#315 Jenny Smith, CDE discusses Coronavirus
Coronavirus disease (COVID-19): Juicebox Podcast conversation with Jenny Smith, CDE
Recorded March 20, 2020
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Scott Benner 0:07
Hello, everyone, welcome to Episode 315 of the Juicebox Podcast. Today's show was recorded on March 20. It is a conversation about Coronavirus with Jenny Smith. At the end of the episode, I've listed some important talking points from the CDC website. Make sure you get to those.
Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. Please always consult a physician before making any changes to your health care plan, becoming bold with insulin, or anything else that might come up. You know what I mean? Jenny Smith is a registered and licensed dietitian, a certified diabetes educator, and a person who's been living with Type One Diabetes for over three decades. Jenny has the exact same person you hear on the diabetes pro tip series during the defining diabetes episodes. And of course, ask Scott and Jenny. Jenny works at integrated diabetes. And if you want to check her out, or even higher, you can do that. Jenny's email addresses right in the link of the show notes.
This episode of The Juicebox Podcast is sponsored by the Contour Next One blood glucose meter. The Contour Next One is without a doubt the finest most accurate blood glucose meter My daughter has ever used in the entire time she's had type one diabetes, go to Contour Next one.com to find out if you're eligible for an absolutely free meter today. The podcast is also sponsored by touched by type one. When you go to touch by type one.org, you're going to see an organization that is working towards a cure, supporting people with type one diabetes, and putting on maybe one of the greatest dance shows I've ever witnessed. Go find out more about them. They're supporting people with type one diabetes all over the world. You might be one of them, go check them out. And if you don't need that support, and you want to help support someone else, this is a great way. Touch by type one.org is a great way to do that. Get yourself an absolutely free no obligation demo of the Omni pod sent to your house today. Go to my Omni pod.com forward slash juice box. When you get there fill out a little bit of information. And on the pod is going to send you an absolutely free no obligation demo of the Omni pod. You'll be able to try it on wear and see what you think. And of course, find out more about the Dexcom g six continuous glucose monitor the exact same CGM that my daughter wears today. Go to dexcom.com Ford slash juice box. Let's get to the show.
Jennifer Smith, CDE 3:01
Hello. Hey, good morning.
How are you today? I'm
Scott Benner 3:06
we're hanging in there. How about you?
Jennifer Smith, CDE 3:09
Yeah, I'd call it the same. Oh, I would assume calls home from school.
Scott Benner 3:14
Yeah, we didn't even make it through. My gosh, we didn't even make it through is I'm
Jennifer Smith, CDE 3:23
sorry. I didn't realize I was all covered. A little post it notes.
Scott Benner 3:27
I don't want to know what you're doing with your computer in your private time. It's fine. So Cole was in Florida for his college tournament. He got there Friday. We got there Friday. On Sunday. He asked us for Azhar tech thinking that his allergies were coming on the runny nose. On Monday, he asked for another one. Kelly and Arden left on Monday to go home. I stayed behind Tuesday was his day off. And when I picked him up Tuesday, late Tuesday morning to take him to lunch. I was like, are you okay? And he's like now I don't feel right. And I was like, okay, so I took him out to eat. And he didn't look good. So I said hey, go back to my hotel and lay down for a while. So three hours later, he woke up. And he woke up to an email from his coach and said we're having an emergency meeting to talk about the season. So I had to hump him back like a half an hour to his hotel. He was feeling better from sleeping, but, you know, he didn't look magically better than me. Right. You know, and they announced that the season was going to be suspended. That's what they do at the time. And he definitely didn't feel well still. So now he's like ask me kind of like trying to be like, slides like I couldn't have the Coronavirus, right. And I was like, I mean you could you know I said you know what, what are your symptoms at that point he had a sore throat, a runny nose, you know Now you don't have a fever, you know. So, right. So the next day comes Wednesday, he ends up pitching his face off against the number one ranked team in the country. In Division Three, just pitches, these two amazing innings comes out of the game. The game ends, he gets on a bus and goes back to the hotel. I'm supposed to pick him up for dinner, he texts me, he goes, Hey, I'm not gonna go to dinner. But come over here. He's like, I felt like I was gonna throw up on the bus. And so I think he used every ounce of energy, everything he had, and realized that he was sick. So on the way over there, I just stopped at a like a Walgreens. I'm like, let me just get a thermometer. You know? Yeah, stuck the thermometer in his mouth. He must
Jennifer Smith, CDE 5:45
be a dad. Yeah.
Scott Benner 5:46
100.4. I took him right to urgent care. Oh, my God. Now he's an urgent care with a mask on. And they swap him for flu. He doesn't have the flu. And the guy looks at his throat and says, Listen, you have strap? I can see it. You know, he's like, I'm gonna give you a antibiotic. And I said, Are you gonna swap him for it? He goes, man, this is strep throat. And I was like, okay, you know, fingers crossed and all. But I took him out of the hotel where the kids were where the poor kid had to leave his team. Wow, I just basically like shudder, like, just yeah. And the he didn't play the rest of the week, obviously. But the antibiotics did it. That's right. He had strap. Yeah. So but you know, in the moment, it was weird. And when he went back to watch the games, like from outside of the dugout, and the last two days, people were, you know, they're like, hey, how's he doing? Like, you know, we just want to make sure it's all right. It really what they meant. No, they really meant was Hey, got strapped we took given authority has exactly what I was saying. Just like just like, oh my god, are you allowed out of your house? What's the Wisconsin thing so far?
Jennifer Smith, CDE 7:03
So the Wisconsin thing is beyond the like, multiple levels of weather we have happening, like it was raining before and now it's like, fuzzy snowing, sorry, I'm looking out my window. But being trapped in the house. No, I mean, we can go outside. Our kids are out of school. The governor originally had a timeline of like, on April 6, but just two days ago, no, two days ago, we got another email from our school district specifically stating that according to the new guidelines, school is delayed or cancelled indefinitely. We don't know which my husband and I are like, okay, that means that Oscar is just not going back to school this year. That's what I think we will be homeschooling and I mean, the The good thing is that, you know, working from home, I'm here right? But the bad thing is that working from home, I don't have a clinic to go to so I have work that continues which is very good. It's good that people can utilize this type of telemedicine to stay up especially as things change and things happen and there are more questions that come in. But it also makes navigating my day a little bit more interesting.
Scott Benner 8:22
Okay, we're talking about the Coronavirus today. So here is on the pods website if you want to know more about how they're handling Coronavirus. It's it my omnipod.com forward slash Coronavirus. So if you want to get a free no obligation demo, go to my Omni pod comm forward slash juice box but if you want to find out about the Coronavirus and how Omni pod is handling it, my omnipod.com forward slash Coronavirus there they will tell you how insulin is responding to the coronavirus outbreak. They're going to tell you if Coronavirus is impacting insolence ability to produce its products, what sterilization processes are in place to ensure the pods are safe. may talk about reordering. I'm gonna jump through it really quickly. insolate continues to be vigilant monitoring and managing the global impact of the coronavirus outbreak. So that's how they start to talk about their response. They say they also have a comprehensive plan in place to ensure the safety and well being of their employees and they are going to continue to deliver on the pods to those who depend on the product manager type one. At this time. insolate does not anticipate any product supply issues. Pretty cool here. They talk about the sterilization process. Why don't you go check it out if you're interested my omnipod.com Ford slash Coronavirus. Next thing I have to share with you is a lovely email that I got from Rick Doubleday. Rick is the chief Commercial Officer at Dexcom. rick sent me a note and said at this moment, there are not any interruptions to Dexcom his ability to produce and supply product. However, we do anticipate near term delays in both customer service and tech support as we transition more employees to a remote work environment. wait times on the phone will be much longer than usual. We ask that customers Please only contact Dexcom support for urgent requests at this time. Dexcom is committed to communicating with their customers as the situation evolves, and customers should visit dexcom.com forward slash Coronavirus for latest updates. So that's directly from Rick. Now, if you want to get an Dexcom system going go to dexcom.com, forward slash juicebox. If you're already using it, you want to know how Dexcom is reacting to the outbreak, check that out right there. Now, when you start looking around the internet for a little break from all this, go to touch by type one.org. There, you're going to find an organization with the mission to elevate awareness of type one diabetes, raise funds to find a cure and to inspire those with diabetes to thrive. They've got great programs and services, all kinds of stuff. And hopefully, I'll be there and may speaking, if you know, we're allowed to travel again and get together with people. But you know, that's a long way off, I have good feeling about that. Anyway, touched by type one.org. Check them out today. Last but not least Contour Next one.com. That's where you can check out the Contour. Next One blood glucose meter, there's a little yellow tab at the top it says get a free Contour Next One meter today, check that out, see if you're eligible. This meter also has a wonderful app that works both with Apple and Android really helps take your data to a new level. Contour Next one.com. All of these links can be found in your show notes at Juicebox. podcast.com. Alright, let's get back to Jenny.
Jennifer Smith, CDE 11:57
My husband is on medical family medical leave right now from his company. They allowed employees who have family members in home or whatnot that could be at increased risk to take their family medical leave. So he chose to do that. I mean, he sees thousands of people a day at work. And he was like, yeah, I'm
Unknown Speaker 12:16
just gonna be at home with you guys. So I'm sure companies looking for some people not
Scott Benner 12:19
to come in anyway. They're correct.
Jennifer Smith, CDE 12:21
Yeah, yeah, exactly. So you know, that kind of works out for whatever limited time he can use that for? I mean, he'll have to go back to work at some point. You know,
Scott Benner 12:34
we'll figure it out. We're gonna become a socialist nation pretty soon.
Unknown Speaker 12:37
Right? Well, yeah.
Jennifer Smith, CDE 12:39
But I mean, I'm, it's interesting, because, you know, grocery stores and everything, those things are still open. I expect for like limited time. I haven't really looked at the websites to see Are you still 24 hours? I would expect? Probably not. But yesterday, I thought, I got the brilliant idea from actually somebody I was working with. And she's like, Oh, I just, I just go online. And I just ordered all my food. And I just pick it up at the door. And I was like, why did I not think about? Oh, so I went online. And I did that, oh, the next time I could pick up groceries at the grocery store that we most often go to is Monday, March 30. Like, at 6pm. I'm like, I'm out of all of the fresh stuff that I eat every single day. I'm like, I'm not living just on like frozen broccoli. So we picked
Scott Benner 13:27
one person. So one of us goes to the grocery store. Nobody the other person's not going. Yeah, tomorrow, we're supposed to go move cold stuff out of the dorm. I don't even know if they're gonna let us do that. But wait and see. But no, I think this is going to go on for months. I don't think the kids are going back to school this year. And everybody is now seeing, you know, for all the things we talked about that are important. If you can't walk outside without getting sick, nothing else matters. You know, it's really, really something else there. I there's that one model out of England that says between 600,002 point 2 million Americans could die in the next year and a half or something like that, which is it's funny. It's a staggering number, right? And at the same time, my son said to me, because he's, you know, he's younger, and he doesn't feel like he's gonna get sick. Right? He goes, how many people die anyway. And I was like, what, just like before this and I said, about 150,000 people a day worldwide die every day. And he's like, so was 2 million a lot. And I said, it is if it's you. Yeah, you know, there's a way to look at the world personally. And there's a way to look at the world,
Jennifer Smith, CDE 14:40
you know, globally, globally. And yeah,
Scott Benner 14:42
there's two things are they're very different. So
Jennifer Smith, CDE 14:45
we are exactly I see no,
Scott Benner 14:47
I stopped my 20 year old son from going to play basketball. He's like, we're gonna go play basketball like you're not. Yeah, no, you're not PlayStation, that's your dream come true. You can play it as much as you want. So, um,
Jennifer Smith, CDE 15:01
we have everything closed. I mean, other than pharmacies and that kind of stuff. So yeah.
Scott Benner 15:06
Okay, so let me let me first talk with you about this. I think it's just important right now with the timing to put out an episode for as long as it needs to be if it's 10 minutes or half an hour or whatever it has to be talking about how to manage through a respiratory illness. Because, you know, it's gonna happen and we can at least have a baseline idea. We don't know what this you know, what do you call it? By the way, do you call it COVID-19? Or the Coronavirus when you're just chatting about it at home?
Jennifer Smith, CDE 15:35
I've just been calling it the Coronavirus because I just I feel like all of these extra like, names to things just it's confusing in my brain. So I'm like it's the Coronavirus whatever they want to call it beyond that. Fine. Right?
Scott Benner 15:48
We definitely go with Corona here. Because in the you know, in the monsters incorporated movie when the sock touches the thing, and they yell 2319 2319. So when people say COVID-19 Kelly, here's 2319. And it starts the whole comedy routine in the house. So we don't say that like that.
Jennifer Smith, CDE 16:06
That's funny.
Scott Benner 16:08
We go Coronavirus, though. So okay, so we don't see, I've seen I think two people with type one on social media who have had it so far, but haven't really heard much from them. We're starting, you know, you're you're not really hearing from people yet who have recovered from it. Because those recoveries have happened overseas, we're right, you know, we're, we're still in the spot where you're gonna see, I mean, today is the 20th of March, we had a big increase yesterday in diagnosis, and I'm gonna guess it's gonna double today, because we're now starting to see numbers from, you know, people who were tested five, 810 days ago, right. So there was
Jennifer Smith, CDE 16:50
a really good post done, and you might have read it, The Washington Post did a really good article that had graphical of dots interacting with each other, and how, like, you know, no social isolation versus minimal versus extreme socializing, isolation, and how much difference that makes, but you still get a blowout of people, it's just slower, and it decreases that, you know, that you graph essentially, of how many people will potentially get it, I think the problem will be until we have hopefully a vaccination for it at a small level, and I think this is why it draws out how many months we're going to see things closed, and social interaction minimized and things. Because until we have a vaccination, it's just going to keep floating around, just like somebody is always going to bump into somebody that bumps into somebody that bumps into somebody that hasn't had it yet. And you know, they don't, but that being new from everything that I've read, the human body doesn't know what to do with it really yet, or how to form like the antibodies and things that it would normally form for the typical cold and the typical flu and, oh, I see this again, I had this, you know, two years ago. Now I can handle it better again. Yeah. I think
Scott Benner 18:11
a lot of people mistakenly believe that it's gonna have a season like the flu. And it'll just we'll get to a date, and you just won't hear about it anymore. And that I think, listen, I don't know anything other than what I'm paying attention to. But I just had Dr. Adam Edelman on the show the other day, in this episode with us going to go up right after that. He talked, I brought up the Washington Post article, and before I could tell him, it was out of the Washington Post he was was that in the Washington Post? And I was like, yeah, we've all seen that. Right? Yeah. Because it's such a wonderful visual visualization of how you know, spread happens. But I would say, this is gonna last two full Corona seasons, whatever this time is going to be, and then I think there's going to be a break, and then I think it's gonna come around again. And then it'll probably be a normal part of life, like the flu, and, you know, write SARS and MERS, and all that other stuff. But it just spreads so much more quickly. And easily then things in the past have. And so you're just seeing it, overwhelm everything.
Jennifer Smith, CDE 19:13
Right. I think that in terms of, you know, diabetes, I think people with diabetes, or even people with other, like chronic health conditions, where they've become, it's become a habit to be more careful about things like, you know, you change your pump site, or you take an injection, you clean the site, you wash your hands, or, you know, maybe you wash your hands before you do a finger stick or you put your, your continuous monitor site on or those kinds of things. So we we already are a little bit ahead of the curve of just paying attention to hygiene is in it cautiously in that sense, you know, but then, in terms of just management, I mean, the only the only one that I read about online with type one specific was, as you mentioned a guy over In the UK, I believe he was from he had gone on a ski trip in like, December, December, early January or something with a group of friends. And a good majority of the group got have Corona or had Coronavirus. He himself got tested because others in his group, he was positive. And his symptoms actually didn't show up for several days after he was tested positive, and he has type one. And he actually, in his article, he mentioned the fact that it wasn't so much the diabetes management. That was the hard part about it. It was he described it as like uncontrollable respiratory coughing. He said it was just so unbelievable that the only thing that helped was some type of medication, his doctor prescribed him and he went and he picked up steps to stop the actual coughing, but he said otherwise. And of course, this is an end of one experience, right? Everybody's experience with an illness is a little bit different. But I think it gives, it gives good information that if you were fairly healthy outside of just your diabetes, and you have fairly good blood sugar control, which is a huge key in a lot of this, then your management strategy for the illness piece of it shouldn't be that much different. If anything, you're you're gonna likely need I mean, most people with a respiratory illness who have a fever, or an infection, you're going to increase your insulin use. So
Scott Benner 21:35
I Well, it's interesting, because obviously, we this is a new virus, you know, for us and no one's really seen it before, but I've been managing Arden's blood sugar in one way or another for I mean, over 13 years, it's probably coming up on 14 years pretty soon. Viruses don't really change her insulin needs greatly. Now, I've seen it differently for other people, you know, but I just don't see a mass difference. I have to share this somewhere. So I'm going to do it here. So Vicki's been on the show before she talked about eating. What's the thing when you don't have any carbs?
Unknown Speaker 22:15
I can't believe that we're just Oh, like ketogenic ketogenic she was she Yeah.
Scott Benner 22:18
Vicki was on to talk about that. She and I were speaking this past weekend about something different. And she said something just hilarious. She's like, I'm not afraid of this fires. She goes, my immune system has already killed my pancreas and my thyroid. It could take this, it could take this Coronavirus. No problem. I was like, oh, but I think a lot of people with type one feel that way too a little bit. Right. Like, I mean, it's not everybody, but you talked to a lot of people are like, I don't get sick that often. You know, like my immune system is really great. I'm incredibly healthy with the exception of the fact that my pancreas doesn't work,
Jennifer Smith, CDE 22:54
right. I mean, honestly, I was until I had kids who started going that well, one child who started going to school, I rarely had even the common winter cold rarely. But, you know, so and even from that standpoint, I would say when you talk about you know, Arden's insulin needs don't really change so significantly, everybody is a little bit different. And I think the other thing to consider is the severity of the illness. And what At what point you are in illness, right, because I know myself with just a typical cold like the sniffles I might feel a little under the weather. But other than that, I'm going about my normal daily I'm not laying in bed like blowing my nose like minute after minute after minute. That typical cold, I maybe need a little bit more insulin like maybe five or 10% more it's not even as significantly noticeable and if I can remain at least moderately active, I actually don't even notice a difference in my insulin needs. Whereas if I have a really nasty cold my insulin needs will go up 40% from a basal level to start with and then if my post meals still aren't I'll adjust my ratios too.
Scott Benner 24:09
And there are there are illnesses that Arden needs more insulin for sure. It's those ones that are just sort of like she's got a little cough or her throat a little sore or has a little stuffy those don't seem to hit her but when she if she gets like, you know, knocked over by an illness when the body aches stuff happens and when the right rundown thing happens then and then you start getting like you said you start moving around as much you're more dehydrated, like there's a lot of stuff that goes into that
Jennifer Smith, CDE 24:39
well and I think you bring up a good he said hydrated right? It's we've talked about hydration piece just in general before but we talked about a respiratory illness specifically. I'm sure we've all seen the mucin x commercials right it's a little like blob of like mucus like you know haha I'm like in Getting your logs in your nose, and I'm not gonna let you sleep kind of thing. One of the biggest things to do is stay hydrated more. So if you're the person who's like, I drink eight cups of water a day, or I have five water bottles or jugs of water a day, you know what double that, because that fluid will help to move things faster through the system and keep that stickiness down. From the mucus standpoint. Listen, in
Scott Benner 25:27
plain words, if you have fixed not, and you hydrate yourself more thiess not will get thinner.
Unknown Speaker 25:32
That's right.
Scott Benner 25:35
It's just, you know, it's not something that's it's hard to, it's not hard to follow, it's hard to drink the water when you don't feel well. Right. That's the whole thing. It's difficult to maintain these good practices, when you feel like a truck ran you over and then backed up to see what it hit. You know that that really is the problem.
Jennifer Smith, CDE 25:54
There are some other things that are even not like, pharmaceutical, but things. I think that the Tea Company traditional medicinals makes a tea it's called throat coat. There's another one that they make, it's called breathe easy. All of them, they work very well. I've used them in, you know, a respiratory kind of bugs. So beyond going to your local pharmacy and grabbing everything off of the shelf, some of those things to kind of have stocked in your cupboard as a backup, um, peppermint and ginger can help to ease if you've got some stomach discomfort from like, post nasal drip and that kind of stuff. So there are a lot of things that we can do chicken broth, vegetable broth, all of those. I mean, there are there's actually really good research even just into chicken noodle soup when you've got a respiratory illness and the benefit of what that actually does for the immune system. Yeah.
Scott Benner 26:46
Well, you know, it's interesting as this is also new, and I think that it's going to continue to feel new even when we get deeper into it. Just the other day. You know, there's a wash of an article about you can't take ibuprofen if you have the coronavirus, it makes it worse. And I was like Now hold on a second. What just happened here? Like Did you know I started thinking about the podcast a little bit. I was like somebody stuck a pencil in their pocket and robbed the bank and was like, I know what this pencil just made me do. You know? And so and then it didn't take long for I think who to come out and say that ibuprofen is not a problem to take with the Coronavirus, right. It is really one of the problems with with social media, is it just anybody really could say whatever they want it and you know, if a person sees it, and they're scared, you know, they go back. So it's funny, we talked I you know, I talked about having you on for this to talk about management during a respiratory illness. But I mean, what really changes in management? Not a whole lot, right?
Jennifer Smith, CDE 27:47
Not a whole lot, honestly, I mean, you it's an illness. And unless you have another background illness, such as, you know, lung diseases or you know, there are some people with type one who actually have type one because of something called cystic fibrosis, right, which is already a lung disorder. So someone like that would have much more different management needs, even outside of the blood sugar component to it. So but when we're talking just about diabetes management with a respiratory illness, there shouldn't be much that you don't know in your normal Sick Day. packet of no checkoff, I got this. I got this. I got this.
Scott Benner 28:30
So when this all started happening, I thought, I'll put let me put some information out there'll be helpful people, and it was great to talk to Adam because he really did go over what the Coronavirus is and what it is and all that stuff. But as we were talking, and as I've been thinking over the last number of days, I think the most important thing you can do about the Coronavirus whether you have type one diabetes or not is be healthy, right like just be as healthy as you can be because a healthy body does a better job of fighting off viruses, colds and all kinds of things. Rock so much like well, you know, we're all locked up inside. Go back to Episode 210 and start the pro tips over again. It means like like get your blood sugar lower, stable, take out the variability. you'll move around a little bit even though it's probably gonna be in your living room for a while. We're here
Jennifer Smith, CDE 29:24
by the way, we've got lots and lots of online videos now that are free workout options, even my gym my gym like stopped all of our memberships so that we would not like have to keep paying for something and not being able to go but they also sent out a connection link for 150 workouts online that are free for us to use, which I thought that was a really nice thing just from a gym standpoint to do for its members. Um, but their 10 minute workout their 30 minute workouts, there are a lot You've got some equipment at home, you could even use your peloton or whatever it is, you know. So
Scott Benner 30:05
I think it's it's stay moving, stay healthy don't fall into like really poor diet habits because you know, it's going to be easier. And I don't know how easy that's gonna be to maintain over time, I don't know how easy getting food is going to be weeks from now I'm sure it's gonna get a little dicey at some point. Maybe just because you're gonna be scared to go outside, I don't know. But I don't think if you're really paying attention to the day to day numbers, and not listening to political conversations around it, but actually seeing what, you know, the CDC is saying those kinds of things. We are, we are following the bend of that, that Italy was falling, like we're gonna get a really big spike. There are a lot more people here we are spread out further, we have population centers, not just one or two, like smaller countries, too. We have, you know, countless dozens of population centers. This is not ending anytime soon. You know, if I had to bet money, I'd bet my kids aren't going back to school this year. I bet that things are gonna change moving forward, even. Yeah, you might start seeing work from home days for school in the future. And, you know, I think the other thing that's gonna happen here is we're gonna learn a lot about things that we've been afraid to look at. So far, like telemedicine is such a god example, right? You guys, you guys have been, you know, who else is talking to people about their diabetes through, you know, through video interaction, except for you. And now suddenly, every doctor's office in the world is like, this is how you go to the doctor now. Right? Right. Okay, so I think you have type one. Are you doing anything differently? No,
Jennifer Smith, CDE 31:51
I really not. I mean, other than, I mean, in my diabetes management itself. No, I'm not. I mean, we have, you know, all of the Sick Day things in the cupboard that we could possibly need. I mean, we actually went about was like, two weeks ago, before any of these school cancellation and anything of that nature. I was in the aisle just picking up some band aids. And I was like, you know, let's just get some extra things. Just like I could see what was sort of like, coming down the line, right? So I got some extra, you know, like cough medicine and that kind of stuff, just to have got popsicles in the freezer. All that kind of stuff. But other than that, my normal management is it. I'm managing the same way. I'm trying to get exercise every day in my house, or going outside and taking a run with my dog or, you know, whatever. I know some communities even have some restrictions on that, but we don't right now. There are plenty of you. In fact, more people I think I've seen like, I have to get Brashear like, let me out of my house. Right. Fair.
Scott Benner 32:58
Two days ago, Colin, I went to an outdoor cage so he could hit Hmm. And afterwards, no lie. His personality was brighter. He had more energy. He was smiling. Like he just he's not a person who wants to be trapped and sitting around and you have to almost the same as you sometimes can get lulled into being like Oh, 150 is a good blood sugar. 180 is not bad. You know, 200 is not far from 150 you can start getting to the like, Well, you know, Doritos for lunch is fine. Today, three days a week with the Reno's isn't bad, you don't I mean, like I haven't moved around a month, but I've only gained six pounds like you can like
Jennifer Smith, CDE 33:35
you can write, you can sort
Scott Benner 33:37
of just know that and slide into it and not know that it's happening to you. And then by the time that happens, you know, you're having that conversation with yourself like ooh, I've let things get out of hand. And then it's harder to get back from.
Jennifer Smith, CDE 33:50
I do think too, within that. from a management standpoint, we do have to consider some some things that if and when you can get to the grocery store, right? Because you're probably not going every other day or every three days Oh, I just need to pick up the milk today or I just need to do is you're like okay, everything on my list I can get it and I hopefully this will be stockpiled for like two weeks before I have to go back you know running in and out again. So from the standpoint of diabetes management and then making sure your list is full of all those things that you know keep you in line and it might even come down to making some more soups or making some more things that do last a little bit longer. I mean I know fresh fruits and vegetables and we certainly we have to go shopping either today or tomorrow someone in our house you know myself or my husband has to go because we're out of those we've got some frozen stuff but other than that our fresh is gone and I I like living on my frat
Scott Benner 34:50
Yeah, well listen, I am so the the I'm one of those people who usually goes grocery shopping like every few days. I'd much rather like bang in and Because that's how I like to keep the food fresh in the house, you know, I don't want to grab, you know, a ton of vegetables I grab enough to get me through a couple days. That's obviously a little upside down right now and might not be going as well. The other day, we ate leftovers, that I think in a regular situation, I would have been like, you know what, let's toss these out and start over again. But I was like, No, eat this. You know, like, What's another? What's another meal? Like? Let's get another meal. And prior to all of this? I guess not really prior to it. Maybe I just paid attention to it a little sooner. I ordered everything that Arden had a refill for I refilled. I'm starting to think I should have gotten to see but to just in case. She you know, I don't know. I don't know what, just in case three months from now, you know, other stuff starts happening me Meanwhile, pump companies Dexcom they all say like, we don't see this affecting our supply. But what if it? What if it's not them? What if it's delivery? Or, you know, what if it's, what if it's FedEx or, you know, whatever it ends up being. So I got all of our supplies, restocked. And I buy these juice boxes online that come in a big flat, and I was like, I'm gonna get to them, like garden could get low, like, I don't know, 150 times that I'd be okay. Yeah, right. Right, which I don't think she'll get low because you
Jennifer Smith, CDE 36:24
also have a goose box that works very well for her. Yeah, others don't. So you know, what works. And, you know, you kind of stockpile put it away, I know, my my glucose tablets that I really like to use have been out of stock online for quite a while. And so when I went to pick up my last insulin fill at the pharmacy, I grabbed two bottles of the only kind of that pharmacy brand glucose tablet that doesn't have artificial colors or anything in it. I grabbed two of them. And I actually, if I don't hide them, my kids will eat them. Like lip height these way away. So nobody else knows where Jenny's supply. I think,
Scott Benner 37:05
you know, I am not an alarmist person at all. But and I think this is going to be fine. Like I think this is gonna be a natural, it's gonna run a natural course. People are going to die. It's not going to be pleasant. I think we're all going to know somebody who died from the coronavirus next year. But at the same time, I did say to Kelly last night, I was like, let's start thinking more long term around Arden. Like that was the only thing I've said about diabetes so far. Like, I don't know what that means. Exactly. But let's always be thinking months in advance, not days in advance about Arden. And she's like, okay, and I'm like, I'm not worried. I'm just thinking we should change our focus a little bit. Right. You know, I did my best the week or so ago, I put up on my social media. I was like, Listen, if you have refills, filled, do it now.
Jennifer Smith, CDE 37:51
Yeah, absolutely. I know. That's actually one of the things that I also went through even my husband who pretty much leaves my diabetes management to me, I mean, unless I'm like, I need help with this or, you know, can you pinch my skin back here to put the Dexcom in or whatever, for the most part, it's all my management but even came to me is like, sure you're okay, on all of your supplies. You got enough insulin, you got enough of your pods. You got enough, you know everything and I was like yeah, I'm, I'm really good for you know, he's like, how many months? Like, hi, at least four months? I'm pretty good before I'd have like even maybe more than that, quite honestly. The biggest one is sensors, because I can't get more sensors other than what my insurance will cover. Yeah, I can't. The one the one thing to my pump right now is that I'm I'm kind of training on the control like you with hand up. So right now my pads are not being used a little extra,
extra.
Scott Benner 38:58
He's like, I gotta figure this other pump out for my job. So my my pumps are sitting in a pile I'm not gonna use.
Unknown Speaker 39:03
That's right.
Jennifer Smith, CDE 39:04
My Riley link gets a little break. And
Scott Benner 39:06
it's funny. Yeah, yeah, little extra stuff here and there. You know, little stuff off to the side, if you can afford to grab it. It really does make you think about the people who can afford it who are paying cash, or just, you know, that horrible. It's got to be in the back of all of our heads somewhere, right that, you know, if I don't want to be like, I'm not a doom and gloom person. But I do think this and I thought this before Coronavirus society is a paper tiger. It really is just holding together because we all agree to let it hold together. Right? That, you know, I don't walk across the street with a bat, kick my neighbor's front door down and steal his television just because we've agreed basically not to do that. Right. Right. Right. And but you know, it's it's assumed that if you get sick you go to a doctor a doctor helps you even if you don't have insurance. Someone will help you right? Yeah. Now all of a sudden your doctors are like, Look, call us on the phone. Don't come here. You know, the grocery stores always got food right? Now, Wow, well again, but it doesn't right now. And it makes you think, like bigger picture, like would it make you realize is that 10 pretty smart people who were writers sat in a room one day and said, what would it be like if zombies came? And then they wrote what they thought would happen. And, you know, that's probably pretty close to what's gonna happen. You know, it's, it's just where human nature takes us in these situations. The toilet paper is a great example, right? People are afraid, what makes them feel better control. having enough toilet paper feels like control. It seems silly right now. But it's true, like, right, it gives you some feeling of control. I filled Arden's prescriptions and got more juice boxes, and I bought, you know, I got the G vote the kids, you know, like stuff like that, but, and that makes me feel like it's okay. And it is okay. Unless, you know, people just decide to be lunatics. And then I don't know what happens next, you know, and none of us do. And, and that's the real, that's scary for every living person. But more so for a person who has type one or has something else who is who is your ally is reliant on these things working on the on the traffic lights going on, when they say they're going to, you know that that stuff that we just take for granted. So the best thing you can do is be be prepared. And and do your best and not lose your mind. Right, you know, don't go Don't go barging through people's doors with the you know, the bat, right?
Jennifer Smith, CDE 41:45
Give me that. It's so funny.
Scott Benner 41:47
This must have been in the consciousness a month or so ago. Because Because Arden came up to me six weeks ago. And just out of the blue, she goes, Hey, the zombies come? What happens to me. And I was like, so
Jennifer Smith, CDE 42:06
just a random teenager kind of idea.
Scott Benner 42:08
And she wasn't really talking about zombies. She was like, Hey, you know, this stuff gets upside down. You know, with the diabetes, what happens? It's like the first time she ever asked, and I said, I said, well, in truth. I said, If things really got sideways, I guess I would throw my morals away, go down to the corner and overpower as many people as I could and take as much insulin as I could for you. If we're if we're into the apocalypse situation, if that's what you're talking about. I said we'd lower your carb intake, which I don't think would be trouble because I don't think we'd have food. Eventually you I tried to keep the insulin cold. you'd run out of it eventually. And she goes, how long? I'm like, you'd be dead a couple weeks, a month later, probably. And she goes, Okay, that's what I thought. And I was like, I right on. And then we just sort of like, walk around the room. Yeah, it just she she wanted to know. I don't think she'd ever said it out loud. I think she knew, but she never said out loud. Like, what happens if these mechanisms go away? For me? I was like, that's pretty much it. It's like some of the Egyptians stayed alive a really long time. I was like, Oh, yeah, I mean, if you How long do you think you could eat kale before you just gave up?
Jennifer Smith, CDE 43:23
There are lots of ways to cook kale. I like
Unknown Speaker 43:27
that, you know,
Jennifer Smith, CDE 43:28
the other. The other thing to possibly do is maybe you know, get your own pig farm started. And then directions about how to make your own insulin and your you know, pig farm out of the pigs that you're growing in your backyard. Or
Scott Benner 43:41
I'll tell you what, if that kids, if that kids hanging her hat on that on me figure that out, she's in trouble. I could maybe do a podcast about it, but I don't think anybody would care. Right? But anyway, like, I don't think of that as, like, I didn't think of that as a sad thing. She just wanted to understand her reality. She got to an age where she was like, hey, just real quick, like, you know, right? What, what is this about? And it's not something I was talking about. Maybe she was hearing something at school, or like, I don't know where it came from, honestly, but I wasn't gonna lie to her, you know, and I wasn't gonna just be like, that'll never happen. I mean,
Jennifer Smith, CDE 44:16
who knows? We don't know what the future is. in any circumstance. Even without this. We don't know what the future necessarily.
Scott Benner 44:23
And if it if it happens, you're not going to stop it. If it's happening. You know what I mean? Like, it's, you know, and I just I told her, I was like, Look, I said, She goes, do you think it'll happen? And I said, No. And she said, why I said, greed. She goes, what I'm like, we live in a capitalist society. Everybody wants things. The only way they get things is to go to work. They want to go to work, they want to make money, they want to have things. I was like, it's what keeps people chugging along. It's what keeps insulin being made. And insulin pumps being you know, people like they think there was a guy one day who was like, I could make a better insulin pump. I bet you I could do this without tubing and he made it and turn into a business. And it was like, that's what keeps society moving people's desire to do things have things be alive. You don't I mean, I was like everyone's desire to be alive is going to be why you're going to have insulin and pumps and needles and whatever else you need. And, and I said, so while I can, you know, I can think about your little scenario here that you've made up in your head. I don't believe that's gonna happen, you know? No. So we'll say even with this, it's gonna it's going to pass. There'll be a day in the future where you'll say to somebody, do you remember that Coronavirus thing? Wasn't that crazy?
Jennifer Smith, CDE 45:37
Right. Right, exactly. It's, you're right. You're right. But I you know, in terms of even like, your daughter's question, I think you also, you know, you kind of bring we've already talked about like the supply component. But the going back to like, the age old management strategy, like maybe your technology dies, and you can't get a replacement for it. Do you know what to do? To go back to an injection? Do you have pens? Do you have syringes? Do you have you know, your vials? Do you know how to use them? Do you know what your doses are? All of those things are, they should be in your marked down list of I would know how to do this. If this happened, or if this failed, I could go to this parameter. If this fail, I could go down to this like 1940s way of management.
Scott Benner 46:33
I thought about it last night, and we don't have slow acting insulin in the house. And I thought she'd get stuck a lot. But I could do it with just her pager. Like I know I could you know what I mean? Like it wouldn't be perfect. But it would be she'd be alive, he would be alive. Yeah, and in enough time to go get some slow insulin somewhere. Right. But I think I could do it, you know, it's just, you know, there's a certain I'm thinking, I would probably create layers with boluses, like rock, like like just, you know, put in a bolus. Think about where it peaks, probably right at the peak time, put in more and just keep those like dolphins like
Jennifer Smith, CDE 47:15
flying through the muck have to do your own little like graphical chart, I don't sit here it should be done here. I dusted here, it should be done here. We kind of have to keep track that way, mentally, to not drive yourself like insane with a charged brain. But in
Scott Benner 47:31
my mind, if I know when it goes in, I know when it peaks and I know when it crashes, then I can put the next one in and create them
Jennifer Smith, CDE 47:37
for next week at
Scott Benner 47:38
the crash and just keep the peaks covering the crashes. And that should make a reasonably level amount of insulin the whole time. So
Jennifer Smith, CDE 47:46
and that that would work for somebody who has looked at and truly understands the total action time of their rapid insulin. This podcast for a while you're right, you do and I would say you know Scott definitely could do that. If you've not really ever figured that out. probably
Scott Benner 48:05
thinking a lot of people might kill themselves doing it. Yeah, oh, this is definitely one of those episodes where nothing you hear on the Juicebox Podcast should be conservative. But But I was really that's what I was thinking. Right? Like, would there be a way to bump insulin and over and over again, so that she didn't find herself without insulin? Or didn't find herself with too much? Right then? I don't know. I think I could figure it out. But, you know, again, it's because I, I can be like, I can be dispassionate about it. It's not me if I had diabetes, this is what the sound sounds like, Jenny, I don't know what I would do. If I didn't have so I can answer I probably just run around the house, I hit a wall and just passed out, you know, like, so it's, it's an interesting thing when it's for someone else,
Jennifer Smith, CDE 48:48
because you can step back and you can look at it for a second.
Scott Benner 48:51
Wow. And you don't have that Panic of like that your health is on the line.
Jennifer Smith, CDE 48:55
But overall, you should run to the pharmacy. And you should get well Jenny,
Scott Benner 48:58
I'm gonna tell you what I'm gonna. I'm gonna send an email when we're done to Ardennes. And oh, and I'm going to ask for some slow acting insulin. There we go. And I guess maybe two, I don't have a backup. Yeah, that's exactly what I'm going to do. And that's what we should all be doing. Right. It's just preparing.
Jennifer Smith, CDE 49:15
Just prepare.
Scott Benner 49:17
So did we learn today that at the moment with the information that we have, that a person with type one diabetes in the Coronavirus is going to get some level of sick and they're going to manage their type on the way they would if they got any other virus and
Jennifer Smith, CDE 49:32
in a normal illness? Yes, exactly. And I would think, you know, unless you're really newly diagnosed, and you've been a fairly healthy person outside of the diabetes, and you've never really managed an illness with diabetes yet, then sure it will be very new for you, and it's going to be kind of scary, you know, but the biggest thing really is looking at the glucose levels looking where they're going and seeing Gosh, I'm you know, so 7500 points higher than I normally run. Clearly I need more insulin. So
Scott Benner 50:10
Jerry, what's your what's your level of commitment to the podcast? Are you willing to get the Coronavirus? So we can talk about what it's like to have it now.
Unknown Speaker 50:19
Can't get you to go look a couple of handrails or something like that.
Jennifer Smith, CDE 50:23
No, and I can go hang out at UW hospital. Sorry.
Scott Benner 50:28
Gosh, do you think health care workers who are in situations where they may be more susceptible? Do you think they should step back from their jobs? Like, what would you do if you are in a hospital right now working?
Jennifer Smith, CDE 50:43
So, you know, given my profession, I know that my position would have been not necessarily cut, but I would have probably been sent home because I would have been outpatient, I wouldn't have been necessary to be there. Right? If I were a nurse, or a doctor or any other profession that's absolutely needed. And you We need people I mean, what, what would happen with all the sick people, if all the doctors were like, all the nurses were like, nope, okay, I just gonna go hang out at home, I can't get sick. I can't do this, you know. I would have to say that I would, I would do my job. It's even if I had, you know, people at home as I do little kids, a husband, or if I had, you know, an elderly parent, or grandparent or something living, I guess I would just live at the hospital then. Yeah, I wouldn't come home with it.
Scott Benner 51:37
You know, yeah, we're in a situation now where everybody's got a row, the boat, whatever, where they have in their hand they need to use and it's very similar. You know, when you think about police officers, right, or emfs or firemen? What do they just gonna be like how your house gonna fire? I don't know if you have the Coronavirus or not. So we're just gonna have to burn your life. At some point, there are some a lot actually of professions that just you don't get to think about yourself first. Well, that's, you know, what ends up? Kind of,
Jennifer Smith, CDE 52:08
you're doing social good. By continuing to do what you professionally chose to do. It is. I mean,
Scott Benner 52:17
well, when I was speaking to Adam, the one thing I said that was interesting that I've kind of noticed from afar is that we have set up a society that, for the most part for most people, goes the way you want it to go. Do you know what I mean? Like there's not a lot of, like, I remember my parents, you know, talking about getting a car, and it taken them seven years to get money for a car. Do you mean like, we're gonna get a new car one day, they never got a new car, they would always get a newer car, right? But no one ever woke up and was like, I will just take out a loan, and then I will buy this car. And then I don't need the money today, I'll give it to them. Like, like, we've set up a situation where if you have any kind of income and need something, you probably can get it. And that goes for entertainment, as well. Right? Our entertainment are amazing now. Like, we're all at the point now where we're like Disney plus nothing on here. I want to watch it. Like we're a little spoiled. Right? Right. This is the first time in my generation, and definitely my children's where someone said that you're being limited and there's no alternative. Right? You just have to do this. Right? It's very interesting. And people are so far, I think doing a really good job with it. Yeah, I don't see people freaking out or anything like that.
Jennifer Smith, CDE 53:34
I think it's hard. Even from a from the from the child standpoint, though, you know, our kids have gotten so used to social interaction. Right? I mean, very minimal numbers of kids are homeschool. These days. I've got a couple of clients who have I work with Who are they do homeschool their children. And I've actually email I'm like, I bet you're glad that you've been doing the homeschooling you'll know exactly how to do this. I however, do not. So we've been after school or after I'm done with work in the afternoons. Now we've actually just been getting in the car, and going and taking a drive around the city. Just to like physically, like,
Unknown Speaker 54:16
get out, change,
Jennifer Smith, CDE 54:18
and change the visual and change and see that, you know, the world is still there. Everything is still in place. It's just that we've got limited interaction.
Scott Benner 54:28
It really is we're all just trying to stay away from each other so that we don't overwhelm the healthcare system. Right.
Jennifer Smith, CDE 54:34
And for explaining to kids it's also something for explaining to I mean, you know, with a seven and a three year old, they don't really quite understand, you know, why can't we go to the coffee shop and get a flowerless cookie? Why can't we you know, well, they're closed so we drive past the coffee shop. You have to kind of visually explain to many younger kids and well it's closed you know, we can't go and see all the chairs are up. But why Mommy, can't we get a morning muffin. Let's go home and let's make morning muffins. So now we have morning muffins sitting on the counter in the kitchen. Yesterday,
Scott Benner 55:06
I had that conversation with my 20 year old son. I was like, Listen, you can't play basketball. And here's why. Because Do you want to wonder for the rest of your life if your buddy's grandmother dropped dead because you had to go play basketball, you know, like, just go outside, you have a net play by yourself. And that's what this is gonna be for a little while. It's tough because you because it isn't. It isn't hard to look at what you're missing. Like, I watched kids on my son's baseball team and every baseball team who were seniors, who were eight, eight games into their season, be told That's it, you're never gonna play college baseball again, say goodbye to everybody and get back on the plane to go home. Wow, it was hard. It was really interesting. All these kids weren't going to graduate from high school at a ceremony maybe or from their college. You know, that's all total. But like I said, I think at one day, it will just be it'll just be a story to tell people. You know, like, remember the time I'll tell you this. And I mean, this, I said this to Kelly last night, I was like we are parenting through. Our parents never had anything like this, that I can remember that they had to be parents. And my wife's like, my parents just sent us outside anyway, we'd be dead. They'd be like, go outside and play, you know. So I really feel a feel like we're gonna be professional parents when this is over, like really good at it. Because this is just another level Jenny.
Jennifer Smith, CDE 56:22
It's really funny. I said that to Nathan, the other day, I said, this is really kind of a it's a social experiment in teaching people who've been so used to and nothing against it. This is the way that society work. Because moms and dads all have jobs now and you send your child to daycare or you send your child to school. It's teaching parents what it actually means to like spend majority of your time interacting with your child. I wonder if somebody else isn't raising your child? Yeah, somebody is else isn't teaching them. It's on you now. 100%? That's,
Unknown Speaker 57:00
that's hard. Yeah.
Scott Benner 57:01
Yeah, I listen, I've raised two kids, as a stay at home parent, right? That means you get up in the morning, and you're with them 24 hours a day. And it gets long after a while. And you really have to have the fortitude to just push through and find the good and what you're doing and not make it feel like oh my god, this is my whole life like that, that whole thing. But I'm wondering how many people will maybe I wonder how many people will try to go back to a single, like income, like how many people are gonna like this and think, Oh, this is nice, you know, right. I never thought it was possible.
Jennifer Smith, CDE 57:33
I didn't know my kid could do this. Or I didn't know I liked doing this type of thing with my child. Or look how good my child is that like reading and we can read together and we can learn all these things. I mean, I think of all the like, books that hopefully people are reading and the games that they're getting out of the closet that have cobwebs on them and like, Yeah, because especially with kids, you know, specifically, as you know, you have to entertain them up to a certain age, you kind of have to do the entertainment. Yeah, yeah.
Scott Benner 58:06
I've got my pile of books right here. I'm hoping. Yeah, really only five fingers crossed. So okay, so stay healthy. Keep your blood sugar stable. I think the other thing we didn't say that I think is really important is get sleep. And as
Jennifer Smith, CDE 58:19
bunk water.
Scott Benner 58:20
Yeah. And try not to make yourself nuts. Like stress, people don't sleep well. People don't sleep, well don't fight off colds. Well, like the really the things you can really do is, you know, take care of your health, get some sleep, keep your stress down. And you know,
Jennifer Smith, CDE 58:36
and some of that keeping your stress down ultimately is just keeping as much normal in your day as possible. Yeah, you know, you get up every day at seven o'clock, keep getting up at seven o'clock. If you always have tea at nine o'clock. Keep having your tea at nine o'clock. You know, it's just keeping some of those normal scheduled things, helps to keep the stress level down to I think, too, if you're working from home, I know everyone's interested, but don't leave like cable news on 24 hours a day in the background, because they're repeating the same thing over and over again. And it's getting into your brain. So right.
Scott Benner 59:07
Yeah, right, Jenny, I appreciate you doing this. And I hope you guys all stay healthy there. And I hope you do too. Thank you. I hope hopefully this will help some other people do the same. So I'm going to read to you from the CDC website for a second. Older adults and people who have severe underlying chronic medical conditions like heart or lung disease or diabetes seem to be at a higher risk for developing more serious complications from covid 19 illness, please consult with your health care provider about additional steps you may be able to take to protect yourself. The site goes on to remind us to stay home if you're sick. But I think at this point travel bans are starting to go into place as I'm recording this on March 20. So you know that may be that may just be a given at this point. Cover your coughs and your sneezes cover your mouth and nose with a tissue when you cough sneeze or use the inside of your elbow. Throw used tissues into the trash. Immediately wash your hands with soap and water for at least 20 seconds. If soap and water are not readily available, clean your hands with sanitizer that contains at least a 60% alcohol. If you're sick, you should wear a face mask when you're around other people, even if you're sharing a room or a vehicle with them or before entering a health care providers office. If you are not able to wear a facemask or a sample because it causes trouble with breathing, then you should do your best to cover your coughs and sneezes and people who are caring for you should wear a face mask when they enter the room with you. If you're not sick, you do not need to wear a face mask unless you are caring for someone who is sick and they are not able to wear a face mask. face masks may be in short supply and should be safe for caregivers around the home clean and disinfect. This includes tables doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets and sinks. If surfaces are dirty, clean them use detergent or soap and water prior to disinfecting. The CDC goes on to tell you about disinfecting most common EPA registered household disinfectants will work. Use disinfectants appropriate for the surface. options can include diluting your household bleach. To make a bleach solution. Mix five tablespoons or a third of a cup of bleach per gallon of water, four teaspoons of bleach to a quart of water. Don't forget the manufacturer's instructions about proper ventilation when you're using bleach. And if you're going to use an alcohol solution to kill bacteria or the virus, ensure that it has at least a 70% alcohol content. This is all available@cdc.gov there's guidance from the CDC around the 15 days to slow the spread. Listen to and follow all directions for your state and local authorities. If you feel sick, stay home Do not go to work, contact your medical provider. If your children are sick, keep them at home Do not send them to school well. Think that cats out of the bag to around most of the country contact your medical provider if someone in your household has tested positive for the coronavirus. Keep the entire household at home Do not go to work, do not go to school, contact your medical provider if you're an older person stay home and away from other people. And if you are a person with a serious underlying health condition that can put you at an increased risk, for example, a condition that impairs your lung or heart function or weakens your immune system stay home and away from other people. Okay, so here are my plans for the podcast. Next week. There'll be two episodes that are just stories from people with type one diabetes stuff that's more entertaining. We're going to do some after dark stuff, you know stuff to keep your mind off things keep you entertained. I will come back with Coronavirus information whenever it's necessary. Dr. Needleman we'll come back on Jenny and I'll talk again. But the podcast is going to be here for you. I'm trying to figure out how to do a live chat for us all. So if people just need to feel a little less alone, they can get together and talk. that'll probably happen through the Facebook page. So keep an eye there. Perhaps even Instagram and I'm looking for a way to bring everybody in. Maybe in a third party platform. I'm doing my best on that. The Juicebox Podcast will run as scheduled. It's not going to go away. And I appreciate that you guys are such supportive listeners. I hope this information has been valuable for you. Please just use your common sense. Stay well stay away from people. Don't touch things. Wash your hands. be cognizant of your surroundings. Do your best to stay safe. Do your best to stay healthy. If you feel sick in any way, please contact your physician immediately. I'm going to read you one last thing the symptoms of coronavirus. People may be sick with the virus for one to 14 days before developing symptoms. The most common symptoms of coronavirus disease, the COVID-19 virus are fever, tiredness and a dry cough. Most people about 80% recover from the disease without needing special treatment. More rarely, the disease can be serious and even fatal. Older people and people with other medical conditions such as asthma, diabetes, or heart disease may be more vulnerable to becoming severely ill. People may experience cough, fever, tiredness, difficulty breathing in severe cases. Now having that in your head. Don't forget what Jenny and I talked about today. If you're a healthy person, if your blood sugars are well maintained, you don't fall into that category just because you have type one diabetes. Be healthy, keep your routine going. Keep your mind fresh, get some fresh air. Try not to go crazy in your house a little bit. You're going to be okay. The Juicebox Podcast is sponsored by Omnipod Dexcom touched by type one and the Contour Next One blood glucose meter. 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#314 Adam Naddelman, M.D. discusses Coronavirus
Coronavirus COVID-19 discussion for 3-16-2020
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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.
Adam Naddelman, MD 0:00
My name's Adam Naddelman. I'm a pediatrician at Princeton Nassau pediatrics in Central New Jersey.
Scott Benner 0:10
Hello, everyone. Welcome to Episode 314 of the Juicebox Podcast. Today, we're going to talk about the Coronavirus situation. This one's going to be an overview with one of the brightest, most thoughtful doctors that I know personally. Adam and I met. A long time ago when Arden was born. Dr. Adam Needleman joined the Princeton Nassau pediatrics group in 2001. He completed his pediatric residency from New York hospital, Cornell Medical Center, and was chief pediatric resident the following year. Dr. Edelman received his medical degree from the University of Medicine and Dentistry of New Jersey, Robert Wood Johnson medical school in New Brunswick, New Jersey. He attended the University of Pennsylvania in Philadelphia, where he received a BA in biological basis of behavior. Dr. Edelman is board certified in pediatrics, and is a fellow of the American Academy of Pediatrics. So please don't judge him. You know, because he knows me. He's a pretty smart guy. Despite his tastes and friends. I'm going to ask you to 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 health care plan. We're becoming bold with insulin. Today's episode of the podcast is sponsored by the Omni pod tubeless insulin pump, you can go to my Omni pod.com forward slash juice box or click on the links right here in the show notes of your podcast player to get an absolutely free no obligation demonstration pod sent directly to your house. Omni pod will send you a non functioning pump but otherwise it does everything else meaning it looks the same. It's the same weight you can wear it and find out if you like it in my experience wearing a demo pod. You forget that the only pods even there after a very short time then it's kind of up to your imagination what's it going to be like to live with it to shower with the to work out with it? Normally I would say go to school or something but you know right now maybe you'll just in your house what it would be like to wear the Omni pod anyway, to get an absolutely free no obligation pod experience kit. Like I said my on the pod.com forward slash juicebox. Not even the Coronavirus should stop you from making plans to take better care of your type one diabetes. Please don't tell me I was thinking of getting a pump. But oh, this whole thing happened. Don't do that. Just keep moving forward with your health. podcast is also sponsored by the dexcom g six continuous glucose monitor. That is the CGM that my daughter has been wearing for ever and ever. It's the continuous glucose monitor that we use to make decisions about ardens. dosing. Right? When does she eat the stop below? When does she give herself insulin to stop a Hi, how do we Pre-Bolus for meals? What are the trends look like? How do we set her basal rates overnight during the day while she's in school while she's at rest when she's sick when she's well. The data that comes back from the dexcom g six tells you everything that you need to know to make great decisions. And then you can make those decisions with your needles with your pens with your Omni pod, however you get your insulin dexcom.com forward slash juice box. Find out about it right now. Okay, so my Omni pod.com forward slash juice box dexcom.com forward slash juice box. And when you're all done, and this whole Corona thing is overwhelming you you need a happy place to go touch by type one.org. Go watch some little kids with Type One Diabetes living well for a little while, check out what they're doing. Find out how you maybe can even get involved. That'll be good for your soul, touched by type one.org. And now, my friend, Adam Needleman. My goal here is for people to have a really firm understanding of what's going on because I feel like the media, you know is actually I'm seeing them try really hard to do a good job. But it's all piecemeal, right? you'll flip it on, you'll hear one thing, you can't listen all day, you can't listen every time they update their thoughts. And people have been listening for two weeks now. And two weeks ago, it was, hey, there's this thing happening somewhere else in the world. And maybe it won't happen here. And I just think that everybody's got fragments of an idea. So I guess I want to start like simply by saying it's a virus, right. But Corona isn't just this thing that we're dealing with right now. Am I wrong about that?
Adam Naddelman, MD 4:43
No, that's correct. So coronavirus is just the name for the family of viruses. Like for instance, I'm sure most people have heard of SARS from a few years ago and there's another one called MERS that was a basically in the Middle East. Those are both in the same family of viruses. They're different strains of this Same virus
Scott Benner 5:00
family. Okay. And and so do viruses just appear? Do they mutate from other viruses? How do they happen?
Adam Naddelman, MD 5:10
Well, so they typically will mutate. So the thought here is that this most likely originated in an animal, the thought is perhaps probably a bat, in bohan, where they have these open air markets, where there's a, yeah, there's a lot of food, a lot of animals really, that are alive and in these markets. And the thought is that perhaps the virus was sort of native to an animal. And again, the thought is a bat. And then it mutated in some way that allowed it to jump from an animal to a person. It's similar to what happens with like, avian bird flu, where you see this in Asia every once in a while where there's a some strain of a bird flu that gets into chickens. And people get really panicked that it's going to mutate and jump to humans. So they start literally just killing off like hundreds and hundreds of chickens, in order to prevent that from happening. So this happened, it may it may have happened and jumped to multiple people at once. Nobody really knows. But the cluster clearly is the cluster of cases, that seems really seems like it started this all came from that area of China, right. And what
Scott Benner 6:16
I've been able to kind of glean about these wet markets is that they bring the animals in, and they keep them alive for freshness reasons, and then they start they slaughter them as you buy them and cook them right there. Except you have a situation where one kind of animals in a cage stacked on another kind of an animal, they would never be that close to each other in nature and,
Adam Naddelman, MD 6:36
and they wouldn't be that close to someone who was actually like preparing them for sale and for food. And they it kind of reminds me of like the old time butcher shops where you had like the animals hanging sort of in the window, but they were never alive, like you didn't go, you know, you'd go into the back and pick out your lamb or something they were hanging in the window. This is similar to that, except that the animals are alive. And they're stored, like you said, kind of in close quarters. And I don't know exactly how whether or not the those markets would meet the same kind of hygiene and sanitary requirements that we have in the US, etc. So you just don't know. But that's where the thought is that it came from.
Scott Benner 7:12
Yeah, some some of the images I've seen online, these things are being cooked on just wire grates or trash can lids and being slaughtered at the same place, they're being cooked in the same place they're being eaten. It really is. I mean, not that I know a lot about it, but it's it's overpopulation people need to eat, you know, and when there's not when there's not farm produced food, they have to go out in the, in the wilderness, and in this case, find bats and whatever else they can find to stay alive, you know.
Adam Naddelman, MD 7:38
So yeah, but the thought is that it probably jumped. So the virus must have mutated from whatever form it was in before and then jumped to a person and it was highly infectious at that point, and very efficient. So it would, it was very easy to pass from person to person, which is why it's spreading as quickly as it is. And then on top of that it unfortunately has the added characteristic of being quite a bit more dangerous than like a typical flu or a cold virus would be.
Scott Benner 8:07
So let's talk about how it transmits. It's, when they first started talking about it, it was I heard a lot of like, wash your hands, you know, but now I'm hearing more than it's airborne, or be on surfaces,
Adam Naddelman, MD 8:19
there are very few viruses that are actually airborne. measles is probably the best example of one. measles is probably the most infectious agent that we've ever encountered. Like if you take a person with measles, and you stick them in a room with 100 people that have either not had it or not been vaccinated, and you just let them kind of hang out in that room for a while 90 people in the room will get it, then so that's airborne. And that's like incredibly infectious. This is not that at least as best we can tell this looks like it's actually through droplets, which that just means you sneeze, then the virus is expelled from your mouth, your mouth and your nose. And it's on a little droplet of you know, fluid. And that either lands on a person or lands on your hand. And then I shake hands with someone and then they touch their face, and it gets passed that way. So the problem though, is with droplets, it can look like it's behaving like it's airborne, because if you sneeze on a surface, it can survive on the surface for sometimes as long as you know, several hours, then if someone else comes along and touches the surface touches their face or mouth, they can pass it to themselves that way.
Scott Benner 9:23
Is that uncommon for viruses to be able to survive like that on the surface of something
Adam Naddelman, MD 9:28
in a dry? No. I mean, the ones that are through droplets can survive. It's just this one seems to be a little bit more kind of Hardy and how long it can survive. It just it seems like it's it survived for a while. What they're saying now about this virus in particular is you really need like, this is what the guidance says it has to be more than 10 minutes of kind of face to face contact with a person that's less than six feet away. So you can see where all this social distancing stuff and I know I'm kind of getting ahead of myself a little bit but that's where a lot of this these thoughts Coming from,
Scott Benner 10:00
right. So if we just don't have those interactions, we won't pass it around. And, and I guess one of the bigger issues must be that the incubation period takes a while, right. So once I'm affected by it, I might not show symptoms for a while or at all.
Adam Naddelman, MD 10:18
Yeah, so you can be infected and be completely asymptomatic. And some of the data that's coming out from what we're seeing overseas is, looks like people who are asymptomatic are sometimes the highest shadows of the virus, which is why it's so crucial to do the 14 day thing, because the thought is, you probably can be asymptomatic for as many as four or five days before you start either showing symptoms or your body just lights it off. But once you start showing symptoms, the guidance now is that you really ought to be symptom free for a week before you put yourself around other people again, so you could see where the 14 days certified before seven after that kind of a thing. And now it's not precise. And if you're sick with the virus, and it's confirmed, it's probably a little bit different in terms of timeframe, because it depends on how sick you get, how long it takes you to recover. But that's kinda where that comes from.
Scott Benner 11:13
All right, that makes sense. So there's just, there's no end to be really when you stop and think about regular life. You don't realize when any of these situations are happening, honestly, like if somebody sneezes like, it's just you're like, oh, God bless you. You don't think right? Now I have this because even if we get sick, it's interesting, isn't it? Like we don't live, at least I don't live thinking, Oh, I'm gonna get sick. And if I do get sick, I just think, Oh, no, I got sick, and then I'll wait it out or lay down if I depending on how bad it gets. But I never think I'm sick. And this can be passed on to so many multiples of people without me knowing it's happening.
Adam Naddelman, MD 11:52
Now, it's a great point. And one of the things with this virus, too, that makes it a little bit unique, I guess are not unique, but it just makes it more dangerous is it's a little bit more infectious. We think then what the flu even is. So they talk about viruses. And they use this our number, which is basically just a, a variable that gets factored into how they do a lot of these calculations in terms of how infectious thing is, but it basically how many people are you likely to infect if you yourself get sick with that illness. So like I said, before, with measles, if you're in an unvaccinated population, you're going to infect a whole ton of people, just a ton of people, right? with the flu, the average flu and an average season, you're probably you're like, say somewhere between one and two and a half people on average. With this, this appears to be more like two to three and a half or four. Now that doesn't sound like a big difference. But imagine a class of like 30 kids. And if you're gonna if every person and there's likely to infect three other kids, the whole class is going to be sick unless you split them all apart, right? If you only get infected one other person, then you're probably it's probably not going to get to everybody before there's some level of protection within that classroom because you have kids that are now immune.
Scott Benner 13:11
So I've seen a lot of those people are making visual representations of what you're just talking about where, you know, there's like 1000 dots bouncing around in the box, and they give, you know, three of the dots the Coronavirus, and as they start banging into each other, it moves across. And it is fascinating to watch how quickly that happens, how quickly three can turn into six that can turn into 12. And it just multiplies so amazingly fast in random ways that you would just just couldn't imagine, I guess.
Adam Naddelman, MD 13:40
Yeah, I mean, that's exactly what we're talking about. I saw another good one the other day, which was like just a matchbook with four matches close to each other, and one that was further away, and you just like the first one, and then they're all gonna light. And then the fifth one that's further away, it doesn't like the same idea. But the one that I saw the same simulation you're talking about, I think was from the Washington Post. And that, to me was the best example. It was just sort of the random movement of people in a grocery store. And if, if, you know, that's really if it was airborne, like if you all if all you needed to do was sort of walk past someone and you could get it, then yeah, that really makes sense. But it's the same concept. And the more infectious it is, the more likely you're going to be in a scenario like that. I just
Scott Benner 14:19
think it's important to remember that most of the actions that are going to cause this the transfer from person to person are not things that you're aware of, you can't you know, you can you can say don't touch your face, for instance, but, you know,
Adam Naddelman, MD 14:31
it's impossible
Scott Benner 14:32
doubt yourself from doing that. Right, just the same as you when you approach somebody, it's really common to feel like you want to reach out and shake their hand or if you're closer to them, you want to give them a hug and you don't you don't imagine like, hey, that guy sneezed five minutes ago, and then I'm gonna hug him. Then his collar is going to hit my collar then later I'm going to adjust my collar and then later I'm going to pick my nose and then I've got the Coronavirus, right.
Adam Naddelman, MD 14:54
Exactly. Nobody thinks like that. And that's why I think it This has been such a challenge for so many people. Just the process. I mean, I think, you know, it's easy to say, Oh, you know, these people should all understand why they need to do this distancing. But it just doesn't. We're not, we've never been in a situation like this before, where you have to have such a high level of awareness of your personal space, and who you're letting into that space and whether or not you let your kids do certain things. It's just not normal for us to have to deal with it. And it sort of runs counter to everything that we do, like you're saying, on a regular basis. I mean, you're supposed to greet people, you're supposed to hug people that you care about, you're supposed to go visit your relatives, you're supposed to have, you know, fun with your friends at a restaurant or a bar or something like, it's to think that you have to sit in your house and spread yourself out and not get near anyone, it's just, it's really hard to fathom that we could be in this situation, but there is no doubt that we actually really are in this situation.
Scott Benner 15:48
This is not someone's imagination, this isn't media hype, it's
Adam Naddelman, MD 15:51
now is happening, I think you can make a really strong argument that we were actually pretty slow on the uptake of all of this with the knowledge that we had about what was going on to the rest of the world. And that's, I think the fear that a lot of people have, it's just that it may be too late. Like, there's a lot of people that believe once you get to, say 1% of the population, or, you know, maybe 2% of the population, once you get to numbers like that in terms of people infected, you can't contain it the way that we are trying to it. That's why now they're clamping down so hard so quickly. Because I think finally it's really sunk in. And I think the governors are the ones really leading the way on this, because they're the ones that have the costumes right in their backyards. But that's really where that all comes from. I was talking to Kelly, and she said, if this persists into a second season, I don't see how most of the population won't have had this in one way or another a year from now. Yeah, well, it's a lot like the Spanish flu, or the h1 and one from 1918. That's exactly the model of what we're talking about here. And that's exactly what happened. So you had this time of year, incredible outbreak where no one had any level of protection, there was no flu vaccine back then, like we have now. And there were no antivirals. And the conditions were not what they are now. And so a lot of people got sick, and then it kind of started to Peter out a little bit. And then when the fall came, it came roaring back. And now this is probably a little bit different than that. That particular strain of flu was just for whatever reason seemed to really kind of persist for longer than you might expect. But yeah, I mean, this virus, nobody has any native protection to it. And so we're in a similar situation where you could end up with a second wave, like we're talking about later in the fall.
Scott Benner 17:40
I think for people who can't believe that it could reach everybody, at some point, think of this, if you can, it's it's apples and oranges. But it's apples and apples in the same way, I think and you'll stop me if I'm wrong. We all have the common cold at some point during the year, nobody goes through a calendar year and doesn't have a cold, right? Like it happens eventually, which means these things get passed around in ways you don't imagine is that is that a similar way of thinking of transmission? Well, it would be if you weren't doing all the things that are happening out. So the whole goal of all this social distancing, and the you know, getting rid of all the
Adam Naddelman, MD 18:18
sports and Broadway and restaurants and all that is, the thought is that if you can get that coefficient of infection, that R value down to like under one. So if you get it, you're likely to only give it to just one other person instead of two, or three or four, that changes the whole thing. Because then you can get, like, let's say it gets into my house, just God forbid, but let's say that, and I get sick, and I give it to one of the other, you know, four people in my house, then and then the two of us both get better. After the 14 days we self quarantine, we're better in 14 days. And between the two of us we only I only give it to one person. So you can make an argument that the are like in my house was point five, right? Okay, you can see how then it died out, you know, and like my little cluster of it just stopped. I didn't go that I didn't go and give it to 10 other people, it just stopped. picture that all across the country. So if there's, you know, I don't have any cases are reported. Now it changes by the minute, but say there were 10,000 cases. If everyone did that, and only gave it to half of another person, then all of a sudden the new cases being reported that number will start to drop. And you'll get to a point where it doesn't have a way to get around enough in the community. But that's exactly why if you're going to make this these kinds of measures work, they have to be across the board across the country, you have to lock down travel you have to do all of that. Otherwise, like you're saying it what's to stop it from you know, okay, we do that we do a great job for three weeks and then a whole bunch of people come over from wherever they're from. They're where they all have it on a cruise ship and they get off they get off the cruise boat, you know, cruise ship in Miami, and boom, it just started here it starts up again. So everyone has to do it at once
Scott Benner 19:56
right so there's a way to affect there's a there's going to be a curve either up or down. And we can impact it by doing all the things that people are talking about, we're gonna talk about those things, too, so that people understand, I just think it's really important for people to hear, there's no way to just ignore this and stop it. You know, you're not gonna do that.
Adam Naddelman, MD 20:16
I mean, what I was saying earlier today, when I was talking to somebody else, just, I think you have to think of this as not so much that you don't want to get sick, it's that you don't want picture the person in your life who is the most well, most vulnerable, you know, whether that's a grandparent, or it's a relative that's fighting cancer, or it's a, you know, newborn baby that has medical issues, what whoever it is, and picture like these actions being put in place to protect that person from getting it. That's really I think, the way you have to think about it, because those are the most vulnerable people. And that's who we don't want to see all piling into emergency rooms, all at the same time.
Scott Benner 20:54
Yeah. And you have the diligence that's involved is, is extraordinary, actually, because if you think about when you're sick at home, maybe I'm just speaking for myself and about the gross people out. But you know, you make this you live in a family, you make an announcement, at some point, Hey, no one touched my drink, I don't feel well, you know, you mean or you've got kids and there'll be like, Hey, Dad, give me a drink your water that happens all the time. But you know, after a couple of days, once you're not not in anymore, you don't think to say to anybody, your kid comes by and grabs a water or you hug people or give them a kiss again, this is where I think it's going to be difficult for people not just to remember not to do it, but to be militant about the time that it takes, right, you know, now say I do that, say in your scenario, you come home, you have it, you end up only giving it to one other person your house, you wait the 14 days, you're both good. If the third person your house, gets it and brings it back in, can you get it again?
Adam Naddelman, MD 21:46
So that's a great question. It looks like I mean, again, it's just so hard because there's not enough testing to really prove all of this. But when you look at the what people are experiencing overseas, because they're ahead of us, they are not seeing reinfection at all. They're just not now, is it possible that the virus at some point mutates and there's a second strain of it, and maybe you can get the second strain? I guess it's possible. But that's not what's being reported at all at this point. Which is actually very promising, because when a vaccine does get developed, it can be against this particular strain of coronavirus. And you would hope that it would be effective. For that reason? Is there a chance that it could just morph again? Yeah, no, there's, it can mutate and change. I mean, there are lots of I that's what happens with the flu virus every year now that this is a different kind of virus. But the whole reason why you have to get a flu shot every year is that the strains will shift and change over time and turn into slightly different strains than they were the year before. And if you have just last year's flu shot, it's not going to be as effective as the one for the current season. Now, this is not the same type of virus, so it doesn't behave exactly the same way. But that's, in general, that's just a kind of a, like a
Scott Benner 22:58
kind of nonspecific or broad way to think about it. Is that in I realized this is a layman's term, example. But is that the virus or the flu in that other scenario? Is that that thing just trying to stay alive? Like, is it does it adapt? Like, is it adapting the way I think of, you know, we don't need our appendix anymore. Like,
Adam Naddelman, MD 23:19
sort of so think of it this way. It's not so much. Yeah, that I mean, that is the way to think about it. But it's, I think you have to just think about it as more like a series of random events, right? So you have these, this flow that's out there, it's probably mutating slightly over time, and the antigens that kind of get presented on the flu virus that ended up being what triggers the antibody reaction, and you, those are shifting slightly over time. And there's some, at some point, like one of them hits the jackpot and says, okay, we shifted, now we can infect people more easily now we can evade the antibodies that this person has from the flu shot they got last year. So now I can get past person a person. It's really just evolution, it's just shifting, there's little mutations that caused it to shift slightly, that at some point conferred advantage. And that advantage allows it to be passed person to person more easily or allows you to, you know, evade Tamiflu or allows the abaza to evade the the antibodies that are in your body that are from your Western flu shot like that's sets the way it works, typically. So thinking out into the future, it's completely possible that this will run through society will build up some sort of an immunity to it, it will dissipate. And as long as somebody doesn't decide to eat monkey brains next year, we should
Unknown Speaker 24:38
be like, like, don't I mean, like, is
Adam Naddelman, MD 24:39
this? No, I mean, yes, yes or no? Say it that way. I just wanted.
Scott Benner 24:45
This is our new normal, like, Have we reached a new level, like five years from now? Is there just going to be Corona season?
Adam Naddelman, MD 24:50
No, not necessarily. I mean, I think that this is probably going to look more like what happened with SARS and MERS. The difference with the with SARS especially Which is a coronavirus that was in Asia, but never really got out of Asia. And the only reason was for some reason that back that virus, when it jumped person to person, it tend to weaken a bit. So I know I'm not I'm not sure anyone really understands why this is. But by the fourth or fifth jump, it kind of petered out, it became much less infectious. So it was hard for it to get out of where it was, it infected a lot of people in those areas, a lot of people got really sick, but it never like, made the leap onto a cruise ship and ended up in the United States or ended up on an airplane. And, you know, there might have been isolated cases here and there, but it wasn't infectious enough. But ya know, it's look, I think that we're in a very connected world, it is very easy for an infectious agent like this, to jump and end up in the US or to start in the US and end up somewhere else. I mean, with the way people travel now, it's virtually impossible to expect that this wouldn't happen again, at some point down the road.
Scott Benner 25:55
Well, so then. So then I guess the question is, I think what people's there, I think fear, obviously is alive around the subject. I think most of its around the disruption of life, even more than health, at least the people I've talked to so far, I think we've done such a good job in America, at least in building a world a life for people where they get to do mainly what it is they want to do. Like, we're not used to being told no. Right? Yeah. You know, like that, that sort of thing doesn't isn't a custom. I think people don't want to get sick. But I actually think that it really, it really is more towards the people who are at risk. I think the people who feel like they're not at risk are probably like, whatever. So if I get sick, I get sick.
Adam Naddelman, MD 26:38
Well, and I think that explains why you saw so many people who thought it was a good idea to go to restaurants and go to bars and basically forced these governors to say, all right, you know what, you guys, that's it, you're done. Like, it's almost like when your kid won't get off his phone, and you have to eventually take it away from them. I mean, I think you're right, people are not used to this. And they don't believe it's a bad combination, because they're not used to it. And there's also a pretty significant level of mistrust. Among the way the population looks at authority figures and expertise and the media and the politicians and everybody else. Everyone's like, yeah, whatever, it's fine here. But this thing's all the time, no big deal. And people don't don't take it seriously. I mean, they're pictures of people at Disney World. Yesterday, it looked like any other day at Disney World, or, you know, people in restaurants or there was a data clear out Bourbon Street a couple nights ago, because people were out partying till all hours of the night, not taking it seriously. And you know, it's not their fault. I mean, this is like you said, this is the society we're in and, but you need really strong, really clear and kind of consistent messaging.
Scott Benner 27:43
explain to people why this is so important. That's why I wanted to do that's why I appreciate you doing this so much, actually, because I just I don't know, I, you look around you think this this is your reaction to this, like you know, it that Oh, I'm not in the in the group that's at risk. And by the way, too, for people listening. Watch how you say something like that out loud. Oh, it's only killing old people and sick people? Well, you know what, that's a hurtful statement to older people. And you know, people who have pre existing conditions, especially for most of the people listening this podcast, and I want to talk about that too, and find out if people with type one diabetes are at a greater risk. But I want to first find out how you're treating people. So you're a pediatrician, and are you getting massive amounts of calls from everybody now? I guess we'll go back for a second. I was with my son a few days ago, he was playing baseball, and he got sick. It started with a runny nose. And then he got kind of wiped out his throat started to hurt. He had a little bit of an intermittent cough. Looking back on it. He was in a warm weather place and he's got allergies. So the nose and the cough were probably the allergies and the sore throat ended up being most likely strep. But in that moment when it all started happening, and we were like, intermittent cough, it's not wet, his throat sore, you're like, Okay, he's got Corona. You know, like, your brain just jumps right to it. Now luckily for me, I was able to text you, but I texted you from right from urgent care because I took him right out of a situation took him right to urgent care. And I thought, Let's find out. You know, what's up with this kid. But the first thing I find out when I get there, so big sign hanging up, says, Hey, if you think you're the coronavirus, we don't have any test for that. So you know, put this mask on and wait your turn. So it turned out that gave him antibiotics. And he's of course significantly better now because he had it he had strep throat. But I'm trying to imagine all of the people in all the towns across the country calling their doctors offices that that is that your exists
Adam Naddelman, MD 29:47
right now. We're pretty much
definitely you know, my friends like you who text me and said
no, but it also is just No, it's okay. In all seriousness, yeah, I mean, everyone is concerned I mean, I'm sure, you know, for all the people that are hearing this, I'm sure there you have friends that are saying, Oh my god, I'm congested. I wonder if I have it. Or I'm coughing, I wonder if I have it, you know, and it's difficult because the numbers that we're seeing from China and from Italy, as best we can tell, at least 80% of people that get it are going to have a mild illness. Probably even more than that, it's probably a higher number than that, because we can't actually test everyone who's walking around with the symptoms like you described, but at least 80%. You know, it could be as high as 90%. But at least 80% of the people are going to have a mild illness. So what we're doing because we can't test, as you said, at least not yet, there are very strict criteria for who can actually be tested. But what we're doing is just saying, Listen, thankfully, and children, for whatever reason that it appears that the virus is actually quite mild, in general. So we feel very comfortable saying to the vast majority of our patients, if you're congested, if you're coughing a little bit, if you have a little low grade fever, you're okay to just hang tight at home, stay away from other people as best you can. And let's see what develops in the next couple days, and the vast majority of those kids are going to define as if they had a cold. Now, would it be great to be able to do a swab like we do for strep to say, hey, look, you have it, and then to prove to people that you had it, and you were fine, of course, but that doesn't exist right now. When you say in children, is there an age range you're seeing, they're saying that from all the numbers I've seen, it's really, it's really lm under 18. There are a few reported cases in overseas of, of older teenagers that got a little bit sicker than you might expect. But again, without knowing the background on them, it's hard to really say, but everything that we've seen so far is that kids under 18 are really my whole, almost our entire population other than the college age kids are, are really gonna have a mild illness. And it does look like you're the risk factors in terms of being hospitalized or ending up in an ICU. It really ages a huge part of it. So we've interpreted that to mean that if you're young and healthy, which most of our population is, those children are going to be fine. Now, you asked before about type one, there's no data yet that shows that type one is a significant risk factor for especially for the pediatric population. For severe illness with this, I would assume like any other infection, very poorly controlled type one is going to put you at a higher risk for for just getting sick in general. And the virus itself is likely to assuming Yeah, and it will also like in the way that all of you that are listening to this know that when your kids get sick, their sugars are all over the place, it's harder to manage their insulin, that is likely to happen with this too, but not to any extent any not at any greater extent than any other illness that they might get.
Scott Benner 33:01
Okay. It's It's funny, I was making a note to ask you a question, you kind of lead into it. The one thing that occurs to me while we're hearing numbers, you know, five guys found it, you know, had here and another thousand people here and you start hearing this thing? Is it? Is it your health? We don't ever think about that you don't ever get to see the person, you know, is it a person who's in poor health in other ways? Is it perfectly healthy people like it? Does it skew more one way or the other? Have you seen any data data about that yet?
Adam Naddelman, MD 33:30
Well, so there's no doubt that pre existing medical conditions are more likely to lead to more severe illness, like if you look at the population of people that ended up in the ICU in China or in Italy, like the average age of death from this in Italy is 81. Now Italy is a very as a much older population than we have in the United States. And their health care system is a little different. And there's all kinds of rules and regulations that are there. But so that's one, you know, one piece of information that I think is important that 81 for Italy. When you look at the numbers in Wuhan, China, it looks like being older than 50. And definitely being older than 60 or 70 are risk factors. Now 50 is probably I don't know how significant it is. 60 is starting to get significant. 70 definitely significant. So age is a factor. They found that men who were hypertensive with uncontrolled blood pressure that clearly was a factor. And now in that cohort, but again, without being able to do widespread testing, you really don't know these are all the sickest people they're looking at. They're not looking at every person who's sniffles and turns out the habit like some of these famous people that you're seeing in the media, right? Tom Hanks has it. Idris Elba has it now the player on the jazz that has it. Those guys got tested. Like they were sick for like five minutes and got tested and prove that they had. As far as I know, they're all doing just fine. Now if we could test every person that had that level of symptoms, it would probably be a little bit more reassuring because we could say it's About 80% that are mild, it's a higher number than that. The only thing that I think has us worried is, in some of the countries where you're getting a lot of testing now, like in China, the the rate of serious illness and the rate of like ICU admission, and even death, they haven't decreased as much as you would hope, the only place we're seeing the numbers come down in South Korea, and that they are doing an unbelievable amount of testing. And so the mortality rate there, it looks like it's significantly lower than it is in places like China, or in Milan, in Italy.
Scott Benner 35:32
I think that it's interesting, too, that you're seeing some, you know, the really well controlled places are seem to be smaller countries, that is countries that aren't as landlocked sometimes, you know, like they're having, it's just like you were talking about earlier there, it's easier to restrict people from coming in and out, which should say to you, if you're listening, it should say to you, I need to restrict people coming in out of my life, just like you need to restrict them coming in and out of your country. It's it's all the same thing. You're, you're just trying to limit contact with people,
Adam Naddelman, MD 36:03
right? To keep this from happening. And so yeah, you could see why like, going to an NBA game, going to march madness, yeah, going to a concert, or a Broadway show. All those things are tremendous, tremendously dangerous in a situation like this. So it makes sense to not be doing them now. It made me wonder
Scott Benner 36:22
from the conversation so far, if as we get further away from where this began, if you will see it impact less people at younger ages, like will it get? Will it weaken? Or will this be a virus that doesn't weaken as its past? And I guess there's no way to know that now. Really?
Adam Naddelman, MD 36:43
Yeah. So so far, it's not showing the same signs of weakening the way that SARS did like I was talking about earlier. But the hope is, like, if you look at what's going on, in Wu Han China, now, they clamp down an unbelievably crazy amount compared to what we could ever do here. And because they did that, they essentially got all of the active cases, away from everybody else, quarantine them, force them, essentially, to not even be with the people that they wanted to be around that all like they pulled him out of their houses in some cases. But by doing that the person each person fought off the virus, and then they're not contagious anymore. And so they can go back to society. And if you look on the news, now, you'll see videos of people walking around, whoo ha, and like, you know, I mean, not like nothing ever happened. But they're getting back to normal, because they took they took what we're doing here, and they turned it up about 10 more notches, and
Scott Benner 37:36
they were able to because I guess freedoms, not such a concern there.
Adam Naddelman, MD 37:40
Yes, there is a bit of a trade off, which I wouldn't I mean, there's videos of them, like spraying down the streets and crazy stuff. And pulling people out of houses like that, that will never happen in the US. But that just means it's going to take us probably a little longer than it took them.
Scott Benner 37:53
I saw something online that really made me smile The other day, some it said, your grandparents were asked to fight a World War, you're being asked to sit on your sofa.
Adam Naddelman, MD 38:00
Yeah, I mean, in all seriousness, like you, I mean, we all have like 40 hours of TV we'd like to watch and probably, you know, at least 50 hours of podcasts and books to read and all kinds of stuff. Just go and enjoy that stuff. Just go sit down and relax. My son
Scott Benner 38:14
said the most thoughtful thing about it so far. So you just said to me He's like, this is just like summer vacation. I don't really need to do anything. And I was like, yeah, hundred percent. Just go relax. I said, just take a vacation. We're just gonna take it here in the house. Yeah. Now when I when I find myself in the grocery store, are there ways to protect myself? Like when I do have to go out? What do I do?
Adam Naddelman, MD 38:35
Yeah. So I think ideally, you go at a time when perhaps it'll be less crowded. A lot of the grocery stores are doing some clever things like only every other register is open. They're putting a shopping cart between customers. So you can't get within six feet of the person in front of you or behind you. You're not going to stand in line with some guy on the line next to you and watching sneezing and coughing or whatever. So you're going to be spread out. I think you want to get in and out. It's not the time to like, you know, debate which peaches you want to buy for 10 minutes. Like, grab what you need to get out.
Scott Benner 39:08
I am we were so Kelly and I went together. And it was hard. First of all, it was very interesting for anybody that's been out. It was quiet, solemn, almost like there wasn't a lot of extra talking people were very, I think they were trying to be calm, but felt like on edge. Everybody looked at each other a little weird, you know, like when you are passing by. And I watched Kelly pick up a jar of pickles, and put them down and decided against them. And then she changed her mind and pick them up again. And I was like, well, you stop handling everything. Even though if that made sense or not. But I was like, decide if you're gonna buy the pickles by looking at them. And then that made me think about that, like you start your brain starts going. So somewhere there's a woman who's a nurse and she came home at the end of a night shift and she's got the virus on her. She kissed her husband, her husband came to this grocery Or put these pickles on the shelf? My wife touched him. Now we got it. Right. And it's hard not to do that calculus in your head while you're while you're looking at things and doing
Adam Naddelman, MD 40:08
Yeah, this is this is a difficult time for people that have any level of anxiety. And in all seriousness, I mean, you really can make yourself insane. By running those scenarios in your head about every single thing. I mean, the good, the good thing is, like I said before, over 80% of people are going to get a mild illness. So even if you were unlucky enough to pick up the pickle jar that was handled by the nurse who kissed your husband, or whatever you said before, you're likely going to be okay. I mean, even though we worry a lot about the rates being higher than what you'll see for like a typical flu season. I mean, we're not talking about like some movie, you know, some crazy like outbreak in a movie where half the people who get it end up in the hospital, that's that's not going to happen. The problem though, is we just don't have the capacity that we would need in our hospitals to deal with all these people stick at once. And that's really the point of the measures is to, is to flatten that curve that jump that spike in cases, like if you just picture like you were saying before, how fast but just look at how fast the numbers are changing. And then when you hear about it in the media, the whole goal is to get that to slow down and spread itself out so that the people who do unfortunately get more, who are more sick and need hospitalization have a place that they can go and the resources aren't being taken up by too many people all at the same time.
Scott Benner 41:25
So the basic idea is that we don't, we only have a certain amount of hospital beds, ventilators, things like that. And for people who listen to the podcast, it's actually an interesting overlap, because we talk about stopping rises in blood sugars before they happen. Because if you never get high, then you don't have to deal with the things that come with being high, you know, extra insulin crashing, getting low later. So we're really trying to stop the spike of, of infection, not because we think it's going to stop people from getting sick, but so that it spreads out illnesses over time, so that hospitals can handle people's illnesses, if everybody gets sick at once they'll overwhelm the healthcare system, right, we can spread it out a little bit, then your grandmother gets to go in and get the treatment she needs and come out alive. Instead of ending up in there with four other people's grandmothers. When there's only three ventilators and then they got to do any meenie miney. Mo to find out which grandma doesn't get a ventilator.
Adam Naddelman, MD 42:17
Right. Right. That's I mean, that's exactly what the hope is that you can let the healthcare system catch up, like, I don't know if you saw last couple of days, but some of the governor's now are starting to really ask the military as the federal government to even deploy the military and let them put up a 500 bed, you know, mobile army type hospital that they do all the time. You know, they have a lot of experience over the last 20 years doing this. And it would be incredibly helpful. I mean, there are abandoned warehouses, there are all kinds of buildings, how about taking some of the dorms that no one's living in now, and using them if you need to, there's all kinds of structures that could fulfill this. And that would just give everyone a big sense of relief that they're that, you know, the capacity is there, it's temporary. When we're done with it, you can take it all down. It's when there is a tremendous need for it.
Scott Benner 43:07
I think people think that's crazy. But it seems a little morbid, but my wife's lobby of her building was used as a mortuary during 911. Like the need to take bodies, and they just, they use the building, they did what they had to do,
Adam Naddelman, MD 43:20
right? I mean, this is this, it seems like you know, because I think part of the problem is we have a hard time with the notion of this is likely going to happen. So let's prepare for it versus, oh, no, this is happening, we need to do something now. We tend to be more reactive. And I think the governors are, to their credit to being much more proactive and trying to get ahead of this so that we don't end up in a situation like you're talking about. It's, you know, a lot of those calculations that were being done when people were talking about things like you know, rationing care. That was before all these measures were put into place and they and every study that's been done and every calculation that's been done really does show that even a day or two earlier with these measures can make a huge difference. So we're gonna have to wait and see whether or not it was enough and how and whether or not it was early enough.
Scott Benner 44:14
Yeah, we got we got to a too late by waiting that that that week in there because I know people talk about it as this has been ramping up for a few days. But I think if you really look back, it's been happening for a week or so in America.
Unknown Speaker 44:26
It's been a
Adam Naddelman, MD 44:26
week of, hey, should we be doing something about this? No, don't worry about it. Like that's been about a week. I you know, I was away. Like in the beginning or so of February and I saw in the paper an article about a novel Coronavirus in China. It was like a little blurb like on page, you know, 52 or whatever the newspaper. And I remember thinking like how that's interesting. I wonder if that's anything like SARS or MERS or these other ones. That was like six weeks ago. Yeah. And you think about where like, think about where you this was a week ago, think about two weeks ago. If I told you three weeks ago Hey, guess what in three weeks your son's cancelled, a college canceled kids are home from school all the major sports are canceled. There's nothing on TV for them to watch. It's It's amazing. And that's the worry is are we good? Three weeks from now? Are we gonna look back and go? Yeah, you know, when we were complaining about how we had the kids home from school, that's nothing compared to what's going on at hospitals. Now
Scott Benner 45:21
I got lucky. It was really lucky because I did more traveling this year than I have previously. And I've never been a hand sanitizer person. But I just thought, I've so many commitments, I can't get sick. So I bought one with a little pump. And I put in the door in my car. Every time I got in a you know, I got back in my car from a public place. I gave a little squirt. And I rubbed it around. And I even like thought, like I put it on my cell phone like dirty me like I thought, well, let me see what I can do here for myself. And so you'll find this. I hope you find this funny. But then if you do it with the kids, you know, like when Arden gets in the car, like here, and she rubs it around, and she always goes now I smell like Dr. Edelman.
Adam Naddelman, MD 45:58
That's great.
Scott Benner 46:01
And now I'm thinking looking back, I'm happy. It was random. But I'm happy it happened because I have been in a lot more public places and traveling through now. But I've just been kind of cognizant about it. I've been like, you know, like, I go through places, thoughtfully not touching things. I was on a train the other day, I just thought you know what, let me practice my skateboarding skills here. I'm not going to hold on to the bar, you know, and if I hold on to the bar when I get out of the train a little thing, is that stuff really? Is that just in my head? Or is that stuff valuable?
Adam Naddelman, MD 46:30
No, it's valuable. It definitely is valuable. You know, old fashioned soap and water is just as good. If you're worried that you can't find PRL anywhere. Now, you can't find hand sanitizer anywhere, but it No, there's no doubt that it's valuable. So yeah, I mean, practicing this hygiene all the time. Like even something as little as Hey, before you eat your dinner, Go wash your hands. Like I'm sure we're all saying that to our kids, our our parents did that to us. But you know, just like you said earlier, like you get lacs about it, oh, they're outside, they're having to catch thrown a ball around, they come in, they eat a piece of pizza, they don't always wash their hands. Now, I think people are saying, you got to really wash your hands you got to be good about and you got to really wash them, it's not enough to run them into the water for two seconds and say you washed your hands, you got to wash them with soap and you got to, you know, count to 20 at least, and really take your time and wash your hands. But no, there's definitely a value in what you're talking about. Now, for a while we used we were thinking for a while that people were getting like way overboard with the hand sanitizer and not exploiting their kids ever be exposed to any germs. There's a danger that we're going to go all the way back to that and never let kids that playdates anymore, and we're going to shut all this down. There's a value in your immune system being exposed to a wide variety of things over the course of your lifetime, especially when you're young. So there, there's going to have to at some point be a bit of a pullback from all of this, like when when the world returns to normal. But for now, you can't be too careful with this. If you want to use hand sanitizer, every five minutes, do it if you want to wash your hands 20 to 50 times a day do it.
Scott Benner 48:01
Okay, so let's recap here. And I'm gonna let you get back to life. I think, um, Adam has been talking about this a lot lately. By the way, how did you end up on crisc comos radio show talk. So
Adam Naddelman, MD 48:11
I listened to that show a decent amount just because you know, if I'm driving between offices or running home for lunch, I'll put it on and I just called it there was no nothing more than that. I called in and the guy who picks up the phones, asked me who I was I told him who I was. He said, Oh, that's great. Let me you know, I'll put you through first time I got on. He put me through, like almost right away. And then at the end of the call, Chris Cuomo said, Hey, you know, why don't you call back, you know, each day and kind of let me know what you're seeing and whatever. So I figured today that was Friday, I figured let me just see if I actually can get through I thought maybe there was like a back number. I don't know how, how it works. But I called again today. And it got right there again. So I don't know if they set my my number up now to be able to call through or what but I figured lucky. You know, he's talking about this topic. And he wasn't doing it necessarily from a political angle. It was more from the kind of conversation you and I are having. I figured let me offer a medical perspective because not not one of his callers was someone who was actually dealing with this for real and from the health care side. And it sounded like he appreciate I was on there today for I don't know, eight or nine minutes, I think. Okay,
Scott Benner 49:20
well, one day we'll get you back on here and you can tell people the story of how I called you in the middle of the night and you sat on your computer in your underwear finding a hospital to take art into while she was being bad. Yeah,
Adam Naddelman, MD 49:29
it was Virginia Beach right? What are you doing the beach?
Scott Benner 49:33
Yeah, we're on our way to the wrong hospital. And I heard you clacking away on the keys. And it was it had to be like 130 or two o'clock in the morning and you found a hospital that had a kid some kids dedicated center for for diabetes and that's it
Adam Naddelman, MD 49:48
all those kids they're all the people that were there were people that had trained I think at the Children's Hospital Philadelphia so we remember saying he like I have a feeling this might be a better option than whenever the closest place was at that point. You should Did you like turned around and drove in the other direction? But got there?
Scott Benner 50:02
Yeah, it was really. It was really something a long time ago. But uh, so I, I'm embarrassed that I didn't think of you first I for two weeks I've been like, Who am I gonna get on the show to talk about this if this really needs to be talked about. And then I got I landed coming home from Kohl's baseball thing, and I picked up Facebook and there you are talking to, you know, on on the Cuomo show about I was like, why
Adam Naddelman, MD 50:24
am I not thinking of this? So I really appreciate you doing this because I know you've been slammed, your your practice is going to go to is are you going to go to like, this kind of thing? Are you gonna start Skyping with people to see people. So we actually, about a week ago, when we started to realize where this was heading, we about as fast as we possibly could do anything put in place, the whole plan for starting to do telehealth. And so tomorrow is the morning we're going to have a couple training sessions with the people that we're doing it with. And then our hope is that by the afternoon, if not the afternoon, by definitely by Wednesday morning, we will be offering telehealth appointments for basically anyone who has I mean, we could do it for almost anything at least as a starting point. But especially for the kids who parents are worried. You know, just just like you said before, they're calling the office thing, oh my god, he's congested, he's coughing, he has this, he has that, instead of the nurses trying to just triage it without seeing him, we are going to actually do a virtual visit where we can see them and actually observed the child and talk to the parents and do a whole basically like an office visit, it's a good idea. But do it over the phone? Or do I have to do it on the computer, I genuinely think that
Scott Benner 51:37
you know, a lot of bad is going to come out of this whole thing. But a lot of good is going to come out of it too. We are going to become more agile, but we take care of things, you're going to see a lot of businesses follow suit, and maybe some of them won't go backwards again. Or maybe this is the thing you'll keep
Adam Naddelman, MD 51:52
you know, maybe we're definitely gonna keep it I mean picture like even the example you just gave about that awful night all those years ago, imagine if we had telehealth and you said to me Look at her now like you saw her a few days ago, look at her now what do you think's going on? Like, that would be a very different interaction than a cell phone at one o'clock in the morning. And I think I think you're 100%, right? I mean, look, there are times when we all think the world is changing in a way, and we're never going to get back to where we were, and it's all atrocious and good can come out of it. And I think this is one of those situations, it's just gonna take everybody thinking about it in terms of what can they do for each other and not just about themselves, you have to think about it in terms of your neighbors and your community. And if we do that, and I think businesses like you're saying are clearly going to adapt. And I've been saying for years, what in the world do we have to have all these people traveling all over the place to have these in person meetings? for like an hour that you fly to California for an hour meeting and you fly back? like that just seems so foolish? Now when you look at what people are going through, right? Yeah, I more recently?
Scott Benner 52:53
I do I do a fair amount of traveling to give these talks, right. And I just go about, I talked about how we do things on the podcast with blood sugars and stuff like that. And it's really valuable. And I see that I see the people having sometimes very instant, like significant changes in their health. But recently, someone contacted me and they were like, would you come to Japan? I was like, No, but I'll do it over the computer. And we did it. And it worked great. Yeah, I mean, there was really no difference between me not being there and being there.
Adam Naddelman, MD 53:22
Right. I mean, I could see like, for a live presentation in front of a lot of people, and especially question and answers, that can be a real value in a face to face. But, you know, these these meetings that you have some times where you have to really put yourself out in terms of travel, just to spend a couple hours in the, you know, there are certain industries where the face to face thing is still super important. And I think this was is likely going to change that for a long time. Like you're going to do a lot more of this a lot more skypes a lot more kind of video sessions, where you know, as the technology improves, and everyone's in super high def, and the cameras improved. It's not gonna be that different from sitting around a table if you have five computers set up and you can see everyone's faces.
Scott Benner 54:01
Oh, my daughter did her first day of high school from home today. She said she liked it. Is there a way I can keep doing it like this? A couple hours later, Cole got word from his school. They're going to distance learning for the rest of the semester, which is the rest of this year. And Kelly's working for him for for the foreseeable future.
Adam Naddelman, MD 54:21
Yeah, I'm in the same situation. Dana is now working from home. She's not they're not going in at all. My kids are all doing virtual learning. The boys are doing virtual learning with like, they're using zoom where you literally are watching a lecture and the kids are all on the screen at the same time and they're all participating. I think our kids generation is going to be really good at this. Like they actually in some ways, some of them probably will prefer it and may get more out of it because they can it's more condensed like that their lesson plans are right there. There. It's there's not a lot of like walking around between classes, and they're gonna find they can actually accomplish a lot this way. I think it's interesting when you think about the universities, I would I would it would be interesting to talk to people who are in that line of work. But you have to think that there's a real concern among some of these universities that someone is going to come around with a real good online platform for education. And it's going to cost like a third as much as what people are paying, now, you're going to get a degree that's actually really worthwhile, and you're going to be able to do it from your living room. I mean, there's no doubt that the social aspect of college is probably a bigger piece in some ways than the academic piece. But if you can do it for third the price, and this market,
Scott Benner 55:31
yeah, there's right. There's no reason not to try. So I, I just think it's, you know, it's not dissimilar to I say this about diabetes a lot. And sometimes people think it's odd, but, and I don't, I always say like, don't get me wrong, like I would genuinely do anything for Arden's pancreas to work, right. But because it doesn't, we've also had all of these amazing experiences, and she's become a much more resilient person than I think she would be at 13. So goods come from it, too, you can't ignore the good that comes from it, you can hate the bad, but you don't have to, you don't have to ignore the good stuff that's coming. So
Adam Naddelman, MD 56:06
I agree, I agree. And my office is about as crazy as you could ever imagine anything. Right now, there's no doubt about it that we would be life would be much easier right now for everyone who was working in my office and putting in the hours they're putting in if this wasn't going on, but I also have no doubt that when it's finally over, we will be a better practice and better physicians and better nurses. And more probably empathetic even to people like we will all be a little better. Because we worked through all this. It's hard to see it now because we're not at the end of it yet. But I really do, I really do believe that. But you got to really you got to just work it you got to you got to think about everything that's going on, you got to take the measures that the experts are recommending you got to believe the scientists, you have to you have to really think about what you can do for each other. You got to you know, all of those things, I think are critical for all
Scott Benner 57:01
you people who are always my wife said she heard you saying this earlier today. But I've seen it on Facebook a little bit for everybody's always bemoaning I don't have enough time with my kids. there's now an equal amount of people were thinking and saying out loud in some points. I don't want to be around my
Adam Naddelman, MD 57:14
kids this Oh, it's so true. And I was saying earlier that, you know, for every time you complained about all how to want to go to that practice, I really have to take into this. Now, how many people would you know, pay $1,000 to be able to have their kid just go to softball practice.
Scott Benner 57:29
I told my son tonight I said, you know, it's interesting. We live in a time, unlike any other time in history, so you have so much ability to do so many varying things. And he was home from school for three hours yesterday and told me he was bored.
Adam Naddelman, MD 57:43
They're bored out of their mind.
Scott Benner 57:44
Yeah. I said, I don't know how you're bored. You have a computer in your hand that could watch a space shuttle. You could, you know, I you just maybe you needed to dial in one time to the internet in your life to realize how amazing this is televisions that you have and contact with other people. You can speak to people if you want to face to face and all this stuff. And he's like, I don't know what to do. Like.
Adam Naddelman, MD 58:05
Yeah, I mean, it's amazing. I actually kind of hoped that maybe. And this probably isn't gonna happen. But just simple things, pick up a book, go for a walk, like go for a walk around the neighborhood, just you know, the weather's not bad. Get outside, sit outside for a while with a book like something that's just not the constant incessant, you know, in front of the screen and make you anxious and make you crazy because reading every last thing and hearing every last thing I feel
Scott Benner 58:32
I feel the worst for people who just not in the financial place for this for people who don't have a job that sends you home but just tell you can't come in, but you're not getting paid. That's a hard thing to fathom.
Adam Naddelman, MD 58:41
Oh, it's um, but it's unfathomable. I mean, imagine if you owned a coffee shop, or if you owned a restaurant or, you know, you're you're just an employee that's per diem somewhere or you just you're, you know, an hourly employee that you have no benefits, or I mean, it's just, it's unfathomable to think like what in the world is the certain industries going to do? Right? I mean, imagine being like a pilot, for instance. I mean, those guys aren't flying anywhere now. American Airlines cut 75% of their international flights yesterday,
Scott Benner 59:11
I saw that there's 75% of one of the European airlines just shut down. Yeah, they say they said we have no Scandinavian maybe I'm not sure one of them was just like, we don't have any. There's no call. Right. So you know, we're just not gonna fly planes anymore.
Adam Naddelman, MD 59:26
No, I mean, I agree with you. And I think Unfortunately, that's the next big me on top of the fact that the illnesses are going to pick up you're going to start hearing more and more about companies that are not doing well and employees getting laid off and it's going to be really, it's going to be awful for a while. That's why it has that we have to do these things now to hopefully shorten the duration of this and decrease how painful it does get.
Scott Benner 59:50
Yeah, no, I hope people believe that. Is there anything that I didn't bring up or that you didn't say that you think is important?
Adam Naddelman, MD 59:56
No. I mean, the only thing is I do just want to reiterate the social distancing thing. Think keeping yourself six feet apart, you know, with from people around you, including the kids. So no sleepovers, no birthday parties, this is not a snow day, there's a great post circulating about that too, that I saw. Don't treat this, like, you know, it's snowing, and we're gonna pile 20 kids in my basement and let them all watch a movie, you can't do stuff like that. You just have to stay apart. If you have elderly relatives, the best thing you can do is call them and talk to them, don't go visit them, stay away from them. Just because they're family, it doesn't mean that they might not have it. So you really need to take it seriously. If you are going to visit with people do it outside, you know, be outside be six to 10 feet away. Do it for a brief period of time. And but no contact like no hugs and kisses and all of that that has to stop now going to the bow.
Scott Benner 1:00:47
I'm just a genuflect a little bit. And you said that I I called my mother last night who's 76. And she lives by herself. And I just said, Mom, listen, Kelly and I talked about bringing you up here. But I think you're better off where you are by yourself. Yeah, I'm like, Well, you know, text every day and we'll call and everything but I think just you know, she's like, Oh, my card clubs not meeting anymore. And I was like, Yeah, that's good. I was like, don't do any of that stuff. I say go outside. I said the same thing to her. So it's so what I'm hearing, at least between you and I and you and I think pretty similarly about some things but common sense, right? Just use your common sense and don't get in contact with other people. You can't just decide that people look okay, it's you know, right, you know, you should
Adam Naddelman, MD 1:01:31
prompt exactly right just just and be patient because it's going to take some time this is not going to be over in two days. It's going to take some more time.
Scott Benner 1:01:39
Well listen in a world where social There are apps for dating apps that have never once warn people about like sexually transmitted diseases but those those apps are popping up now I'm hearing and telling people listen that Coronavirus blah blah blah, you know, so so I'm gonna let you go with this. What do you call it? You call it COVID-19 or do you call it the Coronavirus? I mean the medical world is calling it COVID-19 I think when we talk to patients and when I just talk about it with friends I'm always calling it the Coronavirus. I think you know COVID-19 just sounds like it just doesn't sound like a virus. I don't know. It just sounds like something different. COVID-19 is really like what they're calling the illness that people get. I'm using Coronavirus. I don't think the people at Corona are so happy that this is the Coronavirus, but it is what it is you must be out of their mind actually. Okay, so I'm going to um, I'm going to in a number of weeks when there's more to say I'm gonna force you to do this again. Just
Adam Naddelman, MD 1:02:29
you know, I'm happy to do it. I mean, look, this is changing unbelievably fast, like incredibly fast. Just thinking back to where we were a week ago. So I'm happy to do it again. If you think it's useful for you, all your listeners find out.
Scott Benner 1:02:42
So thank you very much.
Adam Naddelman, MD 1:02:43
No problem.
Scott Benner 1:02:46
This episode was recorded on March 16 2020. And Adam will be back if there's more to talk about and I think that there's going to be much more to talk about. huge thank you to Omni pod Dexcom and touched by type one for being fervent and long term sponsors of the Juicebox Podcast I appreciate your dedication to the show. Get yourself an absolutely free no obligation demo of the Omni pod sent to your house right now my Omni pod comm forward slash juice box but the links right there in your show notes. Were the ones you can find at Juicebox podcast.com. Start today with the Dexcom g six continuous glucose monitor by going to dexcom.com forward slash juice box again, where the links that you'll find all over the place. And of course touched by type one.org. Head over there, check them out. They're doing amazing work for people with type one diabetes. And you know what i guess if you're in the central New Jersey area and you're looking for a beautiful pediatric center, Princeton Nassau pediatrics, I've been taking my kids there for a very long time. So okay, everybody, listen. Let's do this together. Right, let's look out for each other like Adam was saying, to be cautious and careful. Let's try to ignore the fact that we don't want to stay in our houses for a couple of weeks. Just do the right thing here. And let's get past this as quickly as possible. And if you absolutely have to go out for any reason financial the buy food, whatever. You know, again, what Adam was telling you, keep your distance from people wash your hands. Let's not get in spitting distance, sneezing distance, will be kissing people you don't know or Come to think of it people you do know don't kiss anybody. You understand what I'm saying? Right? If you touch the handrail and something, try not to touch anything else till you handle yourself. Soap and water. Good, good, good, you know like this really get in between the fingers. I think together we can put an end to this pretty quickly and get life back to normal course. The next episode of the podcast will be out in a couple of days. Jenny Smith and I are going to talk about Sick Day management for respiratory illnesses. You know, like the Coronavirus
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#313 Fox in the Loop House - Part 2
Kenny Fox talks Loop Management
Kenny and Scott talk about DIY Loop and type 1 diabetes.
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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.
Scott Benner 0:00
Hello, everybody, welcome to Episode 313 of the Juicebox Podcast. Today's show is part two of a two parter with Kenny Fox. Now Kenny's name might not ring in your head like, oh, Kenny Fox, is that like Michael Jordan for diabetes? Well, no. But what Kenny is, is the data of a little girl who has type one diabetes, who really dug in to the DIY loop. And he understands it in a way that I find it inspirational. Now, Kenny and I are going to walk step by step through every setting in the loop, talk about it and kind of a big picture way. If you're not into a do it yourself algorithm for insulin pumping, I get that you don't need to be I'm not telling you to be. What I am saying is listen to the episode anyway. Because it's just another way of thinking about how insulin works. This episode of The Juicebox Podcast is sponsored by Dexcom. The Contour Next One blood glucose meter, and touched by type one, you can always go to touch by type one.org Contour Next one.com or dexcom.com Ford slash juicebox. To find out more about the advertisers, there'll be a little more about them later in the show. But for now, I think we should get to it. We're going to start right at the top by saying nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please consult a physician before making any changes to your health care plan, or becoming bold with insulin. And today. Also remember that what we're talking about is an algorithm that Kenny and I downloaded from the internet. It doesn't belong to a company, you just completely do it yourself. It has not passed through the FDA. So understand that while we're talking. Now that aside, using the algorithm. And watching the data come back from it and seeing how it reacts will absolutely supercharge your understanding of how insulin is working in your body. I'm telling you to watch a an app, a computer algorithm decide about insulin, it just elevates your understanding. At least it did for me. It's taken me a while to figure looping out and I'm probably not all the way there. But I'm getting closer. And I'm going to keep having these conversations with people who are ahead of me until we're all at the same level together. Luckily, I found Kenny and Kenny understands looping. And that's why this episode is called Fox in the loop house. Part Two. So insulin model, when you have yours, even lower than mine is what's the intention of making the insulin model a shorter time period.
Kenny Fox 3:01
So whenever I try to deal with loop, I'm doing my best to represent reality. So because I know that her incident her bonuses and stuff with good bazel only last four and a half hours. That's why it's four and a half hours. It's not just to get like a performance out of it, it's because I really think that the that's how long the insulin last. The rest of the model is a little interesting. If you see that top option is always that Walsh model, it's always got the line like higher than the rest of them. That's kind of what the pumps use it. It's more like a I don't know, like a straight line steady decay of insulin or insulin is really kind of peaky, right, it's slow to start, it hits hard kind of around an hour ish hour and a half. And it stays strong for an hour or two. And then it kind of fades. And so these other models more more accurately represent like how much insulin is left, because it's kind of more initially and then less later, where that wash model stays really high. And so that's why the that's one reason, even endocrinologist know that insulin lasts longer than three or two or three hours. They like to set people at like a three hour because for most of that curve, a three hour four hour Walsh model will accurately represent how much instance on board until of course, you get to the end when you say hey, it's over after three hours, and there's still two more hours left. And so then people are like, Oh, well, why do I says no more instance on board? Why do they keep dropping? Why is my blood sugar keep dropping? Well, it's because there really is more insulin on board but your pump is lying to you. So you either got to have your pump lying to you the whole time until the very end when zero is zero, or and then you can kind of just round down or you set it shorter and then it's like kind of accurate most of the time and then at the end, you still have insulin on board left for another hour too. So it's a tricky thing.
Scott Benner 4:51
Is this a case of because insulin works in choppy like ways, not smooth ways that you're going To have to lie to yourself or lie to the pump, or have the pump lied to you, however you want to think about it one way or the other. So let's lie on the more
Kenny Fox 5:10
cautious side. Yeah, I think for a lot of NGOs, they use the instant action time of three hours to give people permission to bolus when they're high, like, hey, if it's close to zero, go ahead and correct because after three hours insulins mostly done, rather than tell people, hey, this is how long it's been last. And if you see this number, round down, a better idea would be to use a better tool. But those are limited, right? You can use nightscout has a better, like in insulin action calculator, extra spike, these other open source apps and loop their insulin models they use for how insulin hits indicators is much more accurate than what comes standard in most pumps, where it's just a matter of getting these tools.
Scott Benner 5:52
And what I would do prior to loop is, I just wouldn't pay any attention is on onboard.
Kenny Fox 5:59
Exactly. Yeah, it becomes so inaccurate that you don't trust it anymore. So no one looks at it, which is what we'll talk about, we get to base rates and stuff like that's, that's the the piece people kind of ignore they people look at it and go, Oh, wow, there's a lot of insulin on board when someone's falling, but then they don't really look at it other than that,
Scott Benner 6:15
yeah, I just think of it is, I don't know, like, it's like putting out a brush fire to me, like, I've always got to charge toes ready. But I'm not always squirting it, I turn the water on when I see the flames. And so like it just, you know, I go I put something out, I keep walking around, there's more, there's more carbs, more more insulin. Now stop again, it's just to me. Diabetes is like a common sense. Like you can use insulin in a common sense way. It's when you get out of balance or out of rhythm, that everything gets messed up. And then common sense doesn't seem to apply anymore. Which is why I always tell people like when you get when you start bouncing, the best thing to do is to get low, get down, get steady and start over. Because you're just you're trying to you're trying to grab sunlight otherwise, you know, yeah, like it's just it becomes it just becomes an endeavor. That doesn't make sense. Okay. Kenny, also, by the way, at the beginning of the podcast, we're gonna let people know, this is an algorithm that you downloaded offline. It didn't come through a company it has not by anybody except the people who wrote it, who, by the way, are really brilliant people, but are not the FDA. And that you're not a doctor by any stretch of the imagination, or am I? We have no, not even close. Right. And that none of this is advice. We're just talking through how we do it people should you know, definitely be precaution. You know, take precautions. Keep in mind that when I started the loop with my daughter, I had Jenny to talk to by text, I was able to reach out and speak to Katie, and had I not I don't think I would have made it two days. Honestly
Kenny Fox 7:54
with it. It was it's very frustrating to start to or it could be scary depending on which way you're coming from
Scott Benner 8:01
hundred percent. Okay, so what should we talk about next? Do you think basal rates?
Kenny Fox 8:05
Well, real quick on the model only thing left is that peak, you don't really see it much. But it's mostly like supposed to represent when insulin is at strongest. I use the adult one for my daughter, not the child one. So the child one has like a 65 minute insulin peaking and the adult 175 I feel like a little over an hour's when I see insulin pulling her down the best. So I went ahead and did that. You also see that if you extend the peak out and use the adult one instead of the kid one, you'll often get larger initial bolus recommendations, just because of the way the math works. So I use both a lower insulin action time and the adult peak that's a little higher. a fun thing if you want to test or kind of play with the shorter da instant action time without or peaks. without, you know, really testing it like an open loop or with your PDM or whatever is you can when you do the build. And there's a screenshot in that loop docs on how to change the insulin action time and peak, Katie had a great suggestion, just take one of the models you're not using, for example, we don't use vs. So I took the settings for Fiesta, and I changed it. So I just changed the peak to be what I wanted it to be like matching the adult one for example. And then I change the insulin action time to you know, the five hour one or the four and a half, whatever you're going to test. That way once you build your app, you can just switch between the models, and like use them for what you want to use them for. So if you want to try a five hour interaction time, and then find it's like too much, it's too aggressive or whatever it is, then you can just go into the settings and just tap and use the different model. You don't have to go back and rebuild. Sometimes building causes a lot of stress for people. So if you can do it once then you can just kind of toggle back and forth without having to do a new build. It's helpful. I guarantee you just spoke about most of the people's understanding as well. If they're getting into that Lu customisations. Yeah.
Scott Benner 10:03
Okay. sila rates is good. Yeah, rates is the next place to go. So you just said something, you know what? Maybe it's not maybe those things strategies the next place to go. So that's a cool one. Yeah. And here's why not all of you who even download loop are going to have this setting. So in very basic terms, if someone has written a program, it's an app, right? And this app is an algorithm that takes the data from the Dexcom, and sends it to your insulin pump, and makes these insulin decisions happen around it. There are other people working on additions to the idea. So there's sort of a basic one, is that called the is that always dev? Is that the one that's being constantly being developed? Or am I speaking wrong here?
Kenny Fox 10:51
Yeah, you're right. So the master one is the one that you know, is should be the most stable, it's kind of the one people would mostly download. Typically speaking, Dev is where all the is where some of the playing, there's actually like, kind of sort of a layer beyond that, like a what they call like feature testing, someone might build a little, a little change, they want to try, and they'll build that. And then once they kind of test it, it looks good. And they kind of put it into Dev, and that's where all kind of the fun stuff, the new stuff comes together, and hangs out for a while while people use it and make sure that all those new features don't just work, but they work well together. And then eventually, that gets promoted up to master after it's,
Scott Benner 11:32
everything looks good and proven out. So the very first time someone mentioned to me about an automatic bolusing. So right now, this this, this, this master branch of loop does not does not give you boluses of insulin, it manipulates your basal rates to try to try to get you to where it wants you to be. But I was somewhere a number of months ago, and some guy says to me, yo, have you seen this Auto bolusing? You know, addition to the loop? And I said no. And he told me about it and helped me check it out. And I forget if it wasn't written by a man named Ivan, maybe Ivan. Yeah. And Ivan's was cool. And you could turn it off and turn it on. But the ways to make it work were a little too detail oriented for me. So I was able to make it work pretty well. When there were carbs present in her body, it actually had a setting for like, have this work while carbs are present, or while carbs aren't present. And I couldn't make it work without carbs. And I and I could make it work with carbs. But when I tried to leave it on constantly, overnight, her blood sugar would be like, you know, 80 and all of a sudden it would like be giving her insulin. Oh my god. That's no good. So we got away from that. When an auto brand showed up. Did Pete right it? p pizza and the main steward and developer of lupia. Right. So Pete wrote this one, I gotta tell you, I've been using it for a while now. As a matter of fact, I got a note from Kenny and Kenny, he's like, yo, you seen this developer? This, uh, Audubon springs from Pete and I was like, already got it. And so yeah, you were ahead of it. I was surprised. Sometimes I sometimes I'm out the right out in the forefront. The flag I don't even have a sword. I'm just running ahead with the flag. So I'm the first guy to get shot Kenny.
Kenny Fox 13:24
Someone has to be
Scott Benner 13:25
shoot the guy with the flag first. So. So anyway, we're using that. And I have to say, it's pretty Skippy. So Am I understanding it right that when and insulin is pending, or when the you know, the loop is telling you, we think you're going to need another half of a unit soon. It will give you 40% of that.
Kenny Fox 13:48
gas. Yeah, exactly. So like the by default. So instead of increasing basal rates, it only decrease your basal rate, it will never increase. If you need more insulin, instead of ramping up your temporary basal rate, it will give you a bolus. But then just for safety, there's a a number you can actually change it to in the code, but it just uses 40% of whatever loop thinks you need. And it gives you that as a Bolus in the next five minutes. So I'll give you another 40% of that. So it kind of its slows down. So I mean, in theory, if your insulin need was the same, for let's say half an hour, because that's how long loop kind of can can give you a basal rate for it would give you it end up giving you less insulin over that half an hour because you'd never get to 100%. You know, 40% 40% 40% just gets smaller and smaller and smaller, but never really gets to zero. But it gives you a lot more up front. So Pete did some cool math was basically saying that if you had consistent insulin needs and you're going to run a single basal rate, increased basal rate for half an hour. You're basically getting 17% of what loop thinks you need every five minutes. If you just held steady for that half hour and then but With the auto bullets, you're getting 40% of it kind of right away. So you know, within the first 10 or 15 minutes, you're still way ahead in terms of like timing of the insulin, but after about 20 minutes, you're kind of about the same amount of insulin delivered. Unless you count the fact that we might change the base rate every five minutes, in which case you go back to what I mentioned before, where it starts counting over again to redeliver. So
Scott Benner 15:22
right, so using Arden's current situation, which, by the way, please believe me, no one set up just because it works perfectly during Kenny's conversation in mind right now. Like, so I want you to know, first she comes out of gym, you know, she's lost connection, Toradex calm, while she was disconnected the loop had taken her bazel away completely, so she didn't have any insulin coming in. And she gets back over finds out, hey, my blood sugar is actually you know, 60 I want you to know that we checked that with a finger stick. So she whipped out the Contour Next One meter, she checked her blood sugar, she's definitely 60 she feels fine. You know, I didn't share everything. She said in the tax. She's like, I don't feel dizzy, I feel 100% fine. She was you know, 15 or 20 minutes before that, like in the low 70s. And most of your like, the kid just went the gym class with a 70 blood sugar. But it also is because I knew that for the time prior to that she did not have a glut of even bazel running because this 85 blood sugar that was trying to drift eventually to 60 which it did over a number of hours. Loop has been taking away bazel for a while now. So I was pretty certain that even if she kind of got a little lower, it wasn't going to be a crashing low. It's just going to kind of like float down, which is exactly what happened, which is cool. But I just want to be clear we you know, I my daughter seven units of insulin based on the hope that her CGM pop back on it was right which by the way, it did pop on and it was right she it had her at 64 the the meter header at 60. You know, I'm that makes me comfortable. You might imagine the next reading drifted down to about 60 and then come back up to the meter. Yeah, we're at 60 right now. And but here's the great thing. She's now been eating for quite some time. So just like we talked about earlier with the cereal, like where you know, she looks like she's 85 or 90, but the cereals in there. Clearly, she's going up because she's eating the cereal, but the glucose monitor has not adjusted out of it yet. And we gave her some crushing amount of insulin vino for the cereal. And it still didn't help by the way Arden's coming out of that cereal, she still at one point was 171 error straight up. And the way we stopped that was by opening the loop. And hitting her with a big bolus of like three more units, she eventually had 13 units for that cereal, which, ironically, is how much I would have given her without loop. And I don't know why I didn't just do that it was because it was because I wasn't with her and nobody was around. But we stopped that cereal spike at like 185 200. And that space, it it leveled out. And as soon as it started to come back down again, we close the loop right back up. So the loop could start taking away bazel. Because those three units were too much they were enough to stop the spike. But they weren't going to be needed moving forward. And because ardens bazel rates like 2.5 an hour, I just basically I threw in an hour's worth of bazel to stop the spike, and then took away an hour's worth of bazel. And let that three units act as the bazel.
Kenny Fox 18:25
Does that mean we do something very similar. When I see a spike like that, I just don't bother to open loop because one, I can't do that from the watch. I'm not going to bother my six year old to say Come over here. Let me have your phone. And then I'll do that. But also I know exactly what you said, which is that what I'm giving ultimately is probably too much unless it's unless I miscounted the carbs. So that's one of those situations where it's like, well, if I miscounted the carbs and I'll go in and edit or add a carb entry kind of back in the past to kind of stack on top of the meal. But But even before I can even figure that out, it's just a big bullet. So you just need to stop the arrow, give it a big bolus, let Luke cut bazel I don't care if it cuts bazel or not. And if I think I miscounted the carbs then I go back and I add carbs. If I didn't miss count the carbs and just missed Pre-Bolus or whatever Miss timing, then I just let loose cut the bazel because for the same reason, she's going to go low eventually if it doesn't, so I just let it do it. That may mean you get a couple more ticks up versus open looping. But I just I let it ride. I just give a big enough Bolus to stop it in its tracks and loop cup bazel and hopefully land safer or safe safely or safer than she would have otherwise. I've done
Scott Benner 19:37
that too. I don't it's funny, isn't it like what you just said makes complete sense they but I would have been uncomfortable giving her five units to stop a one at going up. Even Yeah, even though I think you're not wrong. I think it probably would have gone the same way. So I'll try one day like I just like having the bazel back there.
Kenny Fox 19:57
Oh, it definitely helps. Yeah, it makes it makes a difference.
Scott Benner 20:00
So, so now right now at this meal, we've put in seven units for what I'm guessing is like 80 carbs. But at ardens ratio. She has more than that she needs more than that. Now I'm going to tell you right now I've seen it work enough times, going back to Pete's Auto Bolus, those things strategy to tell you that if we don't do anything else, that Auto Bolus is not going to let her go over about 170. That that's what I know is going to happen based on what because I've watched I've let the auto Bolus do its thing a number of times, so I can watch it. And so if there's a if there's a reasonable Pre-Bolus, you're starting with a lower number like this, it's going to stop her up in there, and it'll get her back down again. But the truth is, is that as soon as Arden's blood sugar adjusts, in a way that makes me comfortable that we're seeing some sort of upward mobility, you know, movement in her blood sugar, I'm going to ask her if she finished all of her food. And if she did, then she's going to put in probably three more units on her own put in the rest. Yeah, yeah, it's so it works. And I don't know, the technical side of it is lost to me. I don't know the changes that they've made in the basic Master, you know, version of this since we first started. But when we first started this, I think I've updated the master vert, you know, loop, maybe once or twice in the last nine months, the first two goes of it that I was using, were really, night and day, not nearly as good as what this is.
Kenny Fox 21:32
Yeah, yeah, it was a big, big one was how, how loop assumed that the only pod was delivering those basal rates, how it calculated when to start and stop its delivery. That was the big thing that was off a lot of the Medtronic pumps that had been used before, they instead of they just do it differently, they start, they restart the counter, but then they start a little sooner, without getting the detail to start sooner in like the Omni pod and a couple other of the Medtronic pumps so that and I think they sort of knew about it. But didn't think it was that big of a difference in the amount of insulin delivered and how much difference that would make. But with especially with littler kids like us, it made a huge difference, it would say that she'd have a larger percentage of insulin on board then than she really did, because it thought it delivered insulin and it didn't. So that that was probably the first big change. And the second big change was a the car model how loop expected the impact of carbs the hit, I thought it would be kind of steady like all those 80 carbs, we hit evenly, evenly raise the blood sugar across those two or three hours, instead of like more accurately modeling that most food hits faster sooner, and then it kind of steadily goes down. And so those were the two like significant changes that you probably experienced. And I did too, that sort of made me start to trust the system a little bit more.
Scott Benner 22:55
So let's jump to base. All right, let me ask you, for me, you heard me break Arden's Bolus into two different decision making entries? Yeah, well, actually, it's one it's so she makes an entry. So she said whatever it was, if it was 35 units, two hours, it means it says two or however much it thinks she should have, I always tell her just choose zero and enter it, then get that Yeah, put in the next one that it bundles them all together for the next one, so that you don't have to watch insulin, so that it doesn't deliver the first few units of insulin for the two hour model. And then you have to sit and wait for the to do that. So instead you deliver nothing on the two hour or whatever the first time because you're thinking and the adult delivered on the second go round. But I do that, so that Luke has a better understanding of exactly what you just said, some of these carbs are going to hit faster, some of them are going to stay with her longer. And that used to keep the bazel from going away. And it still would if I didn't have the dosing strategy of auto Bolus on. Because I have auto Bolus on it's now taken her Basal away, but it's going to try to come back with Bolus if it needs it. Whereas if we didn't have auto Bolus on that thing I just did with a two hour and three hour would have tricked the loop into keeping the bazel on.
Kenny Fox 24:15
Yeah, so like that three hour people find what those carbs is that if you put a longer absorption time, the initial impact is less you get less insulin recommended up front, typically you'll get the most insulin recommended up front on a two hour. But on a three hour let's say it's going to last longer, and it's going to the carbs have a chance of outlasting sort of the peak Enos of the insulin and Luke knows that so that it will offer more insulin later to kind of help compensate for that. So sometimes when people find themselves kind of high at the end of a meal, it may not be because there wasn't enough insulin it may just be that you needed more insulin but you needed a little bit later and you seem to totally pay This food actually is lasting longer than I thought. And it will often recommend another Bolus once you modify that absorption time. In the past like, Oh, this one, I thought it was two hours, it's probably more like three, you change it, it'll probably give you a bolus recommendation in most cases. So but doing the like, representing the food properly is isn't is important. And it's kind of a new thing I had to learn with lupus like, I don't know, how long does something take to eat night last in your system? So
Scott Benner 25:26
no, I know. It's interesting. I just, I kind of blank I do two and three hours. And it works every once in a while. If it's something like rice, like with a Chinese food, I might do two, I might do two and four hours. But it's you know, it's not always perfect. Again, I want everyone to keep in mind that Arden's a one c does not come from an 85 line that never moves. Like to be perfectly honest, like, because she was sleeping in. And you know, it all, you know, it all went well for me this weekend. But that's not normally what her it's not normally. Yeah,
Kenny Fox 25:58
it looks like for eight hours, you know, and I think that's part of the secret sauce or magic sauce of like a control IQ or some of these other algorithms is they you just enter carbs. And you don't talk about absorption time even like open APS and other systems, they have other algorithms, they tend to handle the dynamic carb things looks like a little bit better. You don't have to worry about how long the food is necessarily. I think that's that's pretty magical. But loop is, lets you kind of see all the pieces like it helps you understand, like, biologically what's happening.
Scott Benner 26:28
I think that that's really why I'm telling people about I always talk about glycemic index and glycemic load with people like you really need to understand the impact of the food. You know, it's how, how hard is it hitting? How long is it hitting? How long could it go? You know what I mean? Like, is this a? Is this a food that can only make it two rounds? Or is it going to go the full? You know, is it gonna go the full way? Is it gonna crush you? Is it gonna come out like Conor McGregor? And just like jump through the air and, you know, jam its face into yours? Or is it gonna go a little slower and you know, start more of a seductive dance with you before it starts the pummel you.
Kenny Fox 27:02
Yeah, like juice or candy or glucose tabs like I enter those 30 minute absorptions. I mean, they're probably more like an hour, but I do it as 30. So that loop doesn't try to overcorrect those. But I mean, generally speaking, like juices, kind of a hit quick and go away fast. You don't want to put a play introduces a two hour and she's just having it just for fun. Or having grapes by themselves. And that's it. Yeah, they don't last two plus hours and loop will end up making her golo kind of later that when you know because it just thinks the carbs are gonna last longer, and they don't.
Scott Benner 27:34
So let's talk about the basal rates then. And I guess we have to talk about them in two different ways. Like, do if you're using an auto Bolus pizza? And if you're not, so if all right, I don't know, though, it's funny. I have no
Kenny Fox 27:46
basal rates to just bazel Yes,
Scott Benner 27:48
I haven't changed ardens bazel rates, since we went to the auto mode, the only thing to understand is that is is how it makes up for stuff, it doesn't make up for bazel anymore, with anymore.
Kenny Fox 28:00
So I think this is where this is where I think this is where I start with most people that I end up helping out is uh, basically you know, is like switch your body needs some and you and Jenny have talked about that multiple times. So it's like if you didn't eat, or run around or whatever, and just kind of fasted all day and watch TV or something, you should be able to stay flat. Same with overnight. And so that's kind of the goal with Basal. And so but what I've found out get into like how you track it here in a second. But what I found is most people have like one bazel rate, maybe a couple but if you start with one, you end up able to see when those other changes show up. And I came to this just because on shots, Tessa was level that the basal rate and the insulin on board calculation worked all day, every day at any time. Day or night, it would always end up zero ended up being zero when she had no insulin on board. It was everything was done. So I just came from the mindset that she only had one basal rate, but I got the pump and start playing with it. And it just would mess up the math for tracking how long the insulin was working. So I just kind of stuck with one. But I found that with other people, it works pretty well to you just pick one. And then you can kind of see if you need another one. But you start with one I guess I just heard the other day that the sugar surfing guy, Dr. Ponder, I think sort of thinks the same thing. And what I think actually changes throughout the day, which we'll get to in a minute is sensitivity not bazel but when in a world of dumb pumps, all you have for automation is basal rate changes. So I think people are in one sense programmed to think oh, it's probably bazel but really what I think doctors and people are compensating for with base rates is often sensitivity changes not bazel but yeah, so Basal is is what is supposed to be but loop sees Basal as neutral as free insulin as zero doesn't track it. It trust that you said hey, I need this much insulin. Kind of as a baseline for my body. And so it doesn't really keep track of that. So if you have bazel too high, you may end up with the insulin on board number may show that you have zero or maybe even a negative number. And really, you're falling you actually have more insulin in your body than loop is aware of. But because I trusted you, I said, Hey, you said you need to this much insulin all day. So like, that's, that's what I'm giving you. So when you do an override, and you increase those bezels, it also can kind of complicate that calculation. So yeah, I think that's kind of the main thing is, is Basal is free, so you don't really track it. So what I do to test bazel, with closely if I find the search with like the tandem system as well, is you can test bazel without testing bazel in a closed loop. And it's pretty awesome, because you can look at that insulin board calculation, you know, assuming that interaction time is reasonable, anything six is a fine place to start six hours. But if you look at the insulin on board, overnight, you should get to kind of where you want to be in that correction range we talked about, and iob needs to be pretty close to zero and flat. If I obese, not zero, meaning like just bazel is all you have running at night, and you should be flat. If it's not zero, then something's wrong with your bazel. If you're constantly have positive insulin on board, like a bigger number more than zero, then your basal is probably too light, because it loop is constantly having to add more insulin to kind of push you down into your range. And if you're especially if you're above the range, you want to be insulin on board, that's a positive number, especially at night should always mean you should be falling. But if you're not, then something's not Luke doesn't know what it should know. And then the weird one that really throws people off is the negative insulin on board when you see a negative number in there.
Negative is is a deficiency of insulin, you and Jenny have talked about that a little bit before where if you turn your let's say your level when you wake up at 80, but someone wants to be at 100. When they Bolus they could turn their pump off, they could do a zero beta rate for a little while and you'll drift up. That just means your body has less insulin than it really needs just to hold you level. And that's on purpose. So negative insulin isn't a bad thing. But when you see negative insulin on board, you should always see you know, giving some room for sensor lag, you should see either right away or pretty close. Blood Sugar readings should start going up when you see a negative insulin onboard situation. If it's not going up when it's negative, then you're not representing the insulin properly in the body and loops gonna loop thinks you need more insulin you don't. So what happens oftentimes is people are falling, the blood sugar is falling and there's negative insulin on board means their bases are too strong. So as soon as you start curving up, let's say you treat a low loops like oh, yeah, I expected you to come up not knowing that you actually gave carbs. And so it's going to try and fill in that negative because what should work in this situation I talked about where you turn your pump off before breakfast, you actually can't just turn your basal back on, otherwise, you'll still keep drifting up because your body is missing the insulin, it needs to kind of maintain that balance. So loop tracks that negative amount how much you're missing. And it's going to fill it in for you to try to level you out. And then also correct for any, you know, upward momentum. So what ends up happening is you know, getting slammed back down, because you have too high of a bazel you have negative insulin on board and you're falling, and then you correct but don't tell loop about it. And then it's Oh, good, you're coming back out. Let me give you more to level you out and it's pushing you back down again. So you end up in this cycle overnight, we're constantly trying to bring someone up and lips pushing them back down because he thinks you're missing insulin, but you're really not. And that's what that negative insulin on board will tell you. And so you have to adjust your bazel. So that insulin on board is 00 means level, negative means up and positive means down, obviously, without food. And that will tell you so you can kind of scan your day and look for points in time where loops thinks you're kind of around zero and see what the behavior is of your blood sugar. And then you can know if your basal is too high or too low, and starting with a single basal rate will help with that because the insulin runs for four or five, six hours. So feel really high basal rate to catch a nighttime rise like most kids do. And then you cut it back later the insulin that you gave is still running you know until four or five in the morning and it's you're still gonna end up with this like negative iob and falling kind of situation. And it's not the not because your your little basal rates during those eight hours are are too heavy. It's because the heavier when you ran from like 10 to midnight, was probably a little bit too strong and it's just causing an impact later on the night. That was a lot but hopefully that makes sense.
Scott Benner 34:48
No, it doesn't. And I think it's important for people to understand the idea of like sensor like the CGM is reporting behind time a little bit.
Kenny Fox 34:55
A little Yeah.
Scott Benner 34:56
So by way of an example because you spoke there for A few minutes when you began speaking, Arden's Dexcom was telling me her blood sugar was 58. But it's not because she's had food in her for 35 minutes. Right. And so I'm not panicking. It's, even if it's, it's not 58. But let me jump to the end of the story, but it was stable at you know what I mean? So I know this food is now going to do what I expected to do, right? Like trust what you know is going to happen, it's going to happen as food went indoor, it's going to start impacting her as you were speaking, the Dexcom flipped over to 66. So obviously, her blood sugar didn't magically go from 58 to 66. In five minutes, it has been trending up. Like you said, it's now gotten two reports in a row to its to the text comms algorithms now gotten two reports in a row that it believes. So now it's going to start reporting it right. Exactly. Yeah. And so as soon as that happened, it took a little bit of more time for nightscout to know it. So I can kind of see it on a on a different screen, someone watching everything while we're talking for this explanation. As soon as nightscout knew her blood sugar was 66. It put her bazel right back on again. Like immediately, and now I shouldn't be right. And now in truth, this is the moment we should be bolusing that other insulin right now, whatever more insulin I believe she needs for her food. This is the time to put it in probably sooner even. But now for I can be certain with the data. I have backed it. Now's the time. But we're gonna let it go for a little bit just to see the loop does to let let it see what loop does. Now if she jumps from 66 to 90 next time or something like that. I'm bolusing right away. Oh, yeah, maybe even a little bit extra, right. But if she just drifts a little bit here, I'm going to be interested to see because the auto bolus is going to kick in because we only use seven units for something we told her that we told the loop and the loop believes needs 10 units. What's your suspend set up? 6060
Kenny Fox 36:55
Okay, yeah, so it will it could even start giving. That's why it turned the bazel back on. Okay.
Scott Benner 36:59
Right. Yeah, I used to have it at 55. But I she was getting low too much when it was 55. Where's yours? 70.
Kenny Fox 37:05
Okay, yeah, 70. Because again, bazel and curvaceous are locked into the base of the big one. And you got to make sure you you believe that loop will drop you the other big one will be sensitivity we get to but yeah, if you're, if you're not getting down where you want it to be like a lot of people will drop their suspend lower. And I think 60 or 65 is, is fine for the most part. But I find if I'm trying to push that kind of ad overnight, and lose my overcorrect a little and then I get woken up at my 70 alarm. So I just put the suspend a little higher so that mostly so I don't get woken up as often.
Scott Benner 37:38
I believe that I listen, I believe in our basal rates really well, like Arden got up this morning. 630 she didn't eat anything until, you know, just now. Right? And so and you know, she got down to 60 with Jim. So I believe in our basal rates. Perfect. Yeah. And overnight. She's, it's gorgeous overnight.
Kenny Fox 37:59
So I think what's nice about loop and that neutrally makes us all nicer people and talking about having tools is you have an insulin board calculator, right there. So you can see in nightscout, especially, but you can see on your phone too. It's called active insulin in the loop app, as you can objectively measure your basal rates, which is nice. It's not dislike, well, I think it's fine. It's you can at any point in the day, if you see zero and she's not level, then you can kind of question without the bezels right. And I think the other fun thing that comes into play is that idea of school for a lot of kids maybe makes them go up oftentimes, like stress or something maybe work for some people. Once you I'd like to try to tell people get your basal rate, like create a baseline where like to say, like weekends and not school will not work. So you know what normal life is so that you don't have to worry about crushing someone you know, on a weekday, if you can avoid it. And then you play with overrides the override feature increases your basal rate or decreases it however you set it. And use overrides for school and work that way. You can if you feel like maybe you're not as stressed at school or at work one day, and you'll end up meeting it you can just simply cancel the override and kind of go about your day and be fine. But if you need it, then it's there to use it and you don't have to keep fiddling with your settings every Sunday night or Friday night. Things like that.
Scott Benner 39:19
Okay, let's jump ahead here. So to insulin sensitivity now, yeah, it's funny. insulin sensitivity is wildly different for so many, you know, for everybody. Right? Ardennes during the day is 59. And overnight, it's more like 64. But I've spoken to people who have their sensitivity, like you know, it's 120 and so can you. I'll tell you how I think of insulin sensitivity and then please you tell me how you think of it and you know, etc. in my mind's eye, it's just sort of the amount of insulin it takes to impact me. You know, mean like just like this, what what's gonna knock me over? Like, you know, you can give me 59 and 59 will do what it's supposed to do. But if it was at 6565, wouldn't do it 65 would be like getting shoved by a six year old. But 50 nines, you know, like me pushing against somebody who's my, my weight, like, it's, it's the, and I know this is it's not it's not clear, because I'm never clear on insulin sensitivity, like, you know, I'm sure there's a really technical way to say it, I'm sure you're gonna say it in a second. But I find a lot of people get confused by it, and no more so than the idea that a lower number is more powerful.
Kenny Fox 40:39
So yeah, that's weird,
Scott Benner 40:41
right? So a lower No, it's a very basic mathematical idea. But still a lower number is more powerful. So my daughter, five 737 pounds, insulin sensitivity 59, during the day, your daughter, you know, much less. You know, wait, I would imagine
Kenny Fox 40:58
what's hers that? So she's her sensitivity during the day is about 200. And I would probably say realistically, it's probably about 225 250. So it's probably more sensitive. But I've looped dialed it down just a hair, because to make it behave a little more the way I'd like I use that as kind of a, an aggressiveness number to some degree to make loopback a little bit faster than maybe it would normally without causing so much of a low. Yeah, so sensitivity is yes, how much insulin it takes to move you a certain amount of points, your your blood sugars or how much insulin it takes to move you. So yeah, I think it's, it's, that's a good way to look at it.
Scott Benner 41:40
So how so I guess the next question is, and I want to talk about overrides more specifically, but the next question is this. Once I found we had Arden's settings close in loop, then I began to adjust them sort of like an equalizer on a 1991 rack system. Okay. Like I'm like, I don't know what treble point oh, nine is, but what happens if I push it up a little bit? Yeah. Right. Or what happens if I push this down a little bit like that? I, once I was close, then I could start fine tuning without knowledge, then I could start going correction range. Let me try 87 to 85, whoo, that was better. You know, you know, bazeley I wonder what 2.3 does versus 2.2. That kind of stuff. But starting out. You cannot adjust loop to ear? Did you know what I mean? Like it's just you have to start somewhere near? Near good. Somewhere near good. Right. And so my question is, do you know if I came to you today, and I was just like, guy on the street and I say, Kenny, hey, I really want this to work for my daughter. Do you know how to help somebody set this up? Like do you know how to go from scratch? Quick kidding. Add today, the dexcom g six continuous glucose monitor. You want to check it out. It's at dexcom.com forward slash juicebox. type that into your browser right now. If you're you know not good at typing, click on the link in your show notes. It's right there in your podcast player. There's notes in your podcast player, just find them and click last thing you could do is go to Juicebox podcast.com and click from there. All of these options are viable ways to get to the sponsors. While you're there, check out the Contour Next One blood glucose meter, go to Contour Next one.com there's a little button at the top, you can find out if you're eligible for an absolutely free meter. This meter is by far the most accurate one that my daughter has ever used in her entire time with Type One Diabetes. Lastly, if you'd like to see some lovely people doing wonderful things for people living with Type One Diabetes, check out touched by type one.org I'm doing you a favor. I'm shortening up all the ads today. You can do me a favor and click on the links dexcom.com forward slash juicebox Contour Next one.com touched by type one.org that's all I'm asking today. No big sell. Just go check them out. Look I'm done before the music it's like you owe me almost tears there's so much time left it's kind of weird, right? touched by type one.org helps people living with Type One Diabetes amazing organization. Contour Next One best blood glucose meter I've ever seen. Dexcom g six continuous glucose monitor game changing technology for Type One Diabetes there. I said I was going to tell you more about it. Weird. Do you know how to help somebody set this up? Like do you know how to go? Yeah Rach
Kenny Fox 44:44
for Yeah, so it took a while a sensitivity was a weird one to wrap my head around to so the my process is look at basal rate, subtract iob. I go back to someone's graph if they've been running it for a little while. Helps I find closed loop is helpful, more helpful than an open Id be a little harder to see it on normal graph, but you could still probably get close. But I like to find how the neg makes sure that negative means up and positive means down and that they're kind of at their range, where they're supposed to be especially overnight. And then we just try to find what I call like that one magic bazel rate. And we pick one that works mostly overnight is easiest way to observe it, run that one all day. And then make adjustments from there we carb ratios and sensitivity sensitivity. I mean, it's so hard to like, really, I'm not going to stop my six year old and doing a sensitivity test that's even longer than a bazel test. So I once we get overnight solid iob, zero means flat, everything's dialed in, I just tell people, hey, turn your sensitivity more aggressive to a stronger a lower number, until you start to see that line that's fairly flat for you start to wiggle start to go up and down and go above your the range you set. And below that range, you set it to make sure it also goes below but doesn't go below, then it's um, you might still not have a strong enough bazel. But basically turn the sensitivity too strong to where you can see that it's obviously too strong and then kind of back it off a little bit. And that's kind of what I use for daytime ISF because I find that people are more sensitive during the day than they are at night. So you find what works overnight, make it too strong and back it off a notch. And the reason why people are more sensitive during the day I think is because growth hormones exists kind of overnight for everybody, me included, were growth hormones, I was reading some studies on this trying to figure out why this rise at night happens for my daughter that just kills me. So what I said earlier is that no matter how much I bolus her during those rises is IRB of zero was still zero. So the interaction time worked well. That seemed to indicate to me that she actually only had one bazel rate or not, it's crazy, intense rise period. So what I found is growth hormones don't make you go up necessarily, but they do make you more resistant sensitivity. But that means something else must also be pushing you up, which I've kind of found a correlation between how close dinner is to sleep or how heavy dinner is to sleep. And so it's probably just this weird digestion process you have when you're sleeping, that stretches out how long the carbs last, and the carbs kind of have a more of an impact because all these growth hormones released during your REM sleep cycles during the early hours of sleep. And so you have more growth hormone in your system at the beginning. So there's just more resistance there. So the only way to really model that and loop is to make the sensitivity, lower a lower number in those first hours of sleep. And then I sort of like ladder it softer and softer or a higher number as the night goes on to sort of mimic the idea that there'll be less growth hormone in the body. And so I might start with like a 200 during the day, and go all the way down to like an 80, which is less than half of what her sensitivity is, you know what, like nine or 10 o'clock when I know she's gonna be asleep, and then ratchet it back up. So you know, 115 131 6180 and then when she wakes up, it's I usually have around 200 or so. So and I found that to be helpful and to help Luke kind of semi automate and for some people automate those nighttime rises, but it's really not a bazel change as much as we're programmed to think, Oh, that's a rise, I need to get more bazel if you use increase bazel there instead of sensitivity, you may find that negative iob and falling kind of at three or four or 5am instead of just making a loop more aggressive because that sensitivity is really only comes into play when you're out of range. Do you that's kind of the cool part about sensitivity is if you're in your range at you know nine o'clock at night, and she's asleep, and great loop doesn't do anything. So if I made the ISF too strong, it's not a big deal. She's in range. But as soon as she's out of range and loop kicks in, you know, puts the pedal to the metal a little bit more. It could be an x faster.
Scott Benner 49:05
Yeah, it could it could be but oftentimes it's not there in those first hours. So it's, it's, as you mentioned, like how much insulin has taken knock you over. So it's but I think it varies throughout the night more than the day. But that's kind of how I approach sensitivity. It's interesting that just because your child is younger and growing, you're having the exact opposite experience night today than we are. Get like Yeah, a little bit. Yeah, when Arden's asleep, she just doesn't need. She needs less sensitivity, not by a lot, by the way, like listen to what you're doing, you're going from like, you know, in the hundreds to double digits and you're bounced around, we're really only moving between, like, you know, 59 and 65. Like it's not it's a pretty
Kenny Fox 49:48
tight tolerance. But how many basal rates Do you have during the day?
Scott Benner 49:51
Just one,
Kenny Fox 49:52
just one. Okay. Yeah, yeah, one during the day one at night. Yeah, I've seen that. If someone's not really going through a growth period I've seen unit with me too. So I wore a sensor for a few weeks. And I sort of like helped prove this theory out by, you know, all for the case of science, having a lot of ice cream before I went to bed, and I could see my blood sugar rise and sort of stay up and kind of in waves like kind of matching my sleep cycles, kind of stay up a little bit longer and take longer to come back down then if I didn't eat something right before I went to sleep, so I was able to sort of mimic the same process as my daughter, but unless eXtreme Scale one because I'm not type one and two. I'm not growing like you said the volume of growth hormone in my body is probably much less than someone who's actually growing. So the sensitivity will be different.
Scott Benner 50:39
We're growing just not in the same way.
Kenny Fox 50:40
So yeah, exactly. When you're having ice cream at you know, eating like a whole bunch of ice cream at 10 o'clock at night. That's Yeah, we're definitely growing that stuff not to be questioned, I guess
Scott Benner 50:49
I am pretty certain that I'll be wearing a Dexcom Pro in a little while.
Kenny Fox 50:55
So that I well, then you should for science, eat something really yummy before bed and see how that happens. I will be
Scott Benner 51:00
Yeah, I'm gonna be wearing the same thing. Like I just I was talking to Rick Doubleday the other day. And I said to him, when we got done, I was like, I'd love to wear a sensor for a while if I could, you know, to really understand, you know, better what I'm looking at. And
Kenny Fox 51:14
so I think Neil is fun is did this and you should eat something similar to what Arden does when she eats it. And you'll see the absorption time play out in both of you. Yeah, it'll look a little different. But you'll see the food stop at kind of the same time.
Scott Benner 51:28
That's exactly the stuff I'm excited to look at.
Kenny Fox 51:31
It's amazing. Yeah, we ate uh, you know, again, for science ate a breakfast sandwich from McDonald's. And it lasted a long time on those chicken ones. And, yeah, you could see kind of the initial carbs. And you can kind of see the sustained fat and protein in both of us. And actually, in one of those cases where we tried it, her blood sugar ended up way better than mine, on average, so. But it's fun. I do think
Scott Benner 51:53
there's many times where I'm doing a better job for art, and then my body's doing for me. Yeah, so interesting enough for art. And by the way, is her sensor went to 75. And then the next adjustment was only to 79. But it did just Bolus 1.15 units a little while ago, then the 79 jumped to 94, diagonal up
Kenny Fox 52:18
high. So you're above suspend, and it's like, Hey, I know you need more for the carb ratio. So it gave it to you. And it popped
Scott Benner 52:23
on like, so I'm gonna see if I can raise her with a text. If I can, I'm not gonna bother. But if she answers this text,
Kenny Fox 52:31
I mean, just take the recommended bullet, because all you're gonna ask her to do
Scott Benner 52:34
it, ask her if there's any insulin that's being recommended right now.
Kenny Fox 52:37
And you can actually you can try it hover over the loot pill with your mouse. And you can see at the very end of that little hover box that pops up, it'll tell you if there's a recommended bolus.
Scott Benner 52:48
Well, so the little loop thing I have right now says, See, I don't even understand this, the loop has put your
Kenny Fox 52:56
mouse over that box and you should see another box pop up.
Scott Benner 52:59
I only have it on my phone,
Kenny Fox 53:00
I do with my Okay, then tap this tap on the loop pill and you shouldn't need so you can refresh that page if it doesn't pop up right away. But p tap on the thing that has the loop put the number in the squiggly line, you shouldn't get a little hover box to pop up.
I don't know I said you need somebody to refresh it.
Scott Benner 53:18
It's my fingers too fat.
Kenny Fox 53:20
That can happen to a lot of pills. They're crammed together. little boxes just says loop device loop. You should see something like on the hover it'll tell you how long ago the Temp Basal that it's currently running insulin on board carbs on board. Predicted minimum and maximum.
Scott Benner 53:36
Let me go over to my iPad. Let me see if I can make that work. Yeah. Yes.
Kenny Fox 53:51
So bring it up on your computer and you can look at it and it's easier
Scott Benner 53:54
to figure out how to do that. I got I don't Yeah, I don't even remember how to bring it up on my
Kenny Fox 53:58
computer. I'm remember her sight. Are you kidding me?
Scott Benner 54:01
Wait, isn't it at the play here it is.
Kenny Fox 54:03
Roku app.com
Scott Benner 54:14
typing, which is always the best thing to do on a podcast. Yeah, people love it. And really, they're huge fans. Oh, here she is. She said what? Okay, so I'm going to ask her is the loop recommending any 1.8 do it. There you go. There we go.
Kenny Fox 54:48
Now it takes all of it instead of auto Bolus would just give 40% of that right. And then again,
Scott Benner 54:53
which it would likely do again the next time the CGM turned over correct. Yep. So Yeah, there you go. So when, listen, I you know, we're not going to be recording when this is all said and done. I'll remember what happened. I'll tuck in at the end. But look at what happened like Arden's a Urban's blood sugar has been right around at all morning five or six hours that she has been awake. She went to lunch, or she went to the gym, her blood sugar went to 60 she just ate a bagel grapes, puzzles, a chocolate chip cookie, popcorn. And a What did I say? tangerine? Something like
Unknown Speaker 55:32
that. Clementine. Yeah, time. Right.
Scott Benner 55:34
And she ate that stuff. It's 1255. Right now here. And that conversation began. Back here.
Unknown Speaker 55:46
Noon.
Scott Benner 55:48
Yeah, two minutes after 12. So it's, it's, it's, it's almost an hour later. And we have gracefully gone from 60 to 95. And even if she makes it to 150, which I don't think she's going to normally she wouldn't be coming out of a low, we would have Pre-Bolus sooner, and this wouldn't be happening like this even. But this is astonishing for the situation. You know, but if you don't understand how this thing works, none of that's gonna matter. Like it? Yeah, for sure. It's damn near impossible. And so, but I also think that for those of you who aren't considering any kind of closed loop system, whether it be loop or tandem or horizon, when on the PI puts it out, or you know, whatever else. Understanding what Kenny and I are talking about here today will help you make better informed decisions even without a an algorithm, I think, because just watching and you heard Kenny allude to it earlier, just staring for a little bit and watching what happens is such a teaching thing. And when I watch Lupe, take bazel away, give bazel back make a small bump with now with the the automatic bolus or before the automatic bolus when it would kind of ratchet up the bazel. It was fascinating to watch loop take bazel from like 2.5 and make it seven but only for like eight minutes and then bring it back again. And like I was like, Oh my gosh, this is really I'm learning a lot from watching that, you know,
Kenny Fox 57:11
yeah. And like I said, we had slightly better numbers in terms of standard deviation and a one C and time and range. When we were on shots, because of the same principles that once I figured out how to apply it to loop. Yeah, it'll just make your life easier. Being able to track insulin on board is really kind of magical in terms of figuring out your basal rate and just knowing when, when the drop stops, you just got to know and how much to correct for and, and all that it's just it's really empowering or most people are just kind of, again, being dynamic about how you talk about in with juicebox. But like at the same time, if you kind of know when it's going to stop, you can be aggressive and be more aggressive because you know how much insulin is working? And if you overdid it, you know how much to correct for a lot more precision in that approach.
Scott Benner 57:56
I think that loop is going to represent, you know, I shouldn't even say look, I think that algorithms in general, but for everybody, but for us specifically, I think it's going to represent a mid fives a one C. Just base I think so what I've seen and what I know.
Kenny Fox 58:13
Yeah, as I tell people like if they're in the sevens now like if you can just get the settings right and moderately Pre-Bolus then, and don't learn not to overcorrect, you'll get sixes pretty easily it shouldn't be that that complicated. And that's what I'm seeing with some of these people, once we figure out especially like, people that have their kids and they get really stressed at school and just need a lot more insulin these overrides work super well for that. And then, and then they ended up having, you know, like I Oh, there's one person I'm working with now that was in kind of a seven range and is now looking trending toward kind of a 6.2. You know, and and they just have even before that before their stats changed just by making some of the changes I talked about. They just have more, it's more predictable. And now it's not as crazy, you know, at least when they're high kind of know why it happened. So. So that's pretty great.
Scott Benner 58:59
It's amazing. Last thing I want to bother you about is overrides. And I don't know that I think about them correctly. So let me just tell you how I think about them. And you correct me if I'm wrong? Sure. I, I know I don't understand exactly what they do. But when I said an override for art and whether it's a decrease like you know, instead of it 100% of, you know settings, I go to 80% of settings or 50%. That's a decrease in insulin power. Or vice versa. If you go to 120 It's a 20% increase, like that kind of thing. Is it just an across the board increase? Is it literally like the correction range stays the same? The suspend threshold stays the same. But this is an increase of bazel rate. insulin sensitivity is the heart rate show carbery show is that in
Kenny Fox 59:49
Yeah, yeah. And the kind of the tricky thing about using them is that once you turn one on any like entries like carbon trees in that time have that Change applied to them. So if you used too strong of one, and entered carbs or a low one, some people get a little too extreme and they go, Oh, they're falling. So I turn an override on, which is not the time each and an override on but they'll do like a 20% or something really small and then enter like lunch. Well, then it thinks that lunch needs 20% of the insulin, your carb ratio, like 80%, less than what you'd need. And so there's no way to really go back and fix that. So you, you'd have to basically know that that happened and add 80% more carbs to that carb entry to get something equivalent. That's a tricky part. But yeah, an override changes everything, which is good and bad. I think there's a lot of cases where you only want to change one or two things, but because bazel and insulin on board, that bazel calculation is so important. I try to tell people that the override is should only be used in cases when bazel actually changed. Otherwise, you end up throwing off the math if you use like if you're stuck high and you're frustrated, and you use a 200% override 100% more than normal, you're doubling everything. Later on, you're probably gonna end up loops gonna think you're gonna land and you're not because you actually have more insulin in your body than you told it because all of a sudden, you told that your basal rate doubled. Yeah. And so yeah, you end up with a problem where lube would have landed you if the math had been right, but you won't, because you lied to it for a little while. So
Scott Benner 1:01:24
the only time the only time I really use it is sleeping it. So like I said, Arden's like 1.4 overnight cheese 2.5 during the day, that 2.5 kicks in at 7am. So usually she's drifting, I have Arden pretty consistently drifting to 70, when she wakes up in the morning for school at seven. So if I set an override at 6am, I set it about 50. So about 50% of power, this, that's enough to get in front of the drift, so she doesn't drift to 70. And so that when 7am comes, and the insulin sensitivity goes from 64 to 59. And more importantly, I think in that situation, that bazel bazel jump up, it keeps the bazel back at overnight,
Kenny Fox 1:02:06
and yeah, 50 percents about what your nighttime is compared to your daytime, right.
Scott Benner 1:02:09
And that's and that's how I do it. Now, the longer she sleeps, the less she needs. So if she's just going to sleep till nine o'clock that works, but if at nine o'clock, she's still sleeping, it maybe has to go to 40 or 30. Like you really, because at that point really consider what's happening. She has not had food, and she's not having any like body impacts on her blood sugar. Now for sometimes eight 910 a dozen hours like in a really sleeping in situation. You keep taking it away and taking away. The key is that when you wake up, it's got to go right back on. And when you Bolus, like you said before, it's not just for the carbs. It's not it's and it's not unique to Pre-Bolus still, you're not just Pre-Bolus for the carbs. You are you're also have to replace all that deficit that comes behind because basically, it's a paper tiger at that point, right? Yeah. Like any food you take in is just going to overwhelm you because there's just no insulin happening in your body. That was just enough insulin to basically keep, you know, like, like a, you know, a corpse from blood sugar going low. It's just not a living person. Right then nothing's happening inside of her in this scenario.
Kenny Fox 1:03:18
Is Arden have a drop in the morning before she wakes up? And then like a rise after she wakes up? Typically? No, not at all.
Scott Benner 1:03:25
Okay, that's good. You see that sometimes my settings take care of all of that. Okay, yeah, um, it used to be before loop. She'd wake up in the morning at seven. When her Basal went up with Bolus in the morning with Bolus, the rise.
Kenny Fox 1:03:40
Like she does have that rise. Yeah, she
Scott Benner 1:03:42
has it but we don't see it any longer. It doesn't actually happen. Because we're basically constantly like I said, you know, we've been talking for a while, like I said a long time ago, because I'm thinking about now as before, not now for later. And yeah. So I'm, I'm a head of that I Pre-Bolus. spikes I Pre-Bolus rises, if you've heard me talk about, you know, like, extended bonuses. People talk about extended Bolus is one way the way I talk about them is Pre-Bolus in the food, and then Pre-Bolus thing, the spike. Yeah, exactly. Yeah, just always. It's a time travel movie, you know, what's going to happen in the future. You're just you're just always bettan you know, on the right team to win because you've got the almanac, and you know, who's gonna win? So
Kenny Fox 1:04:25
yeah, so when I use overrides, it's really like bazel changes. So what what's kind of fun with overrides if you have your basals dialed in, like I said, using the IP math, and typically people have the same bazel overnight as during the day but not always. If it's good, then what should happen with overrides and a lot of people don't experience when their settings especially bazel is not right. Is this doesn't work but if you can look overnight, and my daughter typically runs around 80 to 90 overnight, and if for some reason she's not if she's hovering around 100 or Hundred and 15 with some positive insulin on board, that means that her, her insulin needs have shifted maybe just for the day maybe because she's sick, I don't know. And I'll just run an override of about 1020 30% increase. So 120 or something like that. And then I'll run it. And, and I'll leave it on for breakfast and breakfast is sort of like the maker break like was this for reals or is just temporary. And if she doesn't go low from an increased override at breakfast, then I run that override all day long until I see her until I see that negative iob and blood sugar falling sort of situation again, where things sort of settled back at over. So I just roll over out of bed, look at nightscout see where she was at. If I get woken up with a 120 or 130 alarm overnight, and Luke can't keep her under that number, then I know her insulin needs have gone up a significant amount like she's probably sick. So she probably needs like a 130 or 140 or more to and then I just run that all day long. Again, checking it with breakfast. And and that's how we kind of get mostly normal days like I get ahead of it, I see the increase happen overnight, that shift sort of happens in that two to 4am timeframe, most of the time. And I just put an override on the compensate because her basal needs went up, but I don't think it's going to stick around for the next few weeks. And it usually lasts a day or two, sometimes a week if she's actually sick. But I always use that overnight as a measure to say how much more or less does she need. And use an override and I don't really mess with my base settings often because they usually work occasionally, if you get up to like 150% override, because she's sick. Sometimes the carb ratio has to be weakened a little bit because doesn't scale up quite perfectly. But I'd say 9090 plus percent of the time, it's just a 1020 30% override for the day, and then the day looks normal again. And then I watched the numbers overnight and wait for it to shift again. And then I cancel it and then we go back to normal settings. And it's it's really kind of magical to be able to see the patterns. Once you get some consistency. You can see those patterns coming and get ahead of them. Yeah,
Scott Benner 1:07:03
well, listen, I can't tell you how thrilled I am that you found the podcast and and reached out to me because I think that I listened, I edit these shows, obviously. And then I listened to them for sound. So I end up hearing them two or three times. But I'm gonna listen to this one dozen times, because this was a terrific conversation. I just I can't thank you enough. And can I can I ask you, right here, start thinking about how we could take a person who knows nothing about any of this? How do you explain this to them? Like that's the thing. That's next, right? Because you and I are involved. You know, and everyone listening, you know, is involved with their kids, hopefully, but everyone wants to not be and they don't want to burden their children with teaching them all of this like is, is an algorithm based insulin pump ever going to be? You know, I guess skinned in an app where you don't need to understand what's happening behind the pretty picture on the front. Like I hope so.
Kenny Fox 1:08:03
I think the hard part right now is the settings have to be like that's why I think control IQ seems to be working so well compared to like a Medtronic where it's trying to figure out your settings. But then control IQ just trust your settings. So you have to if you can get it close, then you'll get good results. Just like loop if you can get it close, you'll get safe and good results. But I think the real trick will be how can could that Medtronic idea of just figuring it out for you ever work? I'd love it. I'd love for that to be true.
Scott Benner 1:08:30
Yeah. Okay. All right. Okay, I'm gonna ask you to hold on for one second. I'm a thank you first and, and I'm gonna ask you because I'm gonna ask you a question. I'm not gonna let anybody hear the answer to I just like the screw with the episodes. So. Alright, guys, Kenny's done, but I'm not done with Kenny. I think it's pretty fair to say that Kenny will be back on the podcast at some point. Kenny could be Jenny loopy. loopy Jenny. Kenny could be loopy Jenny. Kenny Jenny. Kenny loopy Jenny Jenny loopy Kenny. Kenny Jenny late. I'll work on it let you know. huge thank you to Dexcom the Contour Next One blood glucose meter and touched by type one. Please go to touch by type one.org dexcom.com forward slash juicebox or Contour Next one.com. To find out more about the sponsors. Continued gratitude to the community that has put so much time and effort into the DIY loop. Talk to you again soon.
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