it. Can't get her down, like, because now our settings are for Arden at home, not stressed out. Arden, not Arden's at school, thinking about all the things she has to do art. And knowing
Jennifer Smith, CDEthe algorithm you're using, I know that it takes a little bit of adapting to actually, yeah, nudge it back, yeah.
Scott BennerIt'll keep up a little bit eventually. But the truth is, is that the person she was on her graph yesterday and for eight weeks prior to that is not the person she is today. So, and I'm telling you, that's exactly what it's from anxiety life, you know, foot on the floor, that doesn't go away. Basically,
Jennifer Smith, CDEkind of going back to the doctor's comments about the cytokines you're like, I have to look that up. There's a lot of really good cellular investigation as to insulin resistance and what's not happening right in the body, and what are some of the lifestyle things that we can get to beyond adding extra medications that could, you know, again, help. So I don't
Scott Bennerwant to get into it now, because we'll get off track. But he had an interesting take that I'll share with you privately, and people can go check on it, the livers role in insulin resistance. So how could the liver be impacting people? Yeah, I mean,
Jennifer Smith, CDEyou know, your liver is a really interesting organ, right? What the liver does a lot of things. It's a detoxifier. It helps with management, not only of blood sugar, but a lot of other systems in the body. And so if your body isn't using insulin the right way, there's a disconnect to the liver. For you know, ease of explanation, there's a disconnect to the liver, then about what it's supposed to do for. You and it gets off balance. That's the best way to really, you know, simplify it overall.
Scott BennerSo I have a little bit of language here. I want to know how you feel about this. Under normal circumstances, insulin suppresses the liver release of glucose. When there's insulin resistance, the liver doesn't always receive the stop message, effectively Correct. That's what I said. It gets what you said, Okay? Because I was like, Oh God, I'm not sure if I'm understanding, nope. So I just wanted to make sure. Okay, awesome. Moving on. Because these are also, I should point out, these are questions that were sent in by listeners specifically about insulin resistance. Oh,
Jennifer Smith, CDEawesome. Well, they were very well thought questions, honestly, very well worded and well put together. If you really wanted to get into the science of the liver and all the things we could use big, fancy words, you know that talk all about glucose uptake and fatty acid oxidation and like all of these. But right? People are gonna be like, I don't know what that word means. Like, what does that have? I don't understand. Just tell me why my liver isn't doing the right thing,
Scott Bennerdoing the right thing. How does insulin resistance impact long term diabetes management beyond just needing more insulin? Are there complications that are associated with it? That was the question that we got from a person. What do you think? I think
Jennifer Smith, CDEthe deeper question is, with insulin resistance, it creates a problem with overall glucose management, that's the bottom line. And so really the question there is, if I don't get on top of the resistance, meaning really, I'm not managing my blood sugars because I'm not able to get my insulin to work, well, down the road, you have all of those long term complications that we're really trying to prevent, right? And the biggest ones really being heart conditions and those micro vascular things like in your eyes and the nerve cells and all of those things are relative to the bottom line being your blood sugar management. But if you're doing the best that you can, and you're using a lot of insulin, it's not quite controlling everything yet, then the real issues with resistance are the downline of what does that mean with blood sugar?
Scott BennerIt's funny, as I thought about this one, what popped into my head was a well maintained classic car. It's gonna sound strange for a second. But I have a friend who drove a Camaro, you know, built in the 60s. Not just beautiful car, but like original three speed transmission, 326 motor. It was convertible, had the headlights that uncovered and like the covers, came off and slid into the car, all run by air. And 40 50, years later, the car looked brand new and worked brand new, and it made me think about people who say, I'm fine. Like, look at me. I have type one diabetes. But, like, I know you're saying my A1C should be this, or my variability should be more like this, or maybe I should eat like this or that, but I'm okay. And to them, I would say that in 1965 that car looked brand new, and the reason it still looks brand new is because of the meticulous way he took care of all the little parts and features of it that you don't recognize are even happening day to day. Like, yeah, I know this is an old timey idea, but there's a big piece of plastic that like, flipped out and slid into the car, all off of air pressure that still worked. 50 years later, you have little functions inside of your body like that, and they're just really important to keep up. And so if you're wondering why, sometimes you buy a car, and 15 years later, it's garbage and you basically throw it away, it's because you ignored some of the little things that day to day seemed like they were okay, but could have used a little tender, loving care. So
Jennifer Smith, CDEyou made me think of my dad. He and honestly, I It's like you were talking about him truly, because he had a 68 Camaro.
Scott BennerOh, no kidding, dad.
Jennifer Smith, CDEI should say it's actually my brothers now. I mean, my dad's been passed away for a number of years already, but he willed it to my brother, so my brother now is the one who maintains it. And you're right. I mean, my dad, if anything I learned from him beyond just exercise, it was you take meticulous care of the things that you really want to last. That was his bottom line. I mean, he waxed our bicycles. Scott, so it sounds like the same guy you're talking about, like all the care that you give, but you have to think about yourself. It's like the advice that's often given to parents. If you have a child you're taking care of you have to take care of yourself too, or you're not going to be there to take care of those who need you, right?
Scott BennerMy friend eventually sold his car. Oh, that he bought from the first owner, which was an old lady who literally, just like the story goes, like, put it in the paper. And he got there, and she's like, I can't handle this thing anymore. And he bought it for $2,000 and sold it many decades later for $60,000 and I think if you want to still be valuable many decades from now, you gotta polish the chrome a little bit. You know what I mean. And that's not a euphemism. Yeah. But no, not
Jennifer Smith, CDEat all. If you want yourselves to be as healthy and lovely and at 90, you want to grocery shop and carry your bags in the house and all of the things there's maintenance to your body, you have to do, right?
Scott BennerYeah. I mean, it's the difference between whether you go to the junkyard at the end or you gracefully, you know, drift off. Here's another question for people, many type one struggle with unexplained high blood sugars despite pre bolusing and adjusting insulin. How can someone tell if this is insulin resistance playing a role? I think this gets into management. I think this is more about settings, right?
Jennifer Smith, CDEI do and because I think the question just begs more discussion, really, it does, because it's not defining all the time. I sit high. No matter how much insulin I dump in, I sit high. It's specifically around meals and going high. And so with the idea that this person feels like their Pre Bolus has been worked on, and that that's potentially not the issue, then maybe there are there some some other components within the meal time and or maybe the ratio has changed, right? Maybe they've grown. Maybe they've gone through a life change of some kind, and so maybe the ratio has changed, but they haven't changed that. They've just been playing with the Pre Bolus.
Scott BennerI tell people all the time, because people all the time say, I don't know what's going on. My Pre Bolus time is 30 minutes. I have to Pre Bolus an hour before I eat. I'm like, well, that's not a Pre Bolus issue. Like, that's something else. So I always tell them to go back to the beginning make sure the basal is okay. Yep. You know, has anything huge changed in your life about your activity? You know, the things you're eating, right? That kind of stuff, you're sleeping, etc, essentially,
Jennifer Smith, CDEthe variables, that's what you're you know, I mean, looking at at those variables. Maybe the person was used to walking their dog three miles in the morning before they actually got to breakfast, and that was a benefit, and now all of a sudden, they're not doing that. Or you know what I mean? So absolutely. So
Dietary Approaches to Insulin Resistance
Scott BennerI'm going to read now five questions in a row that are all part of a bigger conversation. Okay, there seems to be two schools of thought, one focusing on low fat, high carb diets, like the mastering diabetes diet, and another one, low carb approach. What does the research say about the best dietary approaches to improve insulin sensitivity in type ones? The next question is, are there specific foods or micronutrient ratios that have been shown to improve insulin sensitivity. The next one is for someone who's insulin resistant. Should they be focusing on cutting carbs, reducing fats, or prioritizing protein? And there are mixed opinions on intermittent fasting. Can fasting improve insulin sensitivity type one diabetes, or does it pose a risk? I'm going to throw in this one as well. Some people say that processed foods contribute to insulin resistance, what specifically in processed foods makes them problematic for blood sugar control. So we'll go through them one at a time, but I think they're all part of this conversation. They are,
Jennifer Smith, CDEand I think we'll, we'll kind of mush them together, even though trying to kind of go through them separately, it's probably going to answer
Scott Bennera lap, yeah, they're gonna go for a lap, yeah, yeah. The first one is the tough one, because, you know, people who are very strictly low carb, that have a lot of success with it are just going to tell you, you know, love, like, what do they say? Low numbers, right? You know, little bit of
Jennifer Smith, CDEcarb, the rule of the rule of small numbers, right? A little bit of carb, a tiny amount of insulin, you've got an easier, kind of a little easier control mechanism, because there's not as much overage there from an insulin, but you also don't have a heavy hitting macro nutrient being carbohydrate that you're really trying to step on top of and keep managed. Right? The big thing behind this main question of the two schools of thought from a dietary standpoint, or like my background, it really boils down to looking at what each of these fueling plans provides. Has science that does suggest it can work. They both do the vegan, low fat diet, plant based absolutely has research that suggests you can reduce insulin resistance, you can bring your medications down, you can help to control the heart issues, even things like PCOS end up being better managed and navigated. Weight loss is something that happens in the picture. Those are 100% the same thing that the low carb approach also is able to prove that they can achieve, you know. But the bottom line is, you decide on it, and you don't falter from the plan. That is it in a bottom line picture. If you're going to do something like all plant based, low fat, then do it. Figure out. But you have to stick with it. It doesn't mean every week you will go out for your 16 ounce steak, because you can't 100% give that up. This is a plan, right? You choose it, you follow it, and 100% Your metabolic things, they clear up. They do the cholesterol levels, the blood pressure issues, again, even the metabolic things, the way that your body cells use food, they are changed. Yeah,
Scott BennerI think it's, it's such an important thing to say, because I think that's probably where people go wrong. They're like, they dive in, like, you know, I'll eat super low carb. But then on Saturday, you have a slice of pizza with a bag of Cheetos, and forget, right? Two steps forward, one step back. It was probably two steps forward, 10 steps back, right? It's about whether or not you can really commit to it. You think I
Jennifer Smith, CDEreally do? Because there is when I look at the data, and people ask me the questions all the time, well, should I should I go this way? Should I go that way? I have to say. But what? What do you know about both of those plans? They're almost like opposite ends of the spectrum. Yeah, which one are you most likely to be able to stick with long term? Because if you can, here are the 10 different research articles I can give you. They're not even based in, like, the big ones that a lot of people have problems, like believing in, right? These are really good, defined references that suggest it can work. And we've got communities that are centered on both of them with discussion about why they work, and all the people that that they definitely help. Right?
Scott BennerIs there any scenario where following any of these ideas strictly won't work for somebody? Is there somebody who's just genetically it doesn't work for is that not a thing? Because it's part of the little questions? Question, yeah, like, I mean, is there someone out there just eating low carb exactly the right way? And they're like, how come this isn't working for me or vice because I've heard it for the more the vegetable, like fat one. I've heard people say I've done it specifically well, and it hasn't worked for me, but I'm watching other people do it, and there's got to be something there that's, I'm
Jennifer Smith, CDEsure that there is. And so that also suggests that maybe either you're not following it to a T so really, get the reference materials. Get the books. I mean, there's, there are books on, you know, the mastering diabetes and also on the low carb end of every their books that definitely give you very well defined this is your plan of action. Yeah, you haven't quite done and you've really only been following with some online person who tells you what they're doing. Maybe there's a little piece in there that's not quite what your body is working with. The best way
Scott Bennerthat takes me to the micronutrient idea. Like, how would an average person who's like, I'm going to make sure I'm giving my body exactly what my body needs? Like, how do they figure that out and put that into play? Yeah? I mean,
Jennifer Smith, CDEit also goes into lifestyle, right? If you are somebody who has a really excessive amount of movement in your life compared to somebody who is more sedentary, we would look at what is your overall need to be able to break down macronutrients. And then the lovely thing about the macronutrients is that if you are getting a fair variety of foods, you're going to take in all the micronutrients that you need, both the fat soluble and the water soluble vitamins, the antioxidants, all those things that help on a cellular level, change things like inflammation. It's not as simple as people often think, cleaning up the diet, yeah, just
Scott Bennerpouring in the right stuff, yeah. I mean,
Jennifer Smith, CDEit really does behoove people to sit down with somebody knowledgeable, and I'm not going to say that, you know, find the right person right away. It might take, just like looking for the right endocrinologist. It might take a little bit of navigating through some people to find somebody who kind of fits with you and that you can work really well with, but they should be evaluating your life, what type of stressors you have, what kind of energy level or exercise plan do you have, and then building into that well to meet your need as well as address this insulin resistance and overall help with insulin sensitivity. Let's play with adding this, taking this away, cutting back here, adding this in. You know, somebody who is an endurance athlete is going to have a different macronutrient need profile than somebody who is in the lifting gym three hours every single day and they're bench pressing. I don't know a large amount of weight that I can't even probably live. Does that make sense, though it
Scott Bennerdoes. I want to go to intermittent fasting and then go back to processed foods. So the intermittent fasting, what I have here says that, you know, for some people, it might improve insulin sensitivity, but then it warns against hypoglycemia. But what I would say is, from my own personal experience with Arden, is Arden can fast almost for freaking ever, but she's also on an algorithm that's taking away your insulin at times. So if you're using, like, jacked up, heavy settings, and then all of a sudden, like, I'm gonna start intermittent fasting. I mean, you're probably gonna get low. But if your settings are there, and your system can bob and weave with the fact that there's nothing in there, I've seen art at night eat for 18 24, hours. To not get low, like, as a matter of fact, like, I would tell you, if you can get all that straight, and you're a person who's like, oh, I can't exercise without getting low. Wake up in the morning, don't eat with great settings and single move workout in the morning. Yeah, so
Jennifer Smith, CDEno, it's a, I think it's a quality question. Whoever asked about intermittent fasting, the risks, as you just said, can be minimized, especially with the type of technology that we have today. At it at our disposal, right? Not everybody, but a lot of, a lot of people have access to at least a CGM, great, right? If you have access to an AID pump system, fantastic. That moves you up the mark to avoid risks if you're trying to do some fasting, but even those who do multiple daily injections, you can strategize your insulin and your dosing in order to be able to do intermittent fasting. And there are, you know, by definition, there are a lot of different kind of ways you can intermittently fast. Some people do fasting two days in a row, then they eat for two days and they fast for two days, right? Then there are people who do what's more common, and I think in terms of navigating the real metabolic reason, which I would encourage people to really look up, because it's quite fascinating the cellular level and the reasoning behind intermittent fasting and how it really benefits insulin sensitivity and weight management and everything. Is the idea of time periods of the day where you will designate, this is my eating time, yeah, and then time periods of the day where you will be done eating, let's say by 7pm and then you don't eat again until 10am the next day, right? Or noon the next day, and there are a lot, especially from a women's health perspective, there are a lot of good referenced research in what that does from a hormonal level in women's health. Not enough of it. I think that goes into real type one diabetes. But if you can read into the research, you can understand how it could impact your diabetes management, because most women complain about the fluctuations around their monthly cycle or moving into perimenopause or even menopause, right? And if we can harness that energy burning piece of our cells in the right way, and also clean up our intake with the food that we are eating. It makes an enormous difference on our overall ability to use insulin the way that we're supposed to. I'm going
Scott Bennerto jump to this last piece here, processed foods. You know, can processed foods really blah, blah, blah, like, I think, I think in the information age, we're very used to people saying things, and we just accept them, right? We don't really dig deeper into them. And so some people can also hear that in just this recording, like, oh, processed foods are bad for you. Like, ah, I've been eating it all my life. I'm fine. Like, it's great. Yeah, you're because your car is not 50 years old. Yeah, your body's still able to make it through a ho ho without you dying. But one day, you'll put the wrong gas in and it's just gonna shut off. But I'm gonna keep a lot of this for the nutrition series that you and I are gonna do, because I think we should do an entire episode on why exactly processed foods are doing what they're doing to you.
Jennifer Smith, CDEYes, it's on my list, and I have not organized for us yet, sorry. Give
Scott Bennerme a high level overview of processed foods and how they can, you know, make insulin resistance their car make it worse.
Jennifer Smith, CDEYeah, and actually, it ties into that first question in this little kind of segment that we're talking about is the focusing on either the really low fat high carb intake or the more low carb or ketogenic type of plan. One thing that's missing from both of those plans, for the most part, if you're doing the plans the right way, you are eating food that looks like food, what has that done then, behind the scenes, whether you're low carb, high carb, whatever you've cleaned out. I mean, the question here, what specifically in processed foods makes them problematic. Have you ever read the back of most of the packaged things that you buy? I mean, outside of maybe you bribe brown rice. It's brown rice, right? There's nothing problematic in that unless you're low carb, then you won't eat it. When you look at the back of many packaged items, they are full of things that I guarantee you can't pronounce, nor do you know where they came from. Why are they in there? Outside of things that have parentheses after them, since this anti caking agent or you're like, great, but why does it have to be in my food? Then, yes,
Scott Bennerit went your mouth and came out your butt. But it does. You don't know what it was doing. What was in there. Maybe you could swallow stuck. You could swallow a nickel and it can come back out again. It doesn't mean you want it there. I'm just high level, rapid breakdown of refined carbohydrates, added sugars and metabolic overload, inflammation, oxidative stress, unhealthy fats interfering with insulin signaling, nutrient deficiencies and lack of fiber, chronic overeating and weight gain. Because of calorie density and hormonal dysregulation, on and on and on. Like, yes, processed foods are bad for you, but we'll dig in later about why. And yes, they can listen, if you just ate food that you, like, Jenny just said, like, you lift it up and go, this is broccoli. I see chicken like, you know, and yeah, then eat it right. Don't take the chicken and dump some sauce on it that you bought from somewhere and go look. It's orange chicken now. Now it's chicken with nickels all over it. Think of it that way.
Jennifer Smith, CDEIt's a good brain, like you're eating
Scott Benneraluminum foil or whatever. Like, maybe it'll make it out. Maybe it won't. Right? Can we jump to how are you on time? You good? I have about five minutes. Okay, let's go to medication, supplements, options. What can people take? Type one to help with insulin resistance, if they've changed their diet, if they change their exercise, and it's just not working,
Medications, Supplements, and Hydration
Jennifer Smith, CDEsure? I mean, there are prescription meds, and again, early on, I talked about how you can potentially get that dual diagnosis to improve the ability to get these covered with really good, well written letters from your doctor, things like the GLP-1s. GLP-1, GIPs, things even like old school Metformin is another potential one that you do not need a prescription for, and I can definitely say is visibly beneficial, not to the impact of things like a GLP-1, but definitely beneficial in the here and now, because it gets used up pretty quick, is the inositol that is definitely one that is beneficial. It helps attack kind of around that meal, but not necessarily long term, okay, right? Thank
Scott Benneryou for doing this with me. That's a great topic. Now it's awesome. I'm going to send all the information over to you, and we'll you know, so we have everything for next time. But before we go, how does hydration impact insulin sensitivity?
Jennifer Smith, CDEThat's a really simple one, right? Because if you are not well hydrated, all the things that are circulating in your system that are supposed to get to the cells to allow them to work the right way, one of them being hydration. If you are dehydrated, it's like moving mud or molasses through your system instead of like water out of a faucet, right? It's supposed to fluidly flow at your cells are supposed to have access float around in your body, kind of like, you know, really low leveling biology explanation. But hydration is huge, and hydration, along with which, I think often gets missed, people say, okay, they told me to drink more water. I'm drinking more water. I'm drinking like, two gallons of water a day, great, but now you're probably flushing out a lot of good electrolytes. So there is a fine balance, I say, you know, easy, simple electrolytes on a day to day basis with your water intake, are also very valuable from a balance of things in your body, you know, and the eight cups a day, give or take the person, it's probably more. If you're an athlete, it's probably more. If you're sitting in sauna for three hours a day, right? Based on size person athletics, you can kind of go up and down from there, but if you're going to try a baseline, great, stick with the eight.
Scott BennerAnd what about anybody who's going to say, I'm incredibly well hydrated. I had two liters of Diet Coke today, same thing as two liters. No, okay, not at all. No, not, not at all. There is drink juice boxes all day. No, no,
Jennifer Smith, CDEnot. Hydration. Okay, are you sure? Let's look at let's look at water. Water is hydrating. There's nothing wrong with it. Just
Scott Bennerdrink some water. Okay, what if I take water and I put something in it back in the day when I was a kid, but Crystal Light, I don't even that exists anymore. Now I put Crystal Light in it. Am I still drinking water? Or am I am I negating the benefits you're still
Jennifer Smith, CDEdefinitely drinking water? Again, that goes back to processed foods, and what is in the thing that you're adding to your water to make it taste like you want to be able to actually drink the two gallons of water a day,
Scott BennerCrystal Light Water with three nickels, yes, at least you're getting water. Hopefully they won't grab onto an artery on their way through, or whatever. I know arteries are not in your digestive system. I'm just saying no. Okay. What are your thoughts on supplements like inositol, Metformin or a GLP like ozempic or Mounjaro for addressing insulin resistance in type ones. That's a question right from a listener.
Jennifer Smith, CDENo, I think it's great. I also think it needs to be differentiated, right? Because a supplement is something that isn't technically regulated, at least not most of the time, versus a medication that has approval, is on the market, is available through prescription. Like, you can't get it otherwise, right? So when you talk about things like Metformin or the GLP-1s, GLP-1, GIP, the Metformin is a little bit different, but all of those are prescription you talk about inositol or some of the other ones. Like, I mean, there are a whole list. Of things that help, from the standpoint of even optimizing your own GLP-1 system output, right? Your gut output which isn't working, which is why the GLP-1 meds do work in people with diabetes. So there are a whole host of those. I once
Scott Bennergot listeners to send me all the supplements that they take. And I thought just like, tell every like, let them just tell me everything that they take, and I'll weed through it. Maybe I'll find some like thing, and I can't figure out a way to be certain about any of it. And so like, you know, it's hard to just jump on here and start saying, like, you should try this or that, or this lady said this helped her. And part of me wants to put it out there so people can decide for themselves. And part of me is like, God, stuff could be expensive and maybe not do anything. And, you know, and many
Jennifer Smith, CDEof them are, many of the supplements are, but you also with anything, I think, even with the prescription meds, you should be doing a little bit of your own research. Yeah, you should be doing information searching, because many of the supplements do have good research backing to them, but the information is important to look at, what was the population that was tested most often for some of the supplements we're looking at tests being done mostly in type two diabetes. Does that mean it's not relevant to type one? Not at all, but they're really only doing most of this stuff in type two, and then what's the concentration that's being used? What's the healthy concentration to use that you can get on the market? You already said, what's the cost of using that? What impact should I see? And a lot of people, I think, with supplements, to go down that kind of road, first is you end up getting a list of six things. And you think, Well, great. All of these are supposed to be wonderful for my weight and for my blood sugar and for my my gut health. I'm just going to throw them all together and see what works. Well, if it does, fantastic. But some of them may not be doing much at all, purple, right?
Scott BennerFive at once, if they all so then I think the problem becomes then, because I've gone through this myself or with people in my family, you say to somebody like, look, we're just going to take one of these a day for three months and like, and people are just like, What are you kidding me? And if you don't see a pretty instantaneous like, change or value, it's hard to remember to even do it. It's hard to Shell out the money. And then people tell you what's got to be a quality, you know. And then you look and quality means $40 for a jug of them, and you're like, oh, you know. And so I don't know how to talk about, I wish there was, like, an easier way now what I can tell you about, what I've learned about GLPs Over the last couple of years, taking them for myself, using them for my daughter with type one. Listen, I'm not obviously a doctor or researcher anything like that, but I know a few things to be true after the last couple of years, if you're using a GLP medication, as Dr Hamdy said in Episode 1411 and you are not doing muscle training and taking in enough protein, he says you should not even be using them. It's just too dangerous to lose muscle, especially as you get older, and it's just something you don't get back. So you have to maintain and build muscle while you're using a GLP. It's very important. The other thing I've learned is some type ones are like, Oh my god, I jumped on a GLP and it changed my life. Like, I use significantly less insulin. I like, you know, my spikes are lower. Like, oh, all these good things are coming. Then another type one will say, I tried it, and honestly, I tolerated it well, but nothing happened to my insulin needs. And I guess I've come to believe that some people can have, you know, what I've heard called, like, double diabetes, like they have type one diabetes, but they also have insulin resistance. Correct the dual diagnosis, yeah, without type one, they'd still have insulin resistance. And I don't know if I'm right about that or not, but just watching people, it's the only like explanation I can come up with why some type ones would take it and have such a reduction in someone, and some type ones don't have any So, right? Yeah. I
Jennifer Smith, CDEmean, this actually gets into, I think, another, another question somebody had asked within the same line of questions, it's about like lab values and testing for insulin resistance. So again, if you're looking at supplementation or pharmaceutical type of prescription, it would behoove you to know is what I'm seeing growth in my teenager and they just need more insulin? Or is this truly insulin resistance? Because there are some markers that you could look at that could move you to a diagnosis and again, now with ADA standards, suggesting that people with type one could have these other pieces that are more type two, and so you could have a dual diagnosis, making it quote, unquote easier to potentially get the prescription option
Scott Bennerright, right. I'll mention too in that episode that Dr. Hamdy, who is, I think, on the the arrows tip on this stuff, says that he thinks double diagnoses will be actually common. And acceptable very soon. So I it sounds like behind the scenes, the people who push for this stuff are pushing for that.
Jennifer Smith, CDEAnd it sounds correct, given all of the information that we have and some of the newer, like real research that we are looking at coming from use in type one specifically. And hopefully that's a turnaround for prescribing and not having to sit to get six letters of approval from your doctor stating this, this and this are the issues. Why won't you approve this? But
Scott Bennerif you saw a type one like you see type ones who use GLPs, right?
Jennifer Smith, CDE100% yes, not 100% of them. But yes,
When Everything Fights Each Other
Scott Bennerabsolutely so. If people are interested in learning more, they should talk to doctors. And if you can't, I'll tell you this, if you can find a doctor great that understands it, but if you find one that doesn't seem to understand it at all, like look around a little more, because they're just going to throw their hands up and go, I don't think you should do that, which I think is code for, I don't know what I'm talking about, and I don't want to get involved. So right, yeah. Speaking, yeah. Many people say that losing weight improves insulin resistance. Is this true even in a person with type one diabetes is not overweight, even if the person is not overweight. So if we have a person with type one who doesn't I don't know score as overweight, could losing some weight help their insulin resistance? It could. I want to say that I think there are a number of things happening. I'm going to go back to GLPs for a second, even though we're not talking about them when they first came out. And I had a bunch of conversations with a bunch of different doctors, they would all just harp on the idea that people are using less insulin because they've lost body weight. And they would just keep saying that, keep saying that. And I mean, after having enough conversations, even like with Arden who did not have like, you would never have looked at Arden and thought like, Oh, that girl should lose weight, but she did lose weight, and that's part of why her insulin needs went down. I believe they just are
Jennifer Smith, CDEbesides the true effect outside of weight loss, the true effect of GLP-1s is it goes beyond just loss, and that's the reason that somebody who doesn't have a weight based issue but has high insulin needs, if something else hasn't been identified, such as a normal weight person, lifestyle doesn't suggest that they should be using as much insulin as they actually are. It's very difficult for them to control their blood sugars in the after meal time period, then we're looking for things like PCOS. Is there an undiagnosed thyroid disorder in the picture? Right? I mean, there are, there are pieces that I see over and over. They stand out to me. As soon as I talk to somebody, I'm like, have you had this checked? Did somebody ask you about this? Did you get No, nobody's what is that? Nobody's ever mentioned that. I'm like, let's get these checked first. So
Scott Bennerif you lost a lot of body fat and your insulin resistance didn't change, then look for other impactors. But in a lot of cases, losing that body fat should change your insulin resistance. It should. What about other body composition ideas like, what about adding muscle? Would that help? It should. Is that because you added muscle, or because adding muscle reduced fat? Well,
Jennifer Smith, CDEyou can add muscle and still retain fat, right? I mean, fat is stored energy, right? I mean, we have a lot of stored energy in our body.
Scott BennerSo if I'm like one of those guys that, like lifts tires and throws them over walls, like, for example, I was just that size, but not that strong, had insulin resistance, and added that muscle, I could see a reduced impact.
Jennifer Smith, CDEYou could see exactly because, again, muscle is it's harder for your body to keep healthy to maintain. So the more muscle you have on your body, the more revved up your metabolism is. And that's kind of the like the baseline explanation to that, right? But that's essentially what happens. And we know that when we move our body, even people with insulin resistance, can say, I can take a walk, and I can see the impact of that. I can move my body, and I can see that my insulin does start to work better, probably not as good as if they were a lower weight, brought their, you know, brought their body weight down, or somebody of the same height, but a leaner body type with more muscle on it, but they're still going to see impact. So if you now lose weight, add muscle, and you maintain a movement, you're definitely going to see an improved a lower amount of insulin that you need. So
Scott BennerI'm looking at all of the questions that led us to this bigger idea, and I moved to say there's a person here asking, How much does walking after a meal impact insulin sensitivity? He's had this long conversation privately with somebody I've known for a long time who has type one, and he's in his 20s, and has recently put on a bunch of muscles, started doing like jiu jitsu and stuff like that, and and went to a little more of a lower carb lifestyle, but everything's a mess because his job is very active, right? And he's on Omnipod five, and he's like, I am getting low every day at work. Like, I'm low constantly, like, blah, blah, blah, like, on and on. And I we just kept talking and talking and talking and the the first two things I. Said to him, I ended up going, No, no, no, not that. And then eventually I said, here's what we're gonna do. And I figured out that he was getting low after meals, and that seemed to be the biggest problem, but he was so sure about his insulin to carb ratio, he said it was one to 10. And I said, Listen, let's just make it one to 20. And, like, see what happens. And I got a text the next day. I didn't go under 100 and my spike was only, like, 160 I said, Okay, make it one to 18 tomorrow. Like, keep changing that until we get there. I think that was your problem. But what he was seeing was, is that he was eating and then he was going to work and walking, walking, walking and tanking every time if he didn't walk after he ate, it wasn't nearly the same. So, right? What's the functionality there?
Jennifer Smith, CDERight? Any activity Walking is one of the best. In fact, years ago, during diabetes month, I can't remember what organization they used to have, something called the Big Blue Test, Manny. Would say, who was Manny? Yeah, it was Manny. It was essentially check your blood sugar. Go do 15 minutes of movement, come back and check your blood sugar. And 99.9% of the time, you're going to see movement down in your blood sugar. I don't care what body size or type you are, you're going to see why, because muscles require energy to move, and we know that exercise is, I call it free insulin, right? Your body needs the energy it's moving faster than it normally is. Your muscles are now primed. The doors on those muscles are now they're more free to open at will, and they don't need as much insulin to unlock the doors and let the glucose flow in.
Scott BennerWe know that works. You and I know that works. Is that actually impacting your insulin resistance, or is it just changing the function of the insulin that's inside of you over and
Jennifer Smith, CDEover exercise is going to at some level, it's going to impact your resistance, right? It is okay, but in some people that exercise every day, it's basically holding you at a level. If you stop doing that, you're going to climb in insulin resistance. It's holding you out of stability. The insulin resistance is still there. And if you are the type who needs the GLP-1 type, or the Metformin or something to assist further, then all you're doing is holding things where they are with your exercise. Don't stop doing it. Keep doing it. But if you're not finding you're not reaching your goals of weight loss or post meal blood sugars or as much as you really want to, then you're looking at needing to add something to help the lifestyle stuff that you're trying so hard to do. Follow
Scott Bennerup questions from people is, how does muscle mass influence insulin resistance, which I feel like we just talked about. But can lifting weights really make a difference? Yes, right,
Jennifer Smith, CDEit can. And weight lifting is interesting. It actually many people who lift weights find no change immediately in their blood sugar. In fact, those who really go to some of the more the boxes, right, the gyms that are just all lifting, you have your workout of the day. It's very resistance based. You might actually see a rise in
Scott Benneryour blood sugar right during the lifting itself. During the
Jennifer Smith, CDElifting itself, right? It's an adrenaline based kind of thing, sort of like a sprint runner. You might see from the adrenaline of a sprint or hill repeats going up and down. You're going to see a rise in your blood sugar. But in the aftermath, just like weight training, you're going to see that your muscles are now recouping. And in weight training, you're building the muscle that you broke down during the workout right to build that back up, your body needs to use energy so you become more insulin sensitive in the aftermath, if you do enough weight training or resistance training, lightweight to high weight, whatever is good for your body, what kind of muscle you want, you're going to see that retained long term. Okay, that's the benefit of daily exercise.
Scott BennerOkay, all right, let's move to like beyond diet and exercise, hormones, stress, sleep, steroids, that kind of stuff. When people see a greater insulin need because they haven't slept enough, they're under stress, the doctor gave them a steroid for an infection or they have a hormonal impact. Are they seeing an actual change in their insulin resistance?
Jennifer Smith, CDEIt's momentary. I think, yeah. I think it's momentary. I think it's more right, right now, this is what's impacting my insulin. Need hormones in females, obviously, that's more in the moment, or depending on where they are in a monthly cycle can go up and down, right? Somebody who has a big business presentation to do, they may be stressed for a couple of days while they prep for it, and they plan it, and they work with their team, and then they get to it, and as soon as it's done, if you've changed your insulin doses to accommodate and keep your blood sugar managed, you're likely to need to remember what your doses were before the stress, right? Because it should come back down. That's momentary insulin resistance, which isn't, I wouldn't even. Call it resistance. It's just the effect of a variable here and now.
Scott BennerDo thyroid issues impact insulin resistance? Yes, they do. Okay, absolutely. Hyper, hypo doesn't matter. They both
Jennifer Smith, CDEhave impact on your overall insulin need. Yes, both to the extreme of needing a lot more, as well as a they're both a little bit opposite. We actually see in hyper that because your metabolic rate and the turnover of all different types of medications is a lot faster, you're ending up needing you're clearing that, and you're needing to use a lot more insulin, right? Whereas in hypo, you've got metabolic slowdown until it's regulated. And so you might actually find that while your weight isn't being managed well, and that you feel like you need more insulin, sometimes there is dysregulation in dosing, because you feel like you're taking more but you end up with a lot more lows because of the lagging effect of the amount of insulin that you're taking. So there is, I mean, thyroid is, it's huge to get optimized if you're having issues with your insulin.
Scott BennerOkay. Do you know how sleep impacts insulin resistance, like lack of sleep? You know the function of it, or just that it does. It's
Jennifer Smith, CDEjust, I mean, baseline is, it's, it's a stress, right? Especially quality sleep. You might have something that tells you you're sleeping seven or eight hours a night, but we have enough watches and Rings and Things now to take care of. Looking at what was our sleep quality light, how many times did we roll over in bed? Even some of these devices measure what would be like sleep apnea, kind of dysregulation of oxygen intake during the overnight times. You might think you're sleeping, but you're really not getting quality sleep through all of the different cycles of sleep, deep sleep, REM sleep, all of those things, right? And in the end, it again, is just baseline. It's stress on the body.
Scott BennerSince you mentioned stress at the end, there's these like sub questions under our headings here, how do I manage stress to improve blood sugar control? I'm going to assume that me telling you to calm down is not going to help. I mean, is it just one of those things, like, you got to figure out how to manage your stress, really? What are you going to
Jennifer Smith, CDEThat's right? I mean, it's like a it's like a blanket statement, because I think everybody needs something that's going to be a little bit different to manage stress. I manage stress by working out. I run. I do yoga several times a week. There are different types of yoga, some as meditative. Some is more active yoga. I use weights. So exercise is really my like stress reducer. I also like to cook. So, you know, find your thing, and if that helps you, and you have time to build it in. It might be enough to keep your stress levels at bay. Some people stress, though, is not only their own life stress, but it includes their family's stresses, right? So then you have to navigate it all. Yeah,
Scott BennerI noticed a hot shower makes Arden's, blood sugar go down, and I know that it's, it's like, people are like, Oh, hot or cold or this. I'm like, I honestly just think she gets in there and she chills out, she sings and she relaxes. The water hits her head, and I think she just relaxes a little bit. So, okay, identifying, let's see IR insulin resistance on lab work and early warning signs. What labs or markers should someone ask their doctor about if they suspect that they have insulin resistance, and for those who don't realize they have it, what are the early warning signs to look out for? Are there lab value? Can I get there
Jennifer Smith, CDEare like somebody, and this goes the route of really talking about maybe somebody who has some of the physical identifying markers like you're overweight, you have a more sedentary lifestyle, you may not have the cleanest food intake, maybe you don't work out those kinds of things. Are there markers that someone could be looking at with not knowing that you have diabetes? There are, I mean, obviously one test would be an A1C, right? It's going to give an overall evaluation of is your body not regulating your glucose like it should in people who don't have type one, something like an overnight fasting insulin level, can also be a method of managing your body's output, and it's a way To sometimes also identify pre diabetes, before type two diabetes, because, again, early stages of type two, your body is over producing insulin to make up for that insulin resistance that's there. So that is another piece that could be managed. Obviously, somebody with type one doesn't need a fasting insulin.
Scott BennerI went to our friend online to ask this one so fasting insulin, HOMA-IR, homeostatic model assessment of insulin resistance, a fasting blood glucose, hemoglobin A1C, triglycerides to HDL ratio, a ratio higher than 2.5 to one is linked to insulin resistance. Your C peptide, of course, postprandial blood glucose. Insulin, checking glucose and insulin one to two hours after a meal could let you know if you have form of glucose metabolism and liver enzymes. Elevated levels may indicate fatty liver disease, commonly associated with insulin resistance. It says uric acid. High levels correlate with insulin resistance and metabolic dysfunction. Some early warning signs could be frequent, fatigue, increased hunger and cravings, difficulty losing weight, dark patches on the skin, skin tags, high blood pressure, brain fog, PCOS, dizziness or shakiness between meals, increased waist circumference. There you go. That's from
Jennifer Smith, CDEour most of what's on my list. So you you got to all of that. Jenny's
Scott Bennerlike, am I going to get supplanted by a prompt? I hope,
Jennifer Smith, CDEI think it was a valuable question, honestly, because while some of these may not necessarily be in the realm of type one looking, some of them are even things like your cholesterol levels. I mean, the LDL especially, is one that we end up looking at your triglyceride levels, the relevance of the liver enzymes. All of those, whether or not you have diabetes, can be Hallmark identifiers for yes. It's
Scott Bennerfunny, because I just had this thing I wanted to say, and then I looked down at the next question, and the next question encompasses the thing I wanted to say. So I was like, Wow, this must be building to the right place. I, honest to God, didn't know that this was about to happen. So this next bit is misconceptions, reframing frustrations, vetting information, and the questions that came in from people are, what are some common misconceptions that you hear from people with type one regarding insulin resistance? And I'm going to tell you that my question was, do you think we talk about insulin resistance correctly? Or do you think it's a catch all phrase that we use in a bunch of different places?
Jennifer Smith, CDEI'm going to say that that this about insulin resistance, what we're putting together. I think it's really valuable, because I think we're defining the difference. But I do feel like it can be a catch all. It can be a place where, my goodness, this is a lot of insulin. Like I see a lot of questions often, like, my child, is this this age and uses this much insulin? How old is your child? Who's this age? How much insulin do they use? Right? And again, our insulin needs are our own insulin needs. They are how to know if it's resistance, I think we've defined quite well here. And when it's not, is it a time in life that there's a variable happening that's not resistance? It is the hit of what's happening right now? Yeah,
Scott BennerI feel like there are sometimes where there's variables at play. There's sometimes where it's, you know, a steroid, or sometimes it's you just became sedentary, like your kid used to play soccer, and now they don't anymore, or you've got a job, or you're walking around all the time. Then on the weekends, you sit and watch football like whatever that thing is, no matter what, when someone needs more insulin, they're gonna say, I have insulin resistance, right? And I think the GLP conversation has shown me that some people just need more insulin. They're not necessarily insulin resistant, but at the same time, is that just a heady conversation between you and I That's meaningless to the end user who just either needs it or doesn't need it, right?
Jennifer Smith, CDEWell, and I think to clarify, you need more insulin, what that says to me is without all of the other pieces that you think that you have insulin resistance. It really isn't. It boils down to have you looked at your setting, right if you're needing more around meals, but your overnight is sitting flat at 83 and you haven't really adjusted anything there, and there aren't any big pieces in the picture, and your hits are around meal times, probably not insulin resistant. You probably just need to navigate meal coverage. You
Scott Bennermight not be covering your carbs. Well, your ratio could be off, even if you are counting them correctly, or something like that. Yeah. In the end, I just want people to cover what they need, but I don't want them to ignore the other things that may be happening. Right? If it's as simple as taking an inositol to help with your PCOS and lowering your insulin needs. I don't want you just feeding the PCOS with a ton of insulin when this other thing could be valuable to you correct or something like that, or going for a walk or eating better, or that kind of thing, right? How does someone separate helpful advice from misinformation when it comes to insulin resistance? What do you think the misinformation is that they're getting like, maybe it's just the misunderstanding of the implications like we've been talking about. It's a vague question. It
Jennifer Smith, CDEis a big question. Well, I think it boils down to you have to look at what your experiences are that's leading you to consider, is this resistance, or have I not considered what could be going on right now as a point in time adjustment that needs to be made, okay? Is it some of the things that we've already gone into? Are there lab values? Are there symptoms? Are there other things you know that you're looking at that are an issue that are leading you to consider some of the helpful advice? This is actually pointing you to think this is insulin resistance. I should get further checks or talk to somebody about this, or does none of the information that someone's bringing in fit what you're seeing? Does that right? Does that make sense?
Scott BennerYeah, yeah, it does. But I'm gonna ask another vague question though. I'm sorry, no, you ready for the last one? Yeah. Where should people start if they feel overwhelmed by trying to lower their resistance? Is there a simple first step that someone can take to put them on a path to figuring this out? Do you start with food? You start with your weight. Because you hear people talk all the time, like I can't lose weight. Type ones are going to say to you, all the time, I can't lose weight, because every time I try to exercise, my blood sugar falls and I end up eating to bring it back up again, and it feels like I'm just losing weight on one hand and eating it on the other hand. And I would tell you, if weight is your issue, then getting your your settings right so that you can work out would be step one. It wouldn't just be, hurry up and start working out, correct, you know? But also, if you don't start working out, you won't see that your needs are lesser. So it's, it's a chicken or egg thing, a little bit like, do you start working out and adjust your insulin as you go? Do you adjust your insulin? Get it really rock solid, and then start working out and keep adjusting I think maybe that's it, right? Yes, yeah, yeah. And
Jennifer Smith, CDEI think in terms of resistance, let's say you've you've taken all of the advice, right, especially like from the podcast, let's say all the pro tips, you've applied them, you've tested and you've done the best that you possibly can, and with all the adjustments, you've actually found, gosh, my insulin needs are a lot higher than I actually thought they were, and it is, no matter what lifestyle piece I put into place, it is really hard to keep my blood sugar at the target that I'm aiming for. Great. Now you've got all this information to go to your physician, to your nurse practitioner, to your educator with and say, Look, I've done all this work, and I still feel like I'm using a lot of insulin to actually navigate despite all the things I'm trying to do. Yeah, great,
Scott BennerJenny, I get worried that the the actionable items all fight with each other. For example, we learned in this episode, that a sign of insulin resistance might be hunger. And then you're gonna go to your doctor, and they're gonna say, Well, if you lost some weight, your insulin resistance would get better. You should lose some weight. And you go, but I'm hungry all the time. And then they say, Don't be. And you go, but I can't not be because I got insulin like, you don't mean like, you get caught where? Like, hey, go work out. You're like, I work out. My blood sugar gets low. Everything seems to have it's like a bad cartoon, like superhero movie, like there's a bad guy for every moment that you have. And I can see how it would stop people from it gets frustrating. Yeah, right. I mean, listen, between I don't have type one diabetes, I don't have type two diabetes. I've never been I don't think I've ever been pre diabetic, but I have lost like 60 pounds on a GLP medication, and the hunger going away was a huge help. It just was like, you know, like it was such a big deal that helped me get over the hump. I will tell you,
Jennifer Smith, CDEthat's the biggest thing that I hear from most people who start using it, is the food fog. People call it the constant draw of I even have some people who have said, you know, I work from home. I leave my office and I have to walk through the kitchen. And since using the GLP-1, I can walk through in the refrigerator or the cabinet the cupboard, I can pass it without even a thought of opening it at this point. You
Scott Bennerhave no idea how well it works to the point where you have to remind yourself to eat. I had to remind myself to eat. Like I would get up and be like one two in the afternoon, but God, I feel lightheaded. And then I'd go over and I go, Oh, I didn't eat. I did no hunger whatsoever, like none I forgot to eat today. Easily. I could have gone 24 hours not eaten, and never would my brain have said you're hungry, or my stomach have grumbled. That's the crazy part, but it's also a huge boost. Now, I'm not saying run out and use a medication. I'm saying listen to this. Hear the ideas about what'll make it better, but then identify what's stopping you, because you may have to conquer that before doing the other thing that's all right. They're
Jennifer Smith, CDEall really like valuable things to keep in mind. Because, as you said, people may go to the doctor and say, but I can't he says, stop eating, or don't eat many snacks. Or I can see how much you're in taking cut it back. And for those who really struggle with some mental stuff around food to begin with, that can be a road to nowhere to just tell them something that the doctor doesn't know. What they feel like, yeah, and it stinks.
Scott BennerWell, the and the other side of it is too. And I have personal experience with this, with what happened to my wife is she went to an endocrinologist and said, like, Look, I'm just gaining weight. Eat for like, no reason, and lose weight, lose weight, lose weight. And they tested her thyroid, and her TSH was high, but in range, so they didn't give her medication. So for seven years, they yelled at her to lose weight as she gained weight. And then one day, it just took one of us to, like, you know, I guess you people call it advocating for yourself, but I basically just, like, said to the guy, like, just give her the medicine for God's sakes. Like, if it doesn't work, like, take her off of it. But like, what's the harm at this point, right? She starts taking Synthroid, and, boom, oh, what do you know? Look at that. Yeah. And so, like, even when you figure the problem out, sometimes there's another roadblock. And I see that with people all the time. They go through this horrible thing to figure out their problem. And they get to the person, they're like, hey, gatekeeper, give me the thing. And they go, No, you can't have the thing. And it's tough. You know, finding a doctor who understands what you figured out is a big deal, and I it's a whole other process to talk about how to explain that to a doctor. But, you know, I just don't give up. Is my is my message? I guess, yeah, yeah, no. All right, Jenny, this was awesome. Thank you very much. Of course, yes.
Conclusion and Series Outline
Scott Bennerif you or a loved one was just diagnosed with type one diabetes, and you're looking for some fresh perspective. The Bold Beginnings series from the Juicebox Podcast is a terrific place to start. That series is with myself and Jenny Smith. Jenny is a CDE, CDCES, a registered dietitian and a type one for over 35 years, and in the Bold Beginnings series, Jenny and I are going to answer the questions that most people have after a type one diabetes diagnosis. The series begins at episode 698, in your podcast player, or you can go to juiceboxpodcast.com and click on Bold Beginnings in the menu. Hey, thanks for listening all the way to the end. I really appreciate your loyalty and listenership. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording, wrongwayrecording.com, you
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#1025 Diabetes Pro Tip: Transitioning
Scott and Jenny Smith, CDE share insights on type 1 diabetes care
You can listen online to the entire series at DiabetesProTip.com or in your fav audio app.
You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Music - Google Play/Android - Radio Public, Amazon Alexa or wherever they get audio.
Key Takeaways
- MDI to Pumping: A Foundational Shift. When moving from injections to a pump, your total daily basal insulin is usually reduced by 10-20% because the continuous drip of a pump is absorbed more efficiently than a single large injection.
- Algorithms Aren't Magic: Upgrading to a hybrid closed-loop or DIY algorithm doesn't mean you can forget about diabetes management. If your underlying settings (basal rates, ISF, carb ratios) are wrong, the algorithm will struggle to correct them.
- Pre-Bolusing Changes: Your required pre-bolus time on a pump may differ from your pre-bolus time on MDI. You must re-evaluate your timing when transitioning to a new delivery method.
- The Power of the Extended Bolus: A key advantage of moving to a pump is the ability to use an extended (or dual/square wave) bolus to match the slower digestion of high-fat and high-protein meals.
- Site Rotation and Absorption: Insulin absorption varies depending on the pump site. The abdomen might absorb insulin faster than the thigh or arm. You may even need different basal profiles depending on where your pump is located.
Resources Mentioned
- Wrong Way Recording: wrongwayrecording.com
- Diabetes Pro Tip Series: diabetesprotip.com
- Juicebox Podcast: juiceboxpodcast.com
- Integrated Diabetes Services: integrateddiabetes.com
- Juicebox Podcast Type One Diabetes (Private Facebook Group): Join on Facebook
- Insulins mentioned: Tresiba, Levemir, Lantus, Basaglar
- Pumps mentioned: Omnipod, Medtronic, Tandem T:slim X2
- Algorithms mentioned: Omnipod 5, Control-IQ, Loop, Android APS
Introduction and the Transition Series
Scott BennerHello 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 CDE 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 revisitable. 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. What I would like to talk about today is transition. Just a an overview concept for this one, but transition from just finger sticks to CGM transition from MDI, to pumping, transition from pumping to algorithm. Sure, can we do that? Yeah, I thought we could all thank Isabel here for having her finger on the pulse of the people in the Facebook group and knowing exactly what people ask about and what they seem most confused about. Why don't we start with MDI, because everybody starts there, right? After you're doing it for a while, like let's put ourselves in that place. We've been doing MDI for a while it's working pretty well, or at least at a baseline. We're shooting a Basal insulin once a day, and we are shooting a meal insulin to correct blood sugars and to cover our carbs. That's the basics of MDI. Okay, correct. So then we're in a doctor's office, but it make up yeah, I'm gonna make up some numbers. Let's, let's say our Basal it's like, I don't know, let's say our basal is 10 a day. And let's say we're, I don't know, one to 10 for carb ratio. Okay. All right. Let's say our correction is one to 100. Let's keep it all very like, like that, so that it's easier
Jennifer Smith, CDEto talk about. Okay, round 10 numbers
MDI to Pumping: Adjusting the Basal
Scott Bennerand numbers, we're gonna do that. So the math makes sense when people are listening. So we're in the doctor's office, and the doctor says, you know, you might like a pump. Is he gonna say it just like that? I mean, if it's a lady, she might be like, You made like a bump? I don't know, like, exact. or anywhere in between. There's some women have more masculine voices. Jenny, this isn't the point of what we're talking. Oh, yeah. So they see you might like a pump. You are. I'm guessing. Gonna have a couple of different reactions. I see a lot of people scared. Oh, no, don't change something. I see a lot of people are like, Yes, please. Because this isn't working. And maybe this will they don't know why they think that just right. They're hoping for a change. So the first thing that's going to happen is the doctor is going to translate your Basal insulin to this pump. So Jenny, you do that math for me? I get her I get 10 units a day. Injection. What are they going to do on the pump for me?
Jennifer Smith, CDEMost often on a pump, because it's expected that your Basal insulin which, and this is kind of outside of it, but within your Basal insulin will now be given by the pump as rapid acting insulin. So that's the first thing to understand is that you're injected Basal insulin, which is a specific long acting kind of insulin will now sit in your refrigerator as a backup in case of pump failure, right. So you don't put Basal insulin into a pump. The only insulin that goes in the pump is your rapid acting insulin of any of the brands, right. Depending on the pump, company, they all have a little bit of different kind of recommendations for type of rapid insulin, but it's a rapid insulin and to translate your Basal dose of what we said 10 units into a pumped Basal delivery, you would essentially take 10 units into a 24 hour day. Right? And that translates into a a dripped amount, right? Because insulin pumps drip drip, drip drip consistently to deliver that total amount of basal that you want.
Scott BennerOkay, so let's clean it up for people who get lost very easily. You may be injecting Tresiba, Levemir, Lantus, what are the other ones, Basaglar.
Jennifer Smith, CDEThese are all basal, JL,
Scott Bennerthese are basal insulins, these are now gone. You don't use those anymore. Because as Jenny points out, you're going to take your mealtime or your fast acting correction insulin, put it in the pump, and it's going to split it up, those 10 units are going to get split up over, not just over hours. That's how the settings the pump work, right, you're going to come up with what is it going to be like point four, maybe an hour if you're 10. Today about like that, right?
Jennifer Smith, CDERight, depending on your pump, all of the pumps differ in their precision of a single drip of insulin. Some pumps can drip as little as point one, one, some can drip as little as point oh two, five, or point oh five. So it just depends. But if you broke this down 10 units a day into 24 hours a day would be a rate of about point four, two, if you do rounding, right, some pumps, you may have to round that 2.4, because they can't deliver the point oh two,
Scott Bennerand you're, you're gonna hear that if you're MDI and think, oh, at the top of every hour, it's gonna give me point 14 Its events on but it's not doing that it's going to break those correctly for Twos Up over the entire hour, over the
Jennifer Smith, CDEcourse of the time. Exactly. Now, the other step to this calculation is that we expect that your Basal insulin you've been injecting I'm trying to think how to say it, so people don't think their insulin is not working. But when you inject Basal insulin as its type it, it will not be absorbed as efficiently I guess is the better way to say it as it would from a pump where it gets infused in those little tiny drips over a very precise amount of time, a very precise dose. So your rapid insulin in your pump gets infused out of sight. And so we usually take your base Basal dose down by about 10%. Some even some physicians even go down by 20%. But the general idea is taking your base dose down by 10%. So 10 units a day taken down by 10% is one unit less, so nine units instead of 10 units. So if you do the math there, nine into 24 gets your rate down instead of point, let's call it point for an hour, down 2.37 an hour, which again, we'd probably round down 2.35.
Scott BennerAnd you're going to want to keep an eye on that because I've seen it go either way. I've seen that be right. And it's amazing. I've seen that beat Now. Not enough insulin and people are getting high blood sugars. And they immediately like you hear them say like the pump doesn't work like well, you gave yourself less insulin and turns out you need right. So pay close attention to that.
Jennifer Smith, CDEIt also translates into the next step. Once you've been making some notes on this 24 hour dose of let's call it point three, five units an hour. And you can say Well, it seems okay here. But then at this time of the day, I'm always high no matter what I can skip eating and I'm high I can eat and I go even higher. Well, that's when the next step is Basal testing. Right? We need to really look at it and say, where is that point three, five, sufficient and where is it not and where might it be too much.
Pump Sites and Insulin Absorption
Scott BennerAnd you might notice, and this is this might sound a little heady if you're thinking of switching but you could put your pump on your belly and have a different reaction to the insulin that is if it's on your hip or your thigh. There's reasons like Arden's thigh doesn't work as well. As her stomach does,
Jennifer Smith, CDEyou know, neither does mind I don't use my thighs anymore.
Scott BennerYeah, back of your arm might be better than your, the back of your butt or who knows, like, right
Jennifer Smith, CDEand with with this being new from coming from MDI, to going to using a pump, I would suggest initially utilizing and testing out within an area of the body, you know, we talk a lot about rotation, not only should you be rotating, if you're doing MDI, your injection should be going multiple different places, not just the same site over and over, the same goes along with pumping, those sites need to be rotated. If you're new to pumping, however, you really want to get an idea if your settings are fairly good. Stick with rotating around your abdomen, right? Get an idea. And then once you have that fairly well set, you can then move to upper body or the back of the arm or maybe your thigh or you know, your lower back and see if you notice any difference some people do and some people don't at all.
Scott BennerYeah, right. No, I mean, there's it's your body composition, hydration, how you know where it's actually going inside of you? Is it subcutaneous? Is it very close to a muscle? We don't want to overwhelm people, but the muscle can kind of, I don't know what the term is like, what a large muscle group can, it kind of lessens the impact of the insulin, but for the life of me, I can't think of why right now. Do you know what I mean?
Jennifer Smith, CDELike lessons? I know, I don't know what you know,
Scott BennerI always thought that's why the thigh was in a good spot because it was a large muscle.
Jennifer Smith, CDEWell, it might have more to do with how well the insulin at that site is getting absorbed. Like that's a big reason that I don't use my thighs is because whenever I tried using it, either I got a collusion alarms because the cannula was bumping into muscle or potentially that I had nicked, like a small vessel under and it had been clouded kind of near that site where it was trying to infuse. And so that backs up into the pump and the pump tells you hey, the delivery of insulin has stopped. It gives you nice alarms. Right? So I think in some cases that may be part of the issue is the proximity to muscle. Yes. But also I it was either painful or I got occlusions like it just never worked on my thighs.
Scott BennerOkay, I'll see. Look, I'm learning from the podcast. Finally. Finally, I learned about this every day, you learn a lot. Yes. Okay. So now we've, I think here's a good place to insert that it is possible that there are some people in the MDI who are achieving reasonable lower blood sugar's some how do I say this? Sometimes your doctors over baseline you because they don't think you're covering your food correctly. And
Jennifer Smith, CDEthat, or they may have not looked at your records enough to know why they've you know what I mean? Like, it might just be easier to backup with enough Basil with what they're seeing in your data. Yeah. And it may as you're saying, it might be wrong, right,
Scott Bennerright. So like, imagine if you're a person who has been getting more basal than they really technically need, but you kind of forget meals, sometimes you don't cover all your food. But now all of a sudden, you have this pump, you're like, Oh, it's so easy. Now, I just push the buttons for my food. So now you're covering your meals well, and you're like, why am I low all the time? Right? It might be because you're using more insulin than you have been in the past. So those are things to look for that I see people struggle with the beginning with a pump. And I do want to say I think there's a I think there's a period of transition there. It's not going to be like if you're nervous. It's not unfounded, you know, like you are starting a whole new way of doing something. But it really is just another way of delivering insulin to you. It's not that complicated.
Jennifer Smith, CDEAnd I can say personally, when I switched from MDI, having done MDI a long time before I started using a pump. By the time I started using a pump I was already doing. I was already doing somewhat of a Pre-Bolus. But it wasn't the same once I switched to a pump, there was a definite time difference between my Pre-Bolus with injections, and there still is, I can take an injection and my Pre-Bolus Time is not as long as it is on a pump, right? Again, and have one. But that's what I noticed. And so those are some things to pay attention to between MDI and what you're doing along with what you said about maybe the doses you were taking on MDI. We're covering a certain way for your rapid insulin for meals and corrections. And now that you're on a pump, your meals, the food hasn't changed, your strategy has stayed the same and things are looking weird,
Scott Bennerright right there in You'll have to step back a lot and try to see what's happening. One reasonable reason for that could be reasonable reason why it wasn't right. But anyway, you use an omni pod and delivers insulin a little slowly. Like it doesn't just like you take a needle and you go. Yeah, and the pump is pumping over time. And and I don't imagine you use very large bonuses, but larger bonuses take longer. Yeah, I've seen, I've sat at a restaurant with Arden. And, you know, you forget you've done it, and you kind of still here like that, like think like click clicking, it's still giving her insulin feels like it's been five minutes, you know, and yeah, so that's, that could be part of it. Anyway, these are things you're going to learn along the way. They're new lessons, but they're not a reason, not just try, because you're going to gain weight, you're gonna gain so much, right? Like if, to me a pump is, at its core, I've always thought of pumping as a way to be able to manipulate basal. Whereas on MDI, I shoot it in, it's in there, nothing left to do. If it's too much, if it's too little, it's what it is, you know, with MD with a with a pump, you know, you can go back and listen to the Pro Tip series, I think about like, wow, if we sit down to a meal, that's all of a sudden, much carb heavier than what I usually eat, I could do a Temp Basal increase, they tried to help me with this. You know, I was thinking a minute ago, when we were talking about breaking the 10 units down into point 4.35, that if you think about putting a sprinkler out on a dry, dry lawn, right, and you need to give your lawn 10 gallons of water, you could come along and dump it on all at once. It'll just be there, that'll be it, right, or it could break it up into little point three, five gallons every hour and go back and forth. And just a light covering, covering, covering, covering, you're never gonna soak it down, you're and it's just I think of basal like sort of like that. Sometimes you're just,
Jennifer Smith, CDEand that's a good way to think about it too. Because if you consider that slow Basal drip that you are getting from a pump, when you inject your Basal insulin all in one clump, right? You can, depending on the kind of activity you like to do, you may have found that you have to pay attention to Gosh, I'm doing like a really heavy arm workout, I'm probably not going to inject my Basal insulin into my arm today, I might inject it someplace else, right? Because there's this whopping dose sitting underneath your skin. And any kind of insulin, whether it's rapid, or Basal can get enhanced in action, the more active you are, and especially if you're using that site. So, you know, those are the kinds of things that having those tinier doses that you can manipulate and adjust, especially with the variables that you know, are coming in the day.
Scott BennerIf somebody's listening and thinking like, well, they have spent the first 15 minutes talking about Basal insulin, it's because it's really important, and nobody tells you it's important in setting. So if you listen to this podcast, like Well, I do MDI, they're always talking about, like, their settings on their pump or anything. This is still settings, you know, if it's MDI, it's your settings, it's, you know, these Basal carb ratio, correction factor, they're all settings. So it's just very important to have them. If they're not accurate to your needs, then everything else is just going to be a mess. And especially Basal, basal is wrong. The whole day is confused. So okay, so we've translated our basal, our insulin to carb ratio, does the doctor keep it the same? Do they usually like what is common?
Jennifer Smith, CDEThey may keep it the same, especially if your records prove to show that it seems to be for the most part working fairly. Okay. Right? Could there be improvement somewhere, possibly, or whatever, maybe that's also part of the reason that they feel like a pump might actually be better. Maybe you're the kind of person that just eats really slow digesting food. And so you've had problems with taking your insulin and having these big drops in your blood sugar too fast, and then it ends up catching up with you. And then you end up high later, and you've treated low blood sugars, right? And there's not a timing thing that you can really get quite right with MDI. And maybe the doctor says, Well, why don't we try a pump, because, hey, you're eating these types of foods more frequently. We could actually use some of the smart features on our conventional pumps that allow you to take some insulin for food. We're calling these extended boluses. And you can just kind of like basal. It's almost like a secondary use of Basal but for a Bolus where you drip drip, drip drip drip a Bolus in over a certain amount of designated time. You
Scott Bennerknow, there's just there's so much you're gonna get out of having a pump there. Yeah. There's also going to be some things you need to know, sites can, like they're going to tell you whatever pump you have, they're gonna say this pump you can wear for X amount of days or X amount of hours. But sometimes sites go bad. You know, sometimes new sites don't work as well in the beginning. Those are little things that you'll learn along the way. There's, if depending on Arden's blood sugar, she might put on a new pod, and we might just Bolus a little bit to get the site working. This morning, I woke up in the morning, I saw that artists blood sugar was trending up overnight. And listen, for those of you just switching like Arden is looping, but I can see how much insulin is left her pod remotely, which most of you aren't gonna be able to see. But I can see she was down to like 30 units. So this is the end of her sight, right. And I just spent the weekend with her. And doesn't matter. But we were in a lot of restaurants this weekend. So Arden got a lot of insulin this weekend. And in my heart, her blood sugar is drifting up, because this site is kind of done. So because you have experience, yes, I can just tell and you will be able to one day as well. So I sent her a text and I said I wouldn't go to class with this pump one. Because if she does, she's going to spend her whole day with blood sugar's around 150. And she's going to be fighting with them constantly, and bolusing. And they're not going to work and and by the way, if that happens, and then all of a sudden she gets crazy active out of nowhere, she might experience a low blood sugar from all this insulin kind of sitting in this right over use. Well, yeah, get in this pool, right? And so like, that's just the thing you'll learn along the way, you'll learn, you know what people worry about so much like, well, you know, do you travel with pumps? You know, if we go too far from our house, we do if it's a 15 minute turnaround, we don't like you know what, I'm gonna have to have insulin with me now. Like, Yeah, I don't know, we don't travel with insulin that frequently, as long as we're near home base, you know. But if we go far, you know, half hour, 45 minutes, and it's not something we want to turn back from, we'll take insulin with us, you know, it's just you. My point is, is that it becomes all second nature at some point. Just like everything else about diabetes, you're gonna have experiences they're going to teach you you'll learn from them and move on. Speaking of moving on, you'll think I'm going to go from MDI, to pumping, to pumping to algorithm pumping, but I want to do CGM first.
Integrating a Continuous Glucose Monitor (CGM)
Scott BennerSo okay, you have a meter. And that's how you check your blood sugar. And that's all you have. Hey, you're in the doctor's office. The doctor is like, you know what you want to do?
Jennifer Smith, CDEIt must be the same deck.
Scott BennerI wanted to draw here. Take this a sample you try. You'll love it. They're gonna try to give you they're gonna say to you, hey, you might want to libre, you might want to Dexcom if you're on a Medtronic pump, they might ask you to do whatever the Medtronic CGM is called. And you're gonna say I don't need that or you're going to be newer. You're gonna Yes, please. Wherever you fall on that you do want it if your insurance covers it, you want it? That's for sure. Right? Tell me why.
Jennifer Smith, CDEAnd I think it applies in all realms of diabetes as well. Right? Not just in type one diabetes, but also type two diabetes and even worthwhile and gestational diabetes. I know there are some rules in terms of when it can be prescribed whatnot. But I think it's beneficial all around what you miss with finger sticks are all of the little dots in between. So where things were trending, right, so if it is something that your doctor does bring up? Absolutely say yes. Right. You may not know how to look at the information or what you're getting from it initially. But it's so worthwhile. You want
Scott Bennerto know what you don't know. And with finger sticks, especially if you're newer to diabetes, or if you just been doing them your whole life. And this is how you tend to think of it. You do the well i i test before I eat or I test before I go to bed or I test before I drive. And and I know you've asked yourself what's happening when I'm not looking. Right, like and if you haven't asked yourself that. I wonder how do I go from 250 to 50 in an hour, like how does that happen? And you'll learn you'll start seeing the impacts of activity and the lack of hydration and different foods that you eat, the age of your your insulin pump site, all these different things that have a huge impact on the way your blood sugar moves. And now suddenly, it's there. A CGM is going to show you minute by minute. I think it's every five minutes. Right.
Jennifer Smith, CDEAnd I think there are there are some people who have been using it long enough that can say there can be some frustration around the amount of data that you get. And I wouldn't disagree with that. I but I do you think it's how you interact with the data, right? It's how you actually take a look at things and what you do with it and what you learn from it. And you have to you have to expect that in the first month. Let's call it of using a CGM, you're gonna see a lot of stuff. And so rather than being so very emotionally reactive, again, taking a step back and kind of looking at the data to be able to make better decisions about what you felt like was probably happening. And now you can actually see,
Scott Bennerwell imagine you have your sprinkler out on the yard. And you have to keep the dirt moist because you've planted grass seeds, except every time you look out it's kind of dry. That's the CGM. You look at the CGM ago Oh from 3am till 6am. My blood sugar's 140. It's pretty stable, but it's 140. I wish it was lower or moister. I can turn up the sprinkler a little and put on a little more insulin and make it where I want it to be like push that number down a little.
Jennifer Smith, CDEAnd the CGM can show you that if you're really looking at it. That way the CGM can show you where did it start to lose right effect? Where do I start to need to add more insulin? It's not once you get stuck higher or once you get stuck lower than you want. It's before that so any drifts up or drifts down. Now, you can see that very clearly on a CGM I, you have a really good example I think from when Arden first started using her CGM, it was like that overnight thing that you are constantly missing was at Lowe's when you had finger sticks. And I would put
Scott Benneror you could see them. I thought it was a genius. I've said it before I would put Arden to bed at 180. And she'd wake up at 90. And I was like, Look how good I am at this. And what would happen. We put a CGM on her. She was 180, she'd go down to the 50s sit there for hours, I'm assuming her liver would be like, hey, here, try not to die. Here's some, you know, some, here's some, here's some glucagon, I'll give you a little bit. And then she drift up to 90 overnight was happening constantly. So the reasons for that are mind numbing in not for this conversation, but we were bad at bolusing for dinner, we were her basal wasn't like there were so many things that weren't right, you know,
Jennifer Smith, CDEyou didn't know it because you couldn't see what was happening unless you really did a finger stick even an hourly finger stick, it would have caught a drift, it still would apply it. But it would have still been confusing unless you sat down and you connected all those dots. And you could say, well look, look at this. And you probably I mean, not necessarily wanting to see your child sit at 50 for three hours before your body actually reacts and gets you the glucose that is needed to bring it up. But you'd have on a first finger stick probably under 70, you would have ended up treating, so you also wouldn't have had the information to show. Well, how much do we need to take away? And what do we need to do differently?
Scott BennerI can't I can't say how valuable it is to be able to see a graph and to enter look at it every three hours or you know what's it look like over six hours, like Jenny's point is great is that you? You don't know why? What happened happened? It's um, if you're married here, it's nine o'clock at night. And you're now in an argument. Right? And you think I don't know what just happened. But mostly this is guys like they're like what? They searched the last five minutes in their brain. And I've not done anything wrong in the last five minutes, right. But if you could step back and see a whole graph of your day, you'd realize that at 630. At dinner, you said something really stupid. And now it's hit me at nine o'clock. So I think that can be similar. You could have cheeseburger with french fries at dinner at eight o'clock at a restaurant and hit it with a great Bolus. And you're like, Oh, well, my blood sugar's still where I want it to be it's 140 After dinner, that's not bad. And two hours later, it starts to jump up. And that doesn't make any sense to you. Because you haven't listened to the Pro Tip series. You don't know about the fat and the French fries and the slow digestion and how you're going to go up afterwards. But at least if you see it on a graph, and then you go have those French fries and that burger again, you see it happen again, you can go Oh, I could get ahead of this. Right? Yeah, I could not say that stupid thing at dinner. And now we'd be watching television, and she wouldn't be yelling at me.
Jennifer Smith, CDERight. And if you have a pump, you can also address it a different way than waiting for it to finally start rising and getting too high. You can offset it ahead of time knowing what is coming because you've had the experience that, oh, it always hits around two hours. So I'm going to start doing something about an hour and a half before that. So that it actually doesn't happen. Right. So I mean, yeah,
Scott Bennermillion ways to handle that if you're from Arden, an hour after she has french fries, we have to Bolus for the fat. And there's a calculation you can do. And there's that heads off that secondary rise and doesn't cause a low later. That's the other great thing is that everyone, when you don't have enough data, you think, Oh, if I just keep throwing in more insulin here and there, it's gonna be it's not true. Like you can match the need up with the impact of the insulin and never cause a low. Right. And that's something you're going to learn looking at a CGM that, that uh, that a stable line on a CGM is really, your insulin, your insulin is pulling down, and your food and your other impacts are pushing up. And neither of them are winning like so if you can kind of imagine that line going off into affinity nice and stable. There's invisible lines. cables attached to it. One's trying to pull it up. One's trying to pull the line down, and neither can win because you have a great balance between your insulin and your knee. Yeah, so that in the CGM, like, seriously, like I don't care like there's decks comms and advertiser. It's not like I'm saying that like get a CGM. It's of any,
Jennifer Smith, CDEright? Absolutely. I mean, I've said before, many times if somebody was going to take my technology, I would fight for my CGM. Before I'd fight for my palm. Yeah, no, I would 100% would keep my CGM.
Scott BennerI'll throw this here too. Even though it's about like, leaving quote unquote, finger sticks. You're never going to leave finger sticks by the way, you're going to need them. You're gonna pass when you're not sure about your CGM. You're gonna test when you're making big I listen to my daughter's blood sugar looks high on her CGM, and we're gonna make a big Bolus. I said, Look, you gotta test, we got to know this numbers, right? We can't just start throwing insulin in here. And you're actually 40 points lower than this or whatever.
Jennifer Smith, CDEAnd I think it's also really important to acknowledge what you know about how you feel around certain blood sugars. Because, again, technology. It's wonderful. And it's so much better than it was years ago. But it may still not be accurate at certain points. So always those finger sticks are important to continue to use. Because if your symptoms or how you're feeling doesn't go with what your CGM is reading, I guarantee a finger stick isn't gonna lie to you not unless you still have like, apple juice on your fingers or something.
Scott BennerI was gonna say, and I didn't get to it just an accurate meter, just the blood glucose meter. Yes, they're not all the same. They don't all work as well. Don't just take the one that doctor handed you from the drawer, do a tiny bit of research. He's the one that I that advertises here because that's the one we use and it's amazing and, you know, like or do what you can do your own research and find out I will throw out a little story here. Because I did spend the weekend with my college age daughter, which I haven't done in a while as a visitor at school. Second night she was with me. We replaced her CGM. Okay. So at five o'clock at night, I said, Hey, your Dexcom is going to expire one in the morning. You should switch it now. It's before we're gonna eat dinner. We'll get it back online. It will have it we can do some finger sticks through dinner. And then it'll be rolling and working well by the time we go to sleep, because it does take a little while for some people to look right. You know? She does. I don't want to do that right now. So then when do we change her CGM? 11 o'clock, you know, like, oh, so then it's done. So then it's wonky for the first couple hours. And for Arden, if her Dexcom is wonky, it's wonky low when she first puts it on, mine is too. Okay. So like I made it, it'll be like you're 42. And she's 100. Yeah. 10. Like that kind of thing. Yeah. So there's a lot of consternation in what you should do. I'm a fan of letting it be on for a little while and calibrating it to help it get along a little more. But now we're asleep. And it's like Beep, beep, beep. All I could think was like that tone. I know. I said this. Nobody listens to me. But that's fine. And I'm like, And I know she's not that low, like and but it's worrying. So now she's, she's asleep. And I get up and I'm checking her blood sugar and she wakes up. She's like, What are you doing? I'm like, your CGM is going off. She goes, I'm fine. It's like, okay, so I tested her. And she was 130. And I was like, okay, so she's right. And I did a calibration and it came together pretty quickly. And that was it. Having said that, we could have done that at five o'clock. There. So there is a way to time, your technology. Now the new g7 is going to have a shorter warmup period, which will help overlapping you'll be able to soak your sensor, which I'm not going to bother explaining here. But as the technology gets better, so should those things. But that is not to say it's not like hands down. The most valuable thing that's happened to people who have any kind of diabetes, since I've since I've been aware of diabetes, some absolutely.
Moving to Algorithm-Driven Pumps
Scott BennerOkay. All right, Jenny. Now we got our CGM. We're using a pump. We're looking online. And we're like, see, this isn't that the doctor is not gonna go you know you ought to do. That's not gonna happen now. Because this stuff's also new. Maybe maybe a really in tuned doctor might say, once you get an algorithm, but for the most part, I don't think I think that's the thing you're going to figure out on your own a little bit. So all this stuff we're talking about about, you know, the basal be incorrect. And you might need a Temp Basal here, you might need to extend a Bolus for fat, you might need all this. There are pumps that make those decisions autonomously. Yeah, you have to be wearing at this time, you have to be wearing a Dexcom. Because it works with that. Right, but
Jennifer Smith, CDEor Medtronic's CGM? Yes, because they're their system also works with their pump, right? Yeah, so
Scott Bennerthere's a Medtronic version of this. There's a tandem version of this. There's an Omnipod version of this. All their algorithms are proprietary, they work slightly differently, but long and the short of it is they're going to give you insulin when you need insulin, and they're going to take insulin away when you don't need it. They're going to endeavor to stop you from getting low and endeavor to stop you from getting too high. You
Jennifer Smith, CDEstill had how they do that it was with targets Yes, right. Right, specific targets in each of the different pump systems. Medtronic newest one was just approved, which is really nice. But they all have specific targets. So how that algorithm works is based on when and how to give you more or less be Send a target and based on what the system is projecting off of your current CGM trend. So it's a very interesting like the algorithms don't just willy nilly deliver or take.
Scott BennerLike, I think maybe now more,
Jennifer Smith, CDEright? Yeah, exactly. There's a math to the algorithm
Scott BennerGremlin inside of your pump flipping a coin going, Oh, my God heads. Let's do it. So but it's it's it's stunning. Now there's another version. There's a number of other versions there are Do It Yourself versions. There's Android APS. There's loop. I think, Jenny, you loop. Right. I do. I think you and
Jennifer Smith, CDEI've been looping for five and a half years.
Scott BennerAnd Arden has been doing it I think since 2019. Maybe? So okay, yeah. And your Arden's using loop three as a mic, and you just switched to it as well. So like, so they're all just different versions of an algorithm making decisions about insulin based on your CGM trend. That's it? Yep. They're astonishing. They work incredibly well. They are not magic. Again, all settings, all knowing how to Bolus for certain foods, understanding the impacts of things, your digestion, your hydration, like all the things that are important about MDI are the same things that are important about pumping are the same things that are important about using an algorithm.
Jennifer Smith, CDEAnd you made I know, people can't see you, but you were very in a line going from MDI, to pumping to algorithm. And I think that's, it's a really important piece. For those who are listening to understand if you're kind of listening to this, because these are not pieces in your life already, right, and you want to get an idea. There is 100%, I'd say 1,000% value in learning on MDI. And then moving to a conventional pump, that does not do anything for you, meaning it does not use an algorithm. There's absolute value in that, you know, we talked about testing, and evaluating settings, and learning about all the variables, food and activity and everything, and how to adjust your pump, or your insulin doses to accommodate for those variables. I think, as you mentioned, when you said, you know, your pumps, like, hey, let's start on algorithms. I can't go as deep as you. So it's a totally different doctor. Right. But in that sense, there are I think, more doctors today who are thinking algorithm, but in my personal and professional opinion, I think some of them are thinking that too fast. Okay? They are they are moving somebody to, hey, you're MDI, let's move to this algorithm driven system, whatever the system is, whether it's Omnipod, five, or tandem or Medtronic there is, there's a missing piece in the middle there, that if for some reason, and we talked about CGM is potentially not being always accurate or technology failing. If your pump fails in its algorithmic dosing, and you have nothing to step back to, you're at a loss. And it's important to understand that, you know, so I can't emphasize.
Scott BennerIt's incredibly important. Jenny's been talking to me about this privately for years. Honestly, she's like, people can't just be put on the machine, the machine does the whole thing. And they don't understand why it's happening. Because, you know, the general argument is what if the machine stops working? I don't even think that's the need for that I think the need is that this is a thing you have to understand. Like it right, no matter what none of this machine stuff is at the point where you don't need to know how to how it works. It's not AI, it's not even a computer like you know, you used to have to know how to fix your computer because it would break all the time. Nowadays, you buy a Mac, it'll just do the thing you want it to do, you'll never have to touch it, and it'll die. At the end. You'll recall my math doesn't work anymore, you get another one. And you don't need to understand how a computer works. To use a computer. You need to understand how diabetes works. To have diabetes. I don't care what version of care you're using. I don't care what the next one is. Now, if someone magically comes up with something one day, where it just works, no matter what, like a, like a laptop from Apple, okay, then then okay, then God bless. If you want to skip it, then skip it. But I'm still gonna say that isn't happening anytime soon because of not just the things we've mentioned today. You know, your insulin pump site might not work on time, like your CGM might not be right right away like all the other things. It's just not happening anytime soon. So you don't want The worst thing I can imagine is that you put an algorithm on a nine year old who it works for. And then five years later, the kid hits like puberty hard or something, and you have no idea, like the algorithms doesn't know you just became a completely different person, you're gonna have to change your settings to make that work, right. And that takes experience. If you I think if you ever find yourself listening to Jenny and I talking and thinking, How come whenever something comes up, they just fill the next space with something valuable. It's because Jenny has been living with diabetes for over 30 years. And I've been staring at my daughter for 15 years watching her have diabetes, and I have a never ending supply of experiences and answers in my head because I live through them. Yes, that's why and that's why you absolutely yeah. Like you didn't go to like diabetes University where they told you something secret that they don't tell everybody else, right?
Jennifer Smith, CDENo, no, not at all. I mean, I have valuable behind the scenes, like information about disease states and those types of things from a medical knowledge base. Absolutely. And understanding them helps me to understand some of the navigation of that with diabetes, but the lived experience and the work that I get to do with so many people, that's the valley that you can't teach that right? In a university, you you can't teach, there's no degree and diet.
Scott BennerAnd for your situation, you've been helping people for so long. And professionally. I tell people all the time, like, it's, it's gonna sound self serving, but it's not like, it's that I was able to get advertisers for the show. So I could turn the show into a job so that I could put this much effort into it. Because I learned that every day I talked to people, like you'll hear me say, like, Oh, I was talking to a guy the other day, he said something about this, that's me. hearing something I'd never heard before and right and retaining it and being able to apply it to a situation go, oh, you know, where that'll help here. And then you get to keep expanding those conversations. I'm gonna get to something here. And you get to keep expanding those conversations till they help other things. We did thyroid episodes. Now we hear from people are like, Oh, my God, my life is different. Because I got my thyroid managed, well, I'm getting a lot of my I didn't realize about my iron and my ferritin, like, a lot of women especially are getting back to me, like they're feeling so much better, because it's something they heard on the podcast, they heard it on the podcast, because I was able to focus on this because this is what I think about. And now and now it's coming to digestion. And that because we had to figure out a problem with my daughter's digestion. And then we shared it on the podcast now I've seen that help other people. That goes for little things about diabetes, too. Yes, that's how this stuff spreads. This is a repository of information, but you're gonna build that in your own mind. Correct? Not if somebody slaps new algorithm on you and tells you don't worry about the thing will take care of it.
Jennifer Smith, CDERight? Because it one that's such a, that's such a big thing that I hear well, shouldn't it be helping me with this shouldn't be doing this shouldn't? The one word I hate is learned, I shouldn't have learned that I don't need this much insulin at two o'clock in the morning. Nope, your system isn't learning. I promise you. It's not learning. It doesn't keep track of two o'clock in the morning, gosh, I gotta give less insulin for this person. It's not that's it's not smart.
Scott BennerAnd Jenny, you know, oddly enough, as we make this episode, I put up an episode today called Rise of the Machines, where a guy comes on to talk about his Android APS system and how it he does believe it's going to learn in the future, which is so exciting, but not now. Like, you know, what's one of his examples? He said, location services. So if you say I'm having pizza, and it realizes you're at Domino's, okay, and you have an experience with insulin, someday, it will remember that experience. Yeah, if you go to a different pizza place and have a different experience. It'll remember that if you go to a third pizza place, it'll remember that if you head back to Domino's, it's gonna go Oh, we're back at Domino's. This. That's not happening right now.
Jennifer Smith, CDENo, in fact, there is there are some. There are some apps that actually you can track that way. Like you can take a photo of something and tap the location indicator and the next time you come back to that location, you'll be able to see what your dosing looked like what your CGM trend looked like so you can learn from Bob's pizzas, Friday night last week to this Friday night. Maybe I should change my strategy. It looked like this and I want to improve this right or do it differently, but those they need to be married right into the pump so that not only do you have Okay, now I'm at Bob's pizza. This is what I had. And hey, let's the pump then can acknowledge and I'm going to do something different for Jenny.
Scott BennerBut for that happening just automatically, that's not here yet. 2023 Omnipod five doesn't do that. Tandem T slim doesn't do that the control IQ doesn't do that the Medtronic doesn't do that. They know it may have happened one day. Sure. But the other I think the other thing is, I know you want your days to be easy. And they can be they can be much easier than they are now they can be more your intuition can come into play as you grow. But this is a lifelong thing. And what you want is you want to get to the point where I saw Arden get into this weekend, where we sat down to this meal, there were 16 different things. And she just looked at it and picked up her phone and went and push the button. Yeah. And I was like, How much does she give? She was I don't know, I told her it was like 85 carbs. And I was like, and she and I was like, okay, and then she was okay. And it was okay, look at a table at a restaurant. And she's like, I think about this much. And that's boy, forget this podcast and everything else. It's that's where you want to get to where it just where you wake up at two in the morning, you see a high blood sugar and you go, Oh, I know what this is. And that does come it really does come. So anyway. But you're going to transition along, by the way, I think algorithms are amazing. And
Jennifer Smith, CDEYes, they are absolutely i i love my algorithm. Absolutely. But I've also learned to work with it. And I've learned what it can do and what I still need to tell it to do. I think that's the big thing about algorithms is knowing that you still have a fair amount of action to put in to it so that the algorithm can work with you.
Scott BennerYeah, yeah, I wouldn't want anybody to think like, oh, you're using a do it yourself loop. It's magical over the other. There, it all is about the same. Like they all need your help. They all need your intuition. They all need your knowledge. There's nothing if you think you're going to just put a loop on or Omnipod five, and it's just going to be perfect. Like, you don't have to do anything. Like that's not going to be the case. No, yeah. So but don't be afraid. Like I'll say something here on the spot myself Saturday, make them clean and make myself set up. Yesterday was my friend Mike would have been my friend Mike's birthday. And I don't want to bring all this down. But Mike had diabetes, type one when we were teenagers. He's not with us any longer. I believe that one of the reasons Mike's not with us any longer is because Jenny alluded earlier that I was stepping along with my hands while I was talking about things like Mike never came along. He just somebody gave him regular an NPH. And he used it long, long after he should have been and you know, didn't have updated meters and didn't you know, he didn't do the little things that you do to come along. I mean, I guess what I'm saying is you don't want to be managing your diabetes like it was 10 years ago.
Jennifer Smith, CDERight? I don't think he's tonight. I think you're also bringing something in here. That's really important to consider. Because you've you've talked about, you know, practitioners bringing up hey, why don't you try a CGM? Hey, why don't you try a pump? If, if you're the one always going to your doctor asking for what's new. I don't know. I you know, and your doctor is very willing and can talk about it then with you. Maybe they didn't bring it up. But they're very, they're knowledgeable about it. Once you do get on it fine. But if this is someone who's never really brought it up and kind of like, shrugs their shoulder and like, sure you could try it, whatever you may need kind of like your friend maybe didn't have a doctor who was keeping up with what could have been better for him. Yeah,
Scott BennerYeah. Yeah, you don't you have to take this as a, I don't know if you want to call it a disease or like, some people don't like that word. But this is a way of living, that it begs you to be involved in it. Yes. Like it just it just really does. You have to be aware, you have to take some time to learn what is happening with technology, what's happening with insulins, you know, and you need to move along with it. Because if you look back 50 years, I still interview people who are like in their 70s and have had diabetes forever and they don't even understand why they're alive. Like Like you don't want your life to be a coin flip. You don't I mean, like there are things you can do to to to give yourself better health outcomes. And those health outcomes are not just health outcomes, their quality of life. They're your they're your psychological state of being like there's so much good that comes from just understanding. I know that sounds silly, but How to set your Basal rate and make sure your correction factors, right. And you know how to cover the foods you eat?
Jennifer Smith, CDEAbsolutely, I think and on a bigger scale, we're also we're all supposed to be a participant in our life, right? health in general, you may have been given good health to begin with, but you're the keeper of that health. Right? It's just like, you're the keeper of the car. If you continue to let the salt buildup on you never wash it off, you're gonna have a rusty car? Well, you're your body's the same way, right? You're the keeper of your health, you got to do things to maintain your health, diabetes, it stepped up a level it is
Conclusion
Scott Bennerabsolutely and so prepare to transition by getting as much good information as you can. But then at some point, you just have to do it. You have to just dive in and do it and then learn a new thing. And then once then you'll be surprised at what else comes from that. And anyway, listen, it's also not to say that you couldn't get an algorithm pump right now and teach yourself backwards. I actually think you can. Sure. I think some people have a harder time with that than others. And I don't want you to be in a position where you're lost and something's happening. And you don't understand why because it won't be any different than a person that gets over basal on MDI and thinks they're doing okay, but it's not really covering their meals well, right, you know, and then doesn't get hungry one day and it's up low all afternoon doesn't understand what happened, like crack diabetes. There's no reason that if, if you have an if you have enough information and understanding diabetes doesn't have to happen to you. And I think that's maybe the most important part like I would if it feels like it's happening to you, instead of you are doing something and then something's happening. I think you have to have to look and get a deeper understanding, because it shouldn't just be happening to you. That's all. Okay. Awesome. Thank you, Jenny. 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 Bumping 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 BGs. In Episode 1015, Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two, in Episode 1018 pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025, we talk 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. It 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 this 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 the 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 A1C 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.
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#1024 Diabetes Pro Tip: Female Hormones
Scott and Jenny dive into the topic of hormones, specifically female hormones and how they affect those with diabetes. They discuss the challenges and changes that come with menstruation and provide insights on managing blood sugar levels throughout the month.
You can listen online to the entire series at DiabetesProTip.com or in your fav audio app.
You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Music - Google Play/Android - Radio Public, Amazon Alexa or wherever they get audio.
Key Takeaways
- Honeymoon Unpredictability: During the honeymoon phase, remaining beta cells sporadically produce insulin, causing massive unpredictability. Flexibility and reacting to the blood sugar in the moment are more important than relying on static daily patterns.
- Post-Honeymoon Reality Check: When the honeymoon ends, insulin needs will permanently increase. You must re-evaluate your basal rates and insulin-to-carb ratios instead of clinging to old, lower settings that no longer work.
- Track Your Cycle: For women, insulin resistance fluctuates wildly with hormonal changes. Tracking your period allows you to anticipate these changes. Many women need 20% to 40% more insulin in the days leading up to their period.
- The Ovulation Spike: Aside from pre-menstrual resistance, some women experience a shorter, sharp spike in insulin resistance around ovulation (typically lasting 24 to 72 hours).
- Birth Control as a Variable: Hormonal birth control regulates the cycle but can also change baseline insulin needs. Furthermore, the "period" experienced on the placebo week of the pill is actually "withdrawal bleeding," which may impact blood sugars differently than a natural cycle.
- PCOS and Metformin: Polycystic Ovary Syndrome (PCOS) significantly increases insulin resistance. Metformin is often prescribed to help combat this resistance and smooth out hormonal imbalances.
Resources Mentioned
- Wrong Way Recording: wrongwayrecording.com
- Diabetes Pro Tip Series: diabetesprotip.com
- Juicebox Podcast: juiceboxpodcast.com
- Integrated Diabetes Services: integrateddiabetes.com
- Juicebox Podcast Type One Diabetes (Private Facebook Group): Join on Facebook
- Apple Health App (Period Tracker)
- Book: "Taking Charge of Your Fertility"
- Medication: Metformin
Introduction: Honeymoons and Hormones
Scott BennerHello 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 CDE 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 revisitable. 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. Okay, so we're recording I want to tell you that this lovely woman named Isabel has been helping me with the Facebook page. And she came to me recently and said, You need a pro tip for female hormones and you need a pro tip for the end of a honeymoon. She said these are things that people ask about constantly. And they must not feel like they're getting what they need out of the podcast on this. Now Jenny, you know, in my heart, the end of the honeymoon just means use more insulin. And when you get your period it means use more insulin but darn it. Let's dig in. Let's just dig into it and find out the details. Okay.
Jennifer Smith, CDESure. Yes, they're both good. Good topics. Yeah,
Scott Bennerdetails are apparently what is needed, and I am happy to deliver what is needed. And by that, I mean dig it out of your head and record it so people can hear it. Sure. Okay. Because my only experience with honeymooning that my only experience that I'm aware of personally with honeymooning because Arden had diabetes was diagnosed so long ago, and we had a little meter and some needles. I mean, I didn't really know what was happening in her. So Right. One thing that I can tell you is that I called my friend who was my children's pediatrician one day, and I I told you this before, but it fits in this this episode. So let's put it here. And I told him I preface my conversation by saying I know what I'm about to say is ridiculous. But is there any chance Arden doesn't have diabetes? And he said he sounded sad. I think sad that I asked him and he's and he said why? And I said, but she hasn't needed insulin for about a day and a half now. Right? And that lasted maybe? I don't know, 72 hours, and then it was just going yeah, anyway, that's my entire personal experience with honeymooning but I know how difficult it can be for everybody. So
The Chaos of the Honeymoon Phase
Jennifer Smith, CDEwell, another good question. And that I mean, as you sort of began with I just give more insulin right? Well, a good piece of honeymoon is or coming out of honeymoon, right? When you're you've kind of moved through that lack of insulin need or really really, some people can get by on just Basal insulin. They might not need anything for their meals or their blood sugar's don't go high enough to correct or anything right. But did you notice also Oh, that after that, like three ish days that her insulin needs were higher than they were before that. Here's
Scott Bennerthe here's the honest answer. I don't know. I didn't know what you don't remember. I forget that. I don't remember. I didn't know what I was doing. Right. So like, I think that feeling maybe encapsulates more honeymooning and the and the leaving of honeymooning for people more than anything like, right so somebody you or your child gets type one. It's a whirlwind. A, it's, you know, and if you're honeymooning, insulin needs are changing kind of radically sometimes. So just when you maybe get the nerve to, I don't know, Bolus two units of a basal, you know, and then the next day Your fight is 60, blood sugar all day that won't go up. And then the next day you think, well, maybe I shouldn't use the two units of basal and then you don't and then your body doesn't help that day and your blood sugar's 300. All day, that uncertainty, I think, is the main characteristic of honeymooning, don't you
Jennifer Smith, CDEtrue and honeymoon is it is really different person to person, as well as the like, movement out of honeymooning is different person to person like you didn't have Arden didn't have a very long honeymoon at all. And that's not uncommon from the studies that have been done. It's not uncommon with kids under the age of five who are diagnosed to have a much more rapid rapid onset of type one very quick, very aggressive, really high blood sugars, you know, unless they've been watching for it, or they know because of previous antibody testing that it could be coming, you know, DKA, all of those kinds of things. And what that results in is causing enough of the betas to be stressed enough, and the body kind of decreasing them enough in, you know, in amount that now diabetes presents itself. So but in older kids, and especially in adults, there is often a slower progression of type one, like, you know, here it is, and all those symptoms, and that often leaves more betas in the picture. Also, what's been found is that the sooner you get containment of blood sugars after diagnosis, you give some relief to those beta cells. And because now you know, you're either injecting or you're pumping insulin. And so that's something that's helping to take care of the blood sugar levels. And your betas that do remain can actually help out. And so honeymoon then often comes in, you know, were usually somewhere between about one to four months post diagnosis is the typical, like, honeymoon, time to expect that to come into the picture. And how long it can last again is person to person. It could be a couple months, it could be three days, it could be a year or two that you continue to have this like lack of more typical insulin need.
Scott BennerIt's the consistency that you're that you're missing and and then yes people's hearts I think I'll tell you after interviewing so many people, I've heard, I believe every variation of time and distance about honeymooning from adults and children and, and crazy stories where blood sugars are suddenly super normal super out of whack. One lady I'll never forget told me like she thinks her honeymoon lasted years. And then I'm wondering like, is that? Is that honeymoon? Or is it a slow onset? Like is that like, and I guess it doesn't really matter? Right? Like, what matters is that you're using insulin now. And there's going to be this variability to how much until things, I guess you could just say settle. But obviously it's not settle. It's until your beta cells give up. Right, right completely. Do do some people just not see a honeymoon at all? Where does that happen? I'm not aware of it. In
Jennifer Smith, CDEtalking with so many people that I have, and you know, it's always something I asked about is diagnosis. If somebody wants to talk about it, you know, or if it's been very, very soon after I get to talk or you know, before I get to talk to them, it's been very close to that time period. And it seems like again, everybody is a little bit different. A little people again, very little people tend to be the ones that I hear the most. We didn't notice very much anyone, okay. Or, you know, parents are concerned because they're like, I don't know, I feel like we never had a honeymoon. I feel like we never needed just like a little bit of insulin. We just went from not using any really using insulin you know,
Scott Bennerso functionally, how do people deal with it? So we And you know, let's say I came to you and I said, Hey, here's my seven year old kid. Yesterday, this basal and this meal ratio worked perfectly. Today, it's a hot mess. And I'm saving low blood sugars all over the place. I don't know what's going to happen tomorrow. But as I look back, this is bouncing around. It's two days of this one day of that. But how do you find reasonable stability until things get normalized?
Jennifer Smith, CDEWell, some of it again, in that early time period is, it's a bit of estimation, you can base it on Well, yesterday was a really sensitive day, if it looks like we fought low blood sugars all night, and we're entering morning time again today, with lower blood sugars yet again, that's a good visual that maybe today needs to be covered similar to yesterday, or even less aggressively than yesterday, right. So some hindsight can help. But then, you know, tomorrow morning, you wake up, hi. You didn't do anything strange overnight, and you're all of a sudden, hi, today might be one of those days that you're going to need more insulin. And so it, it's hard, because it takes us out of the picture, a lot of the things that we've done. In other we've discussed in other episodes, like testing, right, and doing things like Basal testing, in this time period, it's kind of hard, because you don't really know exactly day to day, how things are going to move overall, the general idea that kids before puberty, once remission, has kind of gone away, right? Once that honeymoon period, you're expecting it's over. Insulin needs usually are about point seven to one unit per kilogram per day of insulin,
Speaker 3say 2.7
Jennifer Smith, CDEto one unit, per kilogram per day of insulin. So and if you don't know pound to kilogram conversion, just take your pound weight and divide it by 2.2, then you'll have your weight in kilograms. But that's a it's a baseline, you know, if you were really, really, really low to begin with, and now you're doing a really low carb diet as well. You may not really see that insulin dosing kind of go along with what we would expect in terms of overall insulin need, right? Usually, people are considered in remission, if they're at, you know, point five or less point five units per kilogram per day or less of insulin. And then, you know, once you get to puberty, gosh, I mean, you could use anywhere between a unit to two units of insulin a day during puberty, and that's completely normal. Absolutely, and completely normal. So, if you're not so sensitive anymore, you definitely see these swings in blood sugar, you know, especially in that growth period overnight, or in the aftermath of meals, and is lasting and lasting and lasting. guarantee you're probably not in honeymoon anymore.
Scott BennerWell, you know, you I've said it to you, I've said to everybody listening, you have to meet the need. And I don't know if I'm right or enough about that. But if one day the need is greater than meet the greater need. And if one day the the need is lesser than meet the lesser need. And, and flexibilities just it's completely key. It's what you're saying. It's like you have to sort of I don't think that I don't think that during honeymoon, you want to look real macro. Not all the time, right? You want to kind of just deal with diabetes in segments of of half days or hours or something like that. Like, here's what's happening right now. If it starts trending one way than adjust with it, if it starts trending the other way, then adjust with it. But I don't think there's a lot of value. Unless you're matching an apples to apples day and going well last Thursday. You know, she was really low. So I don't want to be aggressive six days later. You don't I mean, like, today's got nothing to know. Yeah, correlation between now and six days ago when you're in this honeymoon fluctuation. And I know that people are gonna think I'm flipping but I think you could just retitle this episode, diabetes pro tip ministration. And I don't know that we're gonna say too many different things when we get to it, which is why maybe for some people, they gloss over it when we talk about these basic ideas of like, it's not always going to be the same all the time. You can't always ask for a cut and dry answer. I mean, if you want to get through a honeymoon period, and it's, it's particularly, you know, Rocky, I think that just staying flexible, meeting the need, you know, taking a little bit of historical knowledge off of days that were similar to the one year clearancing now, I think that's really the whole thing.
Jennifer Smith, CDEI think that's the best that you can do oftentimes, especially in honeymoon and then even, you know, coming out of honeymoon, there's, I know some people use the word like it becomes more stable. Okay. Sure. I mean, more stable in the fact that you're not like giving only one unit and that whole talk takes care of your whole day. Yes, absolutely.
Scott BennerOne day, the units necessary then the next day. It's not necessary. But there's consistency. I think they mean,
Jennifer Smith, CDEthere's more consistency is is it exactly. And I mean, in honeymoon, again, there are ups their downs, yes, you can, you can choose to use insulin from some hindsight from again, I know on a really, really busy day like this. My child needs a lot less insulin, but is running high today. Yeah. Okay. Again, it's the then meet the need in terms of where the blood sugar is right now. And thankfully, these days, I mean, you didn't have an I certainly didn't, does a kid have any visible to where my blood sugar was going at all. It was a one number, it could be rising in 10 minutes, it could be dropping in 10 minutes. And that's what it
Scott Bennerwill. I wonder sometimes when I'm like, speaking to this person, now who's got a very small child who I think still their needs are, well, they're not honeymooning, they were just, they had too much basal going. So it's, you know, by using too much basal, they were getting drops, that didn't seem to make sense, right. And so it took a day or two to figure out that the basal was too high, to bring it down a little bit. But in there, while we were trying to figure it out, this person was using pens. And so they were relegated to point five units at a time. And I just said you have syringes, and she did was like just eyeball less than a half. Next time we go for this meal, and did that and fixed a lot of their problems. And so while this kind of unseen force, obviously I'm talking about basal that we needed to fix though, but you know, let the unseen force be up, you know, your pancreas working all of a sudden, was dropping her down. The limiting factor was the was the measurement on this on the pen. And like, for some reason, your brain doesn't jump over that and go, Well, this might be too much what your brain says this is all I'm able to do. Do you know what I mean? Like and so but the minute we drop, like these quarter of units, then suddenly there was far fewer spikes in the meals and then far fewer lows afterwards. And I'm just wondering like during the honeymoon period, if you are that scared of these crazy drops, do you maybe just draw back your basal a little bit? And then on days when that basal is not enough, just increase your meal insulin a little or do you really mean like, because also these these poor people are probably MDI in this moment.
Jennifer Smith, CDECorrect most often and like you said, unless they have, you know, half half unit dosed or marked syringes in which yes, if you've got to get good eyes or you have a good magnifying glass, you can get kind of a quarter unit ish in there, whatever it might be, that I've got a good friend that does just that, and she's done it for a long time, and it works great for her. But again, you have to kind of use those microscopic doses. And on pens, it's a hard thing to definitely do, because all you can get is a half a unit. I mean, I think on pumps, honestly, in honeymoon and I know a lot of clinics often don't encourage people to start pumping until honeymoon is expected to be almost over. And I you know sometimes I agree with that sometimes I don't agree with that I think it kind of is individual in need, you have to look at what people are able to do and kind of a knowledge base of where are you already. But those doses they do, they do shift and change through honeymoon. And then you know, going out of honeymoon, you can expect the doses to definitely increase your child your teen your you know, adult that you're living with or your partner to or whatever, you're going to expect that their doses are going to increase. And while kids are growing at the same time as coming out of honeymoon, there are a lot of factors there. Another piece in the mix that often shifts things to higher insulin, and we've talked about it before we talked about illness and management is that if a child is also sick within honeymooning, and is now requiring more insulin, then by the end of the illness, they may actually either leave honeymoon sooner, or they may just be still at a higher insulin need as during the illness, the pancreatic beta cells were trying to assist, and there aren't very many of them left. So they were getting stressed out and can can leave less than
Exiting the Honeymoon Phase
Scott Bennerthat makes sense. So interesting. Yeah, I think that so I think that the next step here, I mean, besides telling people like look, it's gonna happen, you know, if it's happening, it's flexibility is key, it's going to be a little more stressful, but only if you I guess only if you're looking macro when you should be looking micro and then vice versa. Like you just talked about a lot a number of ideas where you do want to pull back and see the big picture, but not about the fluctuations day to day those you kind of got to get on like a bowl and ride them you can't step back and have an existential conversation about whether or not you should be bull riding, you know, so but but the other stuff are their illnesses is their growth, you know, activity, those things are, those are big picture items, but to now. Okay, so now you've figured out a way to ride through this honeymoon. The thing that I see from people over and over again, is that when it ends, you know, like when the honeymoons over, they can't believe it. They can't pull the trigger. They can't ramp up. Think about it any way you want to, but they get stuck in the game, and don't recognize that the game changed
Jennifer Smith, CDEnow Oh, yeah, I think the big thing there is that especially in honeymoon, the sensitivity to insulin makes people very wary. Yes, of using more, right, because you can get burned, right, by using more thinking you needed more, because yesterday, it clearly didn't work with this, you know, lunch that we provided we're giving the same lunch today. So I'm going to be more aggressive, you know, gave a quarter unit yesterday, today, I'm definitely giving a half a unit and then on the back end of the drop happens, right? The good thing to know is that in, you know, the coming out of honeymoon kind of moving out of that, that phase is that you will have again, more consistency in more need for insulin, you won't have as much potential for those drops, where you learned they typically happen even if it wasn't every day, you probably got a good idea of where things needed to be lower in dose, or, you know, that won't necessarily be the case. Once you're out of time. I
Scott Bennerfeel like you I mean, when I tell people about it, I say you just kind of have to reset at that moment. That's when you go back to the setting Basal insulin pro tip, you start over again, you get the Basal straight, you reevaluate how long your Pre-Bolus time is, you reevaluate your meal insulin after you've reevaluated your Basal insulin. And you just kind of start over that. The truth is, is that I think that the transition from honeymoon to out of honeymoon is not actually much different sometimes than the transition from MDI, to pumping in that it's just the, it's the same game different players, like I don't know how to like how to think of it, it's like, you know, right church, wrong, pew, I don't know what the what the the thing is, like you're doing the same thing. But the pieces have all just sort of adjusted a little bit. And you have to just step back, take what you know about the thing you've been doing, and reapply it to the new situation. Right?
Jennifer Smith, CDECorrect. And with pumping, you know that you've got a lot more precision that comes along with that. So if you've been doing things as precisely as possible with, let's say, Just half units, right? And basal that's given once or maybe twice a day. Now you can really address where insulin needs are heavier, and are lighter, through the course of a 24 hour day, you can meet the need more precisely, thus, the benefit of doing some Basal testing again, even if you're just doing it overnight, I mean, everybody wants to sleep. So if there's one time a day that you're gonna do it, do it overnight,
Scott Bennerpart done, and you get that part time to a bunch of A1Cs and some just good feelings. In general, if you're if you're thinking all 24 hours or just a train wreck, like maybe you can at least get eight or nine of them straight, you know an answer. And it's a good jumping off point for figuring out the rest of the day. I think that when you were saying something a minute ago, this thought just jumped into my head, and I'm gonna put it here. And I think it fits. I think no matter the situation, maybe I'm talking about just diabetes or life in general. But do something is often the answer. People, there's a few people freeze, wondering what the something should be. But if you're watching the same thing happen over and over and over again, if you just change the variables, the stressors on the situation, you might see something new, that helps you understand a bigger picture something different. And so, you know, if blood sugars are, I mean, I don't think it's a joke, but like online, sometimes somebody will throw up a graph and be like, I don't know what's wrong with this. And I'll literally just type more insulin. Because put in some more and watch what happens and then go Oh, cause and effect. I've done this, but they
Jennifer Smith, CDEwant to know where right. Okay, they want not just more or they're like, but where should I put that more insulin?
Scott BennerLike do something right, right. Like, if you haven't been on vacation in 15 years, take $5 a week and put it in an envelope, you know, do something, try to change the situation a little bit. And I get that it's frightening. And I used to think jetting, I used to think that all these things that I saw around diabetes, were so specific to diabetes, but I've been having some personal things going on with my mom's health recently, which Jenny knows. Probably not at all. Yeah, right away. But but the point is, is that I recognize that the confusion and the lack of knowing when to jump and feeling like you're overwhelmed and feeling like you don't understand what to do next. It's life, not diabetes, right. And maybe it's Feels a little more dire in some situations than others. You know what I mean? Like standing in the store, trying to decide between two waxes for your car might not be as crazy as I wonder if I want to add three more basal units to my kid or something like that. But the truth is, is that that inaction, that's what keeps you where you're at. So if you're somewhere you don't want to be, do something,
Jennifer Smith, CDEright, an easier one to honestly do. Let's say you are running high, you know, all day long. And you're higher after meals, but you're still just stuck high in that scenario, and a safer thing is just add a little bit more basal. Yeah, add just a little bit more basal, right? If instead, in time periods where you're not actually eating, it doesn't look too bad. And then you've got these big excursions after you eat just about, you know, anything, even a microscopic eight grams of carb, maybe and it goes rocketing up, well, then you may be okay with basal, and maybe the next place to add more. And again, not three units more, but maybe add a half a unit or adjust your insulin to carb ratio by one gram to get a little bit more insulin around the times that you see the change that you don't want to see happening.
Scott BennerArden has been getting up in the morning going to school, and her blood sugar has been rising this this school year, like 30 points in the morning. And I tried to let the algorithm mess with it didn't work. I tried making just some simple basal adjustments wasn't enough. And then finally I just said, Doris, like when you leave the house from now on, we just Bolus three units, please. And she's like, what I was like, just throw in three units, get the car go to school, I was like, because whatever's happening is happening enough. I believe it's happening, I trust that what I know is going to happen is gonna happen. And she's using an algorithm. So if you make an uncovered Bolus, it removes her basal immediately. So her Basal is like 1.2 in the morning. So I figured it was about a unit and a half or so to fix the number or to get ahead of the number. And we got to cover the Basal that's gone. So I was like, just three. And then we adjusted off of that ended up being a little too much the next day, we did a little less than next day, we had a better outcome. The next day, she forgot to do it. You know, on the third day, I was like, see it happened again, like, you know, like, do this thing that made her trust that tried to do it, and it becomes a little more important to her. I just think it's another example of do something. Right, you know, I I've been saying online a lot to people lately. And you'll forgive me because I can't pronounce it. in its in its origin language. In Latin, but I've been telling people lately, Fortune favors the bold. Just try something, you know, they mean, stand up thump your chest and go, I'm gonna take a swing here. Let's see what happens. And then you get back to this stuff you hear in the earlier pro tips, you know, right, it's all well,
Jennifer Smith, CDEand I think the bigger thing too, that you're you're bringing in is try something, right? But then analyze what that training did. Right? Don't just try it and be like, Wow, that clearly didn't work. Like, still focus on it. Well, it didn't work, your adjustment either left you too high, or like, you know, happened for you and caused it to be a little bit too low in the algorithm couldn't really save you from that extra insulin well, but now you know, so you use that for that information and you move forward and you say, Okay, tomorrow, we're going to do it this way. I mean, that goes into you know, a lot of things in terms of kind of the exiting of the honeymoon. It does it's try this it looks like consistently in the past week, he's needed more insulin. Okay, great. You're trying to add more insulin? Is it enough? Is it getting to you to the place that you want to be? Insulin needs may actually continue to climb a little bit? It's not like a night and day like yesterday, we needed one unit and tomorrow we're going to need 10 units. That's not typically the exit of honeymoon. But over time, that lack of beta cells that is that was helping you is going to show up very evidently in that you don't return to that minimal amount of insulin.
Female Hormones: The Impact on Insulin Needs
Scott BennerDo you know what made me do this episode when Isabel told me that she thought it was necessary? It was that I had to get over that thing in my head that it's already in the podcast. Like I was like, No, it's in there already. You just have to listen to it. And then I thought, well, it's in there but it's in a different way because what we just talked about what about that? It really is the way when I'm when I was talking about God I don't even know what episode it was now. I guess maybe That's a good point. It's hard to find them all but but when I was talking about like sometimes you know, people's meal insulin meal ratio, sometimes their insulin to carb ratio can be like spot on for a number of meals, but not work for a certain meal. And I always use that silly example, if you have meatloaf and mashed potatoes and green beans, and you count the carbs and it says the carbs say, Oh, this is five units, you make your Pre-Bolus, you spike, you end up correcting later with two units, which brings you down and you don't get low. Well, the next time you have the meatloaf in the mashed potatoes or whatever, seven units, you seven units, right, like you see it happen. And then you take the leap, you stop looking back at the meal ration going no, that's not right, I counted the carbs, it's right, this is five units, very similarly to the idea of you're using a pen that only goes up to a half of unit, and you keep using it and then watching a low blood sugar happen. I go, I'm powerless, but you're not powerless. Like you just need to go get a syringe and do it a different way. And you're not at the mercy of your carb ratio just because it works five days a week, but not on Sunday when you have meatloaf like Right. So it's all kind of the same idea. Like, I know, it sounds trite. But it's all well, and that's
Jennifer Smith, CDEI think it brings in a good a good piece too, in terms of, you know, multiple daily injections, and then we moved to pumping. And then we move to the fancy features of pumping. And then you might move to an algorithm driven pump, right? All of these things take. They take like evaluation. And a good example from somebody I worked with a while ago, who had started using one of the algorithm driven pumps. And she's like, this is fantastic. I love it. It's working so awesome. Like doesn't work on Friday night. And I was like, Okay, well, what were you doing on Friday night, that this doesn't work anymore for you. And she had this like, whole thing figured out for her dinner Friday nights that she would go out to with her husband. And on a conventional pump. She could use like, you know, a temporary basal. She could use an extended Bolus, and she had it down, Pat. I was like, just go to manual mode in your pump. And use it that way overnight and Saturday morning, turn your algorithm back on. And she's like,
Speaker 3why didn't I think I was like, Oh, I don't know, either. But I hope that
Jennifer Smith, CDEit helps. And it it seemed to be much better. Right. So
Scott BennerYeah, because we went to a bar and art and got nachos with cheese steak on top of it and had French fries. And I crushed my first Bolus. I was like, I haven't been this excited about a Bolus. And while I was like I was on top of it. And then I started seeing the fat rise. And we hit it again. And I want and like I was over. And then I go upstairs to start working. And suddenly she jumps up her blood sugar jumps up and I go downstairs to my lab. And what happened? I had some gummy bears. She told me and I was like, no, no, we can't put simple sugar on top of fat and protein. I was like, are you all out of your minds? Without like significant I said art, if you were any gummy bears in this situation, the Pre-Bolus would have needed to be causing a fall before you put the bear the bears in, you know what I mean? Then that would have been okay, but she just did the like my blood sugar is great thing through and some insulin, wait a little while and ate it. And it was not nearly enough. We needed to be more drastic with it. And so I was like, so my text, my text said this, I'll bleep it out. It said that it said, open the loop Bolus for you.
Jennifer Smith, CDEAnd let and let the Basal
Scott Bennerpumping for a minute and stop asking this algorithm to do something that it doesn't know how to do. You know,
Jennifer Smith, CDEbecause it's not it's not a learning algorithm. Unfortunately, it doesn't, you know, it doesn't react the way that we have the experience to say, I know this is what's going to happen. Please don't fiddle with the insulin that I put in purpose
Scott Benneris not the time to take the basal away algorithm. Cheese Steak nachos happening right now. Anyway, Jenny, you know, there was in the past, there was a moment when I, I used to worry. And I think like Well, we've already said these things. And people will find it. And now I realize that that's not how this is going to work that these continuing conversations are incredibly important. I think maybe the conversational part of this episode and many episodes is more important even than the technical aspects of what was said inside of it. Right. So like, if you listen to the Pro Tip series, and you had your brain or my brain or your experience in my experience you could derive from the Pro Tip series how to manage a honeymoon. But for people who are in that situation I think they need Get the information here. Yeah, I mean, in one spot. Yeah. And I just, I don't know if I was just like, super hopeful or lazy, I'm not sure. But I used to think like, just go listen to the protest episodes, it explains the whole thing, you know, and it really does. So I appreciate this, I think we're gonna have to, you know, like I said, I want to do one for you know, female hormones, menstruation, that kind of thing. So yeah, pick the next time we record. And then from there, I'm going to say this year, Jenny, because it'll put us both on the hook. In 2022, Jenny and I are gonna go back to certain pro tip episodes, were going to re listen to them on our time, and then incorporate questions that I'm collecting on Facebook, on how to supercharge those episodes. So they're going to kind of that's gonna get part two, kind of a situation. That's what cool that's how we will you and I will spend our time seeing each other through the winter of 2022 sequels to certain episodes, I'm thinking of them as director's cuts for oh, there you go. Older people who you remember the director's commentaries? Yes. You know, where do you mean you flip the movie on and the audio goes away, and you just hear the guy go? In this shot. What I was thinking was that if the sun came in from the left,
Jennifer Smith, CDEwe could could pan over here and listen to this music from this producer, you know, whatever.
Scott Bennermissoma Hi, X eyes are glistening. I did. I told the DP like, I don't know if you ever listen to them. They're pompous exchanges, Jenny and I will not do that. But we're gonna go back and listen to what we've said. Because I've done it a couple of times, like in Episode 500. I went back to Episode 11. That's bold with insulin. And I listened to it and like tucked over top of it like so people listening in episode, I think it's 100 Oh, my God. 105. Sorry. In Episode 100, I just basically did a director's cut of that, because I realized that when I said it, I was just saying it. Like there was and now I've lived all this time since then, and had these interactions with people that maybe there'd be more to add to that. And I think that exists for the protest series. Like and I'm excited. I'm sorry that you're going to start getting emails from me that say, please listen to this one before we talk again. But
Jennifer Smith, CDEno, that's fine.
Unknown SpeakerYou're a busy person well, and I can do it during
Jennifer Smith, CDEmy workouts. That's not usually I just, that's my mental like, my moving like mental sort of like strategizing time is my exercise time. I am not like a sit in one space and like meditate. I'm a moving meditator, but I can meditate on the episodes so we can make them better for everybody else.
Scott BennerI have a question, then I'll let you go. How do you make out listening to your own voice? Does it freak you out?
Jennifer Smith, CDEIt's I don't know. It's I guess it's kind of weird to me, because I like I hear myself speak, you know, in your brain like, but when you hear yourself, it sounds different. I guess. I don't mind listening to myself. But Yeah, I don't know. I don't think that I sound like what I sound like when I listen. No,
Scott Bennerno, no, I sound so right now we're recording, I can hear you and me and my headphones. I sound different in my headphones that I sound on the recording. And if I'm just speaking out into the world, I don't think I sound like the person on the podcast at all, but people think I do. But in my ear doesn't sound the same. Although And do you ever get on? Do you ever? Do you ever say anything and hear yourself? I go oh, Jenny, you should not have said it. You should have said it like this. You ever correct yourself?
Jennifer Smith, CDEI do. Absolutely. And a lot of the ones that I listen to I'm like, Oh, this would have been a better explanation. Or I could have put this in as an example. And that would have been better. So maybe we Yes, I think it's great to sort of rethink them. Because then we can
Scott Bennerwalk and I agree that there's there's just always going to be other stuff to say. And as we move forward into 2022 and beyond more people are going to be using algorithms. And there's going to be a whole new layer of understanding for diabetes, there's going to be things that you and I don't haven't experienced yet, that that through these experiences over and over again, abusing this technology, you're gonna come out I don't see an end to this podcast, I used to think it was finite. And now I think somebody is going to need to, you know, make up a cure for this podcast not to be necessary. So Well, that's
Jennifer Smith, CDEwhat I was gonna say. I don't think until there's honestly a true like, you don't have to use any technology or anything. You just go in and get your bloodwork done and make sure your doctors like yep, you still look great. It's all perfect. I don't think you know the information that people need, especially with life changing and everything. I think it's purposeful.
Conclusion and Series Outline
Scott BennerI appreciate you doing this with this. It's sort of the end of the year. So let me thank you for giving your time so greatly to the podcast. 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 or 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 Bumping 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 BGs in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two in Episode 1018 pregnancy 1019 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 A1C 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.
Jennifer Smith, CDEJennie 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 can learn more about her at that link.
Scott BennerIf you're living with diabetes, where are 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 If 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
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