#328 Ask Scott and Jenny: Facebook LIVE Edition
Answers to Your Diabetes Questions…
Ask Scott and Jenny, Answers to Your Diabetes Questions LIVE on Facebook.
How do I attack meals that cause spike without crashing later? Is it with a longer pre bolus? More insulin? How to evaluate your bolus strategy.
Any recommendations for helping with Freestyle Libre accuracy?
What are the pros and cons of CGMs being used on patients in hospital settings?
What is the best way to tackle losing weight for a type 1?
Should I calibrate Dexcom on day one if off and how do you manage that if using an algorithm?
How do you know if it’s a bad site or another variable?
What are good tips for managing diabetes when you are trying to get pregnant?
Is there anything physiologically wrong with a post meal spike if it comes down later without extra insulin? Should we try to master that meal?
Let’s talk about pod changes and patterns.
Is it possible to have the opposite of Feet on the floor?
Let’s talk about female sex hormones.
How do you manage the inconsistent eating pace of a toddler?
What is honeymooning?
Is there a cure on the horizon and near future?
How do you manage kids and growth hormones? Finding the right amount of insulin.
Can you explain insulin deficit?
How do you manage unexpected diabetes variables like unplanned exercise, sudden stress?
How do you know when to start eating when pre bolusing and looking at the Dexcom arrows?
What factors affect the hypoglycemic risk value on the Dexcom Clarity app?
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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.
Scott Benner 0:01
Hello, everyone, and welcome to Episode 328 of the Juicebox. Podcast. Today's show is the audio from a recent ask Scott and Jenny, Facebook Live. Now the audio is super good. It's clean, clean the way you like it on a podcast. Don't worry, it's not all Facebook. It's not like Jenny's like, I think that we should do this thing with the input doesn't sound like that at all. Sounds crisp and clear. Right? Imagine Wolf Man jack and your house is like, hey, their kids. No one knows who that is. But that's not the point. The point is, it's a good recording for podcasting. And I didn't want you guys to be left out. So I was just trying to do a little live thing on Facebook if people you know, something to do during the day while they're trapped in their house. But then I wanted to get that audio right up here for you guys to listen to, in your ears the way podcasts are supposed to be heard. Anyway, Jenny and I started with one question from my ask Scott Jenny list. And then we let the viewers of the live ask the rest of the questions. I thought it went great. actually had a fun time was nice to hear from everybody. I'm giving you this episode. As a bonus this week. This is the third episode this week. So there won't be any ads on it. But it isn't going to stop me from mentioning the advertisers so that you remember that the good people at Dexcom on the pod Contour Next One blood glucose meter and touched by type one are the reason why I could be messing around yesterday doing a Facebook Live. So I'm gonna put links at the end. And they're going to be in the show notes here. If you'd like to check out any of the sponsors, clicking on the links is very helpful to me. And I appreciate when you do it. Alright, so let's get to it. This is episode one. I say 328. It's a live ask Scott and Jenny from Facebook. And you need to remember while you're listening to it that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please always consult a physician before making any changes to your health care plan. We're becoming bold with insulin. And just like that, you're listening to Scott and Jenny. redirecting to Facebook. Oh, there it is. I'm making a funny face. There we go. We're alive. Oh, that was easy. Okay, so obviously, it's gonna take a couple of minutes for people to get on. Gonna first say that. I'm Scott Benner. This is Jenny Smith. You may know Jenny and I from the diabetes pro tip episodes on the Juicebox Podcast. Jenny also does ask Scott and Jenny and defining diabetes. And today we thought we would do an ask Scott and Jenny live. Now we have a question to get started with that came from one of you. But we're totally willing to see some questions from other people. So first, I need somebody in the chat on Facebook. Tell me if you can hear me and Jenny Say something. See if I can hear you.
Unknown Speaker 2:53
Hello. Okay.
Scott Benner 2:55
Just somebody tell me in the comments if if you can hear us. Oh, hi, Maddie, how are you? Have you never seen Jenny live before?
We already have 18 people? Awesome. 24. We'll start right at three o'clock because you guys are on time. I like prompt.
Jennifer Smith, CDE 3:18
You got a minute or maybe less? I don't know my plaxis 150 or 259.
Scott Benner 3:23
They should definitely be everybody can hear. Cool. All right. They should definitely be rewarded for being on time that people will come later. Gonna have to watch, you know, watch the replay or hear it on the podcast. I can hear both of you. All right, Laura. Thank you. Whoo. All right. So if you guys have questions, throw them in there. And we'll see what we can do. But Jenny and I thought we would start with let's see, I have it here. I have it here. Here it is. Um, oh, you know what, before we start, did you guys know that? I'm Jenny. I'm gonna give your phone a few days here. Jenny Smith is an RD LD CDE T one day. She has a bachelor's degree in human nutrition and biology from the University of Wisconsin. She's a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes a pumps and continuous glucose monitoring systems. Jenny has had Type One Diabetes for how long journey
Jennifer Smith, CDE 4:17
on May 15. It will be 32 years. Okay, so that's a long time.
Scott Benner 4:23
And that is definitely a long time. So any of you who have heard us on the show before? No. This is basically what you know, it looks like for Jenny and I when we record and you guys just don't usually get to hear so we're gonna get started with the first question. Yeah, it's how do I attack meals or times of day that cause a huge spike, but come down eventually. If more insulin is added, I go low later, when I wait longer, like when I Pre-Bolus I go low earlier in the meal. Now by the way, guys, there's a disclaimer here. We're not healthcare professionals. This is not advice in this cause, just us talking and you hanging out so if everybody's okay with that. Cool if you're not jumping, all right, I went, we did not do any problems for you people just get it. You don't like it? Okay. All right. All right, Jenny. So I, you know, I hear this question a lot. I tried to Pre-Bolus. But I got low before I ate or, you know, I tried to shorter Pre-Bolus. And I just got high later, what are some of the reasons that can happen?
Jennifer Smith, CDE 5:23
So to begin with beginning of the question would be your bolusing getting high, and eventually, without correction, it comes down. That initially would be a bolus timing thing, right, where you need to Bolus sooner to stop the rise. It's an indication that there is enough insulin there because ultimately, the Bolus you took does get you down to where you want it to get later after the meal. There's just not enough time between taking the insulin letting it get started, and the food actually impacted blood sugar. But the further part of the question sounds more like if you add more insulin, like upfront thinking there wasn't enough to begin with or you correct, and then you end up going low in either of those scenarios. Clearly, there was too much insulin, right, you didn't need more insulin, you just did it in a different bit of timing for taking it right. The third part of it. So like little segments here. The third part of it really is, if you do take the amount based on your ratio, you end up climbing, or you Pre-Bolus with enough time, and you end up sinking within the time period after you Bolus, but then you still climb up later. That could be especially for those who are using an insulin pump. That could be not only a timing issue, but also a delivery of insulin issue. Okay, right, where you would probably need to use all the pumps have some type of extended bolus feature. Could it be combo bolus extended bolus dual or squarewave. bolus, all the pumps call it something different. But essentially, it allows you to take a certain percentage up front, potentially in this scenario to stop the bump up, gives you let's say you decided to take 50% of the Bolus now and then distribute the other 50% in the back end, what it allows is the 50%, you take now you can Pre-Bolus thus decreasing the amount at the beginning that you get. So you don't have a drop, but you also get the Pre-Bolus benefit of not having that rise up after the meal. And then the later impact is that you still get a finish of that end of insulin, which you knew was enough. You just needed to distribute it a little bit longer to impact, you know, the full content of whatever this meal, I guess, added.
Scott Benner 7:50
Okay. And I like obviously I agree with you. But what I was gonna say is that when when I see that I don't often see a Pre-Bolus It's so like heavy that she crashes before she gets low. And so I think that ends up being a situation where people are like, well, I Pre-Bolus and then I got high anyway. So I'll keep trying longer and longer and longer. But it's not at some point, the length of the Pre-Bolus is just not your issue. You know, and and I hate to I don't want to put a number on it. But you know, if your Pre-Bolus thing, 30 minutes in the future, you're probably coming out of a much higher blood sugar to begin with, and you have issues on the back end that you're not dealing with. I find myself saying a lot that diabetes, using insulin specifically is like time travel, everything you do now is for later, right, right. But everything that's happening to you now is from before. So if you're putting in a healthy Pre-Bolus, like you said on a good site that you can count on, etc. And you're you know, you're still climbing afterwards. I mean, the Pre-Bolus probably at this point isn't the question. And there's little things for CGM users, you can kind of look at the trend, the angle of the trend, right. So if you're, if you're shooting straight up like this, you've either missed, I think, huge with the amount of insulin you're using, or you know, if you just bolus and five minutes later start eating a real sugary thing. You're going to shoot straight up, if you come more on that, that kind of gentle rise that I tried to describe as the it's the minor or no, not the minor, like the the mountain climber on the prices, right? Any guy keeps like rolling back and forth like this, right? Because when you have a Dexcom and you you have that gradual lineup, everyone's done it, they stare at it, they're like it's gonna stop, it's gonna stop, it's gonna stop and then eventually that guy falls off the end and true Carrie says you can't have the money and it's all over right and your blood sugar's 280. And, and then that's sort of the end of it. So like Jenny's saying, there's just 1000 different ways. But in the end, what you're trying to do is manipulate your insulin and put it where it's needed. So you need that nice Pre-Bolus but if an hour later You started having this crazy rise, like she said, an extended bolus, or even coming back and readdressing with more insulin, at some point is the answer you get low later, when you put so much insulin up front, to control that line, that eventually when the impact of the food goes away out here in the future, the insulin still leftover and you crash low. So you've got to, you know, for the lack of a better term, you have to put the insulin where it's needed. I always say when you're about, you know, you have to address your body's need with with the right amount of insulin. So, right, that's cool. That's a really it's a great question. I appreciate that question. And people have left other questions. So dig in here, and see what I can
Unknown Speaker 10:40
love questions, right? Oh, yeah. But I'm
Scott Benner 10:43
on the wrong browser to see I got to get into it. Everybody chill out a second, this is my first time doing this. So a lot of pressure, like running the show, and
Unknown Speaker 10:52
like asking the questions.
Scott Benner 10:54
I was gonna feel under pressure here. Alright, I'm on a different browser. So one browser is sending you guys the Facebook Live? And then I'm going to look on a different one. Where am I looking at? I mean, the wrong I have too many Facebook groups.
Jennifer Smith, CDE 11:16
While you're looking, I'm going to add something extra to that comment. And question from before to it you were talking about, you know, the trend kind of even coming into the meal. And that can definitely determine things, you know, if you were if you were at an excessive insulin coming into a meal, and you are already on this slope headed down, right, and or if that's commonly happening within the same meal time, it could be that your Pre-Bolus thing with a load of extra previous insulin on board. Thus, you're consistently coming down in this time period of the day. And so any Pre-Bolus, it's going to look like that Pre-Bolus is causing you to drop within the first time period of that meal. So you're less likely to Pre-Bolus as much as you need to from previous experience. And thus you're getting this rise up that you wouldn't have if the hours leading into this meal. Again, if it was a consistent problem at this time of day, it sounds like the hours ahead in this setting, could need to be evaluated. Maybe the bazel is too high heading into this meal, okay, or maybe the insulin to carb from a snack three hours ago, is also giving you too much insulin. So you're consistently coasting down into this meal time. So you've got this excess behind the scenes insulin. So are some other things that could be evaluated to cool.
Scott Benner 12:36
Alright. And somebody said I was lower than you. So I just turned my voice up. So if I got if I'm now too loud, somebody told me. All right, Anna asks, I have been having trouble with the accuracy of my freestyle libri. Sometimes there's a big difference. I think I will change Dexcom was I finished? The my inventory I currently have at home. But do you have any recommendations in the meantime? While I'm using these?
Unknown Speaker 12:59
That's a good question.
Unknown Speaker 13:00
Yeah. Is there an answer?
Jennifer Smith, CDE 13:02
Well, is there anything to adjust? There's nothing from our, from our practice, all all of us within our practice. At integrated, we've all used the libri all got our like trial, you know, couple of sensors to try out and I try to as many people often do you make yourself the guinea pig, right, you try a couple products at one time to see what's actually Right, right. So I wore my Dexcom along with the lever a and the three sensors of the libri that I wore, they were all consistently reading lower than my actual sensed Dexcom and fingerstick values were consistently center to center they were all consistently different. And enough that from a blood sugar and a meal bolus and a correction standpoint strategy, it would have been enough of a difference to make adjustments kind of diff difficult to base off of, is there anything that you can do about it? In this setting, what we usually recommend is for the prime times that insulin is going to be dosed based on a glucose value, do a finger stick, get a finger stick and dose off the finger stick don't dose off of your libri what you can know from any sensor system that might be reading a little bit off or different than you know it should be is that while there is a difference in the number, the trend is still a good, it's still a value for you. So you can still tell whenever you're trending up or trending down, and you can use that to your advantage for future planning. Okay, so but you wouldn't necessarily dose off the value.
Scott Benner 14:43
So um, I guess what he's saying is when you find you're not trusting the device, test, but still look for I mean, I guess I've never used the library but arrows and direction and rate of change and stuff like that. And then when you really need to know I guess what we're saying? Is that if it's a pre meal, and it says you're 120, but you think you might be 150. That's important to know when you're making your Bolus, right. Okay. But Hmm, it's still important. I don't want to minimize the idea that a big a big difference is a problem, but at least you can be safe. When you're when you're putting in like more when you're
Jennifer Smith, CDE 15:19
putting in insulin. Yeah,
Unknown Speaker 15:21
yeah. Cool. So,
Jennifer Smith, CDE 15:23
to let her know that that's not uncommon. Gotcha. A lot of people find the variants,
Scott Benner 15:27
it's gonna be hard to keep. See, I want to, we only have an hour, so I need to keep Jenny movie but Jenny will talk and like, get all her knowledge out. And then we're gonna answer one of your questions if we do that. So Maddie, how do you Jenny see CGM being used in patient hospital settings now that we're seeing COVID-19 error How is going to help diabetics? And Maddie, what I'll say to you is, did you hear the episode of the podcast that went up today? Because Dr. Dan disalvo came on and talked about how decks coms are being used in hospitals right now. But so I have something to add, but you go first.
Jennifer Smith, CDE 16:00
That's pretty awesome. Because I have I've not obviously listened. I've been working with people all day. So I'm, so I have I both pro and con feelings to it. Okay, so from the standpoint that great, there's a lot more information, there's a lot more data, it can be beneficial. On the con side, however, there's a lot of data, and healthcare workers in hospital who we already know, have have little experience with type one, consistent glucose information management, they are used to doing finger sticks every several hours, to base decisions on right, whether it's dosing or whatever adjustments in doses. With all of this extra information, the trends, the alarms, the things that are going to be visible to them. Yeah. There's no, there's no quick education that can be done within 10 minutes to the thousands of health care, nurses, doctors, whoever that's looking at this information to help the person wearing it. Yeah. I feel like there's a lot of information, they're not going to know what to do with it. So that's what I feel like I feel like it's good. But it's also, I don't know,
Scott Benner 17:20
let me share with you what Dan said. Dr. salvo told me that what it was really helpful with in the moment was, it was preserving PP for nurses because they were, you know, they do finger sticks on patients a lot. And now you're asking them to go in and out and change their gear every time. So now they're, I guess, Dexcom. If I, if I heard him, right, gave the patients like Android phones. And so there's a cloud service. And now the nurses are able to look at the patients through the share and follow, right? And then they're like, okay, you know, they come down the line. And here's Mary and Mary's blood sugar's this, it seems pretty reasonable. I don't need to go in there. So that was the idea. What I heard while he was talking was a great opportunity nationwide for health care professionals to see how glucose monitoring works, right. And maybe, maybe in the future, things will go better. I told him a story of when Arden had a surgery. And you know, the nurse didn't know anything about it. I just kept talking to nurses till I found wonders like I have a friend who has diabetes, I go, you're my friend. Now come over here and explain to all these people why we need to leave the CGM honor during this procedure. But anyway, that's what I thought of it, Matty, I thought it was I think it's, um, it's great for that saving of the PP. And on the other side, I think it's a good first step in bringing the technology out to people. So
Jennifer Smith, CDE 18:35
yes, yeah. I also think, you know, in that scenario, as if they're using it based on the protocol that they would have used finger sticks, and they're only checking at certain points to see what the values are or responding to alarms. Yeah, it's absolutely valuable. I just hope that I would expect somebody has schooled them in what to pay attention to what not my, my
Scott Benner 18:57
thought was that it was, it was going to be used in a really, I don't know, like a limited way in the beginning. Just to keep you know, from being with people. I saw Donnie ask about managing weight with type one. So and he said, Thank you for being here. So thank you very much, Danny for being here as well. Yeah. Best way to tackle losing weight for type one. Why do why can people with diabetes who are using insulin have trouble with weight loss?
Jennifer Smith, CDE 19:24
The first thing is definitely insulin management. That's that's a huge piece of it. Because insulin is a storage hormone. It's meant to move food glucose out of the system into the cells, either it gets used by your muscles or it gets packed away into fat, right? So from a physiology standpoint, even if you look at a body that doesn't have diabetes, if you out eat what you really need, then overall your body can only pack away that extra calorie, right? Okay, and it does it with insulin. Right to manage the normal blood sugars that should be there. Same thing is happening though. And so person, even without diabetes can gain weight, that that's how they gain weight. Essentially, their body should packing away more than what they needed because their body is managing blood sugar the right way. In a body with diabetes, though, because insulin management is something that we control, body's no longer doing it for us. It's something that we have to, we have to adjust more precisely than people are often given tools to manage. Right. So overall, one, make sure that your baseline dose that bazel is right to begin with, it's in the right place, then the next thing to tackle is the food management, strategizing around meals timings, you're not using more insulin to cover then you actually need to, you're not covering with extra food when drops happen, because you used too much insulin that you didn't really need to have there. And then the other piece, of course, beyond that is, are you eating what your body needs to eat? You know, because if even in this case, if you've got great looking blood sugars, but you're constantly like popping food in and covering it with insulin, you could have wonderful looking blood sugar values, you could still be out eating what you need.
Scott Benner 21:17
Right? So I usually it's funny, I saw john pop in and he said, Don't feed your insulin, which is this is what I was gonna say. I think I think that when people who listen to the podcast have, there's two trains of thought, when you're learning how to use the insulin in the beginning, I will say be more aggressive, you can always have juice later. I don't mean that for the rest of time In Memoriam. I mean, while you're figuring it out, like if you continue to bolus and get low, fix the bolus, don't keep fit, you know, don't keep drinking juice. But it's a great point. Because people with type one can start to think of diabetes first. And instead of health, right, so all of a sudden, an Oreo cookie is not a bad thing, because I need it because I'm getting low, except your real issue is you need to stop yourself from getting low. So you don't have to eat an unscheduled Oreo. And by the way, don't eat Oreos, they're, they're poison. But But you know, like, I really I don't think there's any food in them whatsoever. But my point is, is that don't feed the insulin, but learn the steps so that you can do that. And Jenny, this is a wonderful place to say that diabetes pro tip calm is now open and available to find all the diabetes pro tips with Jenny and I all in one place in case you guys have had trouble finding them in the podcast player.
Jennifer Smith, CDE 22:34
Yes. And we've also gone over that weight piece in there. It's a great episode at least one if not a couple mentions.
Scott Benner 22:42
Yeah. All right. I have. I have one for you. And one for here's a quick one. Yeah, Jenny, you are g six. And so does Arden. Do you ever calibrate on day one? If it's off? No, you don't you let it go?
Unknown Speaker 22:57
Let it go.
Scott Benner 22:58
And how do you manage that with your algorithm that you're using?
Jennifer Smith, CDE 23:02
I manage it by doing finger sticks. Because I have had, as we talked about right away. I've had diabetes long enough that finger sticks have always been a norm. Even once things got approved for not having to do that anymore. I still do that. So that's my thing. And with the algorithm that I use for my insulin management, I can I can populate in my finger stick value for my algorithm to use that value rather than the CGM value. And then I get proper dose adjustment.
Scott Benner 23:41
And you have an apple iphone, right?
Unknown Speaker 23:43
I do. So you go Apple Health,
Scott Benner 23:45
you go into the health kit, and you tell it, you add your blood sugar there, and then that program you're using, yes, the loop app will see it and then it knows what your posture is. Correct. And so my my way of dealing with it is if it's close eye roll, you know to me like if and I test to their their advertisers on the show, but we use the Contour Next One meter, I find it to be incredibly accurate. And so in those first number of hours while the sensor wire still you know, baking in, I will test but I'm going to tell you that if it says she's 70 and she's really you know, and she's really 90, I might let it go a little longer to see what happens. But there are times I do calibrate to get it together. It's not a frequent thing. I probably only calibrate on day one when I calibrate but having said that we don't do it very often law we leave the finger sticks though
Jennifer Smith, CDE 24:42
and there are a There's your so many that trains of thought in terms of that that I've run into in working with people, some people who've got this like system, it works really well for them. Awesome, great, even if it's not what's recommended if it's working for you. I'm not going to tell you this Stop doing that. Right. But from the standpoint of education, you know, we recommend following the recommendations of Dexcom. Don't calibrate in the first 24 hours,
Scott Benner 25:13
you would never do anything like that. Somebody asked for links, I just put them in the comments. And honestly, Jenny and I are not used to being seen we, you know, I mean, for those of you who are new, I have a podcast called the Juicebox Podcast, and Jenny is a frequent contributor to it. And she's not on every episode. So if you really like her, and you hate me, you're gonna be pissed when you like tune in today, and she's not there. But anyway, calibration day one. Actually, that's sort of covered. The next question I had for you. If there's a person who is excited about algo, their algorithm pumping in the in the future, right, but is worried that because they don't always see their CGM rock, you know, rock solid, and they're afraid of what's gonna happen next, what I would say to that is, you know, Arden has definitely done both ways. And it's never been an issue. Like, I've never ran around the house going, like, Oh, my God, everyone's gonna die. Because you know, Dexcom was off and we're using an algorithm, it just, it's a it's a reasonable worry if you've never done it, but once you do it, I don't think it's something you'll think about again, does that strike you like that?
Jennifer Smith, CDE 26:19
No, it does. And it's actually a question that I've gotten more than a number of times from people that I work with, especially parents of kids, you know, wondering, Well, what about those? compression lows? Right? What happens if an algorithm is using that? And now it's not really low? What will have happened? Well, you know what, because the system if you're using one of these hybrid types of systems, whether it's, you know, on the market, or yet to be on the market, um, if you're using one of them, it's going to adjust based on that change in blood sugar, that's being seen, right. But most often, especially in this example, of a compression low, that writes itself pretty quickly. In fact, you can tell it's a compression low, because it looks like your blood sugar is literally like nosedived off of a cliff. Yeah. And then it comes back up very quickly. I mean, you could you can tell it's wrong. Well, yes, the system will have reacted to that drop in blood sugar, it may have taken away insulin where it was supposed to, but within the quick timeframe of it writing itself, that algorithms also going to write what it took away behind that, right. So I've personally, I've had sensors that have been off, thankfully, not very many, my Dexcom, thankfully, has been very accurate for me. In all the years, I've used it. But I have had compression lows. And since I've been using, you know, this algorithm, I haven't noticed that that's honestly been an issue. I've never had any problems of excessive high blood sugars or no problems with like, strange, odd low blood sugars that shouldn't have been there because of this sensor. You know, okay, she being off.
Scott Benner 28:00
Yeah. I hear you. I'm, I'm down. I think it's, it works. I mean, I've I'm not gonna tell you I haven't gone Norton's room been like, She's like, the first thing I do if she's laying on her side, because she wears hers on her, like her body, her hips. So I'll touch her hip that she's not laying on. And if it's not there, I'm like rollover. Just kind of like shutter and, and then you'll wait a minute, it comes back. interesting side note about a compression low with a CGM. The number it's reading is actually correct still, although not indicative of what your blood sugar is. So it's reading your interstitial fluid, which is you know, freely running through your body. But when you press down, it disperses it. So it's dispersing some of the glucose that it's reading. So it might tell you your blood sugar's 60, all of a sudden, the truth is, the interstitial fluid around the wire, the glucose value is 60, your whole body might be 110. But that's why when you roll off of it after it gets to the algorithm gets to think a couple more times, it'll come back and tell you Oh, no, you're one time. And that's it. How does that engineer makes a great point, if that happens, the worst thing that's gonna happen is the algorithms gonna take insulin away, you might get hot, but you know, you might get a little higher, but you're not going to be in a dangerous situation. And that's a great trade off, I think, yeah, you know, Jenny, I'm gonna ask you, somebody jumped on and said that I recently said on the podcast that I don't abide a bad pump site that I get, I get away from a by a pump site pretty quickly. But she wants to know, how to, you know, it's not just your period, or, you know, and so I'll you know, because you and I deal the same way about that we don't stick around for like,
Jennifer Smith, CDE 29:39
I don't stick around. And and I guess, you know, from a female perspective, if you're like, well, gosh, is this my period? Or is it you know, a bad sight or whatever? I mean, most women, most not all, but most women have a pretty consistent timing rhythm to their cycles. Yeah, right. So if it's You know that it's probably coming into that time, or you know that it's that time and your high blood sugars are usually associated with that. You wouldn't necessarily think that this is unless you, you haven't changed your, let's say, your settings or your insulin doses as you needed to for this time period. And if you forgot to do that, obviously the high could likely be associated with that. The best way to tell though I mean, because even in your period, you could certainly have a bad sight. Like two things hitting you at one time. That's not fun, either. It's
Unknown Speaker 30:31
okay, hit from both ends. Right? That's not
Jennifer Smith, CDE 30:33
that's not joyful at all. So, you know, if that's the case, I think, regardless, for anybody, whether you're male or female, if you've got an odd looking high blood sugar,
Unknown Speaker 30:45
yeah, that
Jennifer Smith, CDE 30:46
shouldn't be there. Right? You know, you've done everything you would normally have done. And this is just a weird, all of a sudden, you're like, double arrow up and you're to something. You take a correction, right? In my case, and what I recommend, if it's not coming down within the next 30 to 60 minutes, that's it's done. Yeah, it is done. I don't play with it, even if I pull it off. And I'm like, well, it doesn't look like I don't know, whatever the problem was, that the candle is not bent. It's not bloody, it doesn't look weird. Sometimes it might look a little bit wet, or mediawiki. So maybe for some reason, the site was like leaking up along the canula. And you didn't really get as much insulin as you should have. Yeah, um, but yeah, I don't, I don't play with like numbers that aren't where they want to be. Right. And
Scott Benner 31:32
there's a couple of ways that the way I taught myself so the answer to a lot of these questions ends up being repetition, you do something over and over again. And one day, it just makes sense to you, right? And you don't you lose that checklist in your head, like, well, I said, this is it, this, like you stopped doing that. You just see it, you recognize it, and you go, so before I could recognize it, I would inject with a needle. So if the pump didn't act the way I expected it to, I'd come back with a syringe. Now if there was no reaction after that, then I was pretty sure that my site was over also, last day of a sight, you know, or you just put it on and it just never ends up working. Because I know some people switch their pumps and they, they they'll experience a little bit of a high when they put it on. There's a lot of you know, talk about why that is I part of me thinks in children that it's anxiety. It's the you know, it's the that whole thing kind of gets you jacked up a little bit. That could be it. That's what it used to be for Arden. She's obviously much more relaxed around it now. But we've changed upon this morning, it went on and we did a more aggressive bazel rate for the next hour to try to her blood sugar was good at like 110 but to try to mitigate any kind of arise you know, same thing on the other side, if you think it's not working anymore, once you get it back on, you have to really think about for a second How long has this like not been working? And now I'm just going to slap on a new site and go oh, everything's fine now because the insulin deliveries back it's not because everything for now is for later and everything that's happening to you now is from before I get insolence always from before, go back to the beginning if you're falling late, but that's really it. Now the next one is more for you. Although people are asking follow up questions, so hold on. This is great info inside. Oh, great. Okay. Oh. By the way, there are people in the comments helping each other somebody was like, what's the compression level before we could explain it they jumped in You guys are awesome. Jenny, I drew a picture of a lady with a big belly to remind me that someone asked about good tips for thinking about getting
Unknown Speaker 33:41
everywhere just didn't write down pregnant. But anyway, I'm not showing anybody it's not a good drawing but
Jennifer Smith, CDE 33:47
good tips for getting pregnant. So preconception time. Um, we we kind of define preconception time, the three to six months, potentially even a year up to when you want to start trying to conceive. And the goal there is to aim to get glucose values into the pregnancy target. If you think about and or don't know what the targets are for pregnancy. The goal is to be under 7%. And then in pregnancy and even see more around 6%. Within the fives if lows aren't the big reason for being in the fives. But typically, most practices will say under 6.5%. through pregnancy more around six is the preferred just from the standpoint of health of you and the developing baby. For the preconception time then it's really focusing in quite a lot on what are the variables that you can learn and manage better in your life. And if some of the variables like every Friday night you eat the whole box of chocolate, you know ice cream bonbons And you can't manage around that. You know what, for nine months, you can manage not eating your bonbons on Friday night? Yeah, I mean, that's, you know, those are the things those are the strategies that you sort of learn in that preconception time. I mean, the beginning tips really are, look at what preconception or look at what pregnancy targets for blood sugar should be. Because aiming to get those as close preconception will make it so much easier. Once you're pregnant, as you don't have to shift this whole mental. Oh my gosh, now my blood sugar has to be 90, and it's been riding at 150.
Scott Benner 35:36
Just count on, I'm going to get knocked up, and then I'll do this better. Right, right, just and that probably wasn't the right way to say that. But you know what I mean, thoughtfully and through love, make a baby and then trying to get better at your blood sugar, get better first, prove it to yourself that you can do it over and over again, Jenny, if you had to say to somebody, how a way they could get better at this, what would you tell them to do?
Unknown Speaker 35:57
What would I tell them to do? Like a web address? Yes, well, they can call me
Scott Benner 36:03
just put Jenny's email address in the comments.
Jennifer Smith, CDE 36:05
They could. They could also i we've got, I wrote a book with a good friend of mine, Ginger Vieira, who's written a couple of her own books. It's, it's pregnancy management for type one diabetes. You can find it on Amazon. And we actually have a big preconception, month to month guide for pregnancy management, postpartum lactation, we've got all of the information in the books, I would
Scott Benner 36:31
also bet that sometime later this year, there might be a pro tip episode about being pregnant with somebody too, because that just sounds like a good idea. And I typed it into our running list of ideas for the podcast. Awesome. Yeah. Okay, that's a great answer. I wanted to just say that.
Unknown Speaker 36:48
I think
Scott Benner 36:50
I think that once you figure this all out, you get pregnant, you keep your blood sugar, super stable, and you're a onesies nice and low forever. It's gonna be difficult, but try not to lose track of it after the baby comes. Like, just you can do it. If you did it, then you could do it forever. You know what I mean? Like, you know, it's interesting, as I interview more and more people over the years, to see that some people who have trouble managing their diabetes, for themselves, don't have trouble managing it for someone else, you have no idea how many people have come on and said, I met somebody and I fell in love. And I got married, and I wanted to be healthier, so that our relationship or I had a baby, and I realized I wanted to do more. That's not specific to diabetes, by that it's a very human idea. But yeah, keep putting yourself at the top of your list of things to worry and be concerned and
Jennifer Smith, CDE 37:38
he can take care of you. You can take care of other people.
Scott Benner 37:40
100% I think and Wait, do you see having a baby? It's It's wonderful. Nothing like having a kid my wife and I were just sitting on the other night going, we think having these babies was really, really good idea. No, we were choking, because they were both being annoying at the same time. People are thanking us, which is very lovely. Thank you very much. We really appreciate that. You guys listen. evany asks a question back about bolusing. That I feel like I have something to say he said, Is there anything physiologically wrong with a post meal spike? If it comes down later, without extra insulin? Would you try to master that meal? I think you probably can. I mean, unless it was, like you said, Well, you know, I can't even say unless it's cereal, because I can get cereal, right? Sometimes, too. So yeah, I have an In my opinion, if you're going up, hanging up, coming back and leveling out again, and never getting low, there is a way to get more insulin up front. And you know that and we talked about it earlier that really Evan should go back to the beginning of the live, right.
Jennifer Smith, CDE 38:44
Yeah. And I also think, you know, from the standpoint of that kind of management, what it also leads into longer term, if you consider, for the most part, you're looking at your day, let's say you're using a CGM, and you can see how much of the time you're in range and where you want to be. And you're only, let's call them problematic times are these spikes above where you really would want to be after a meal. Yeah, but the end result is that you're back in target. And that looks awesome to you. Right then, one managing the timing, again, it's all about timing the insulin right, but to that peak is still leading into your overall a one C, okay, it's still leading into time out of range. And those post meal spikes also lead towards things like some of those many things people don't want to talk about, but the complications, more of those microvascular complications with these peaks that come into play, the more you can minimize and have more gentle roles, the better long term, so right.
Scott Benner 39:57
To do your best and keep messing around little sooner, a little later. Little more or a little less in there somewhere is the answer. It sounds like he's got the amount right and the timings off. Listen, even if you don't listen to podcasts, I maintain that most of managing insulin is timing and amount, it's just about getting the right amount in the right place where the need comes in. If you can get more up front to stop that initial spike, it might not have to be that much more, you'd be surprised it could end up being a couple more minutes of a Pre-Bolus or another half a unit of insulin or something random like that. That's still because that momentum from the food is so great. At that moment, it'll eat up that insulin, it won't leave you extra on the back end that will make you low. Right, hopefully. Julia asked, What do you consider a gentle roll? Did you just use the words gentle roll? Okay. Do you mean like one of those little Pillsbury things with the?
Unknown Speaker 40:47
Oh, no, no, no.
Scott Benner 40:48
Julia, I can I can talk Jenny as a matter of fact of Jenny's husband ever leaves her we're perfect for each other. what she means is not like, not like sharp, sharp down. She means like, it's cool if you go like this a little bit. By the way, this. So much of what we do is, is easier when people can see our hands moving Jenny and my hands move a lot while we're talking.
Jennifer Smith, CDE 41:11
And the funny thing is, nobody can ever see like our expressions or anything because it's just all voice. There are times when Jenny goes, I wish
Scott Benner 41:17
people could see what we're doing right. And I'm like, Yeah, they can't so Oh, Rachel, it is the best podcast ever. Thank you for saying though. I asked if the group earlier forgot. I would ask here. I had been pumping on the pod for six months. And I've just noticed the pattern. Day one runs high. Day two, good day three low. Any ideas how to combat this? More or less insulin? She's heard of the opposite problem. Brittany has a day three being a little higher. I would say that's if I see anything. It's day three higher Ardennes pumps either work, right out to 80 hours, or right around
Unknown Speaker 41:55
two and a half days.
Scott Benner 41:56
Yeah. 70. I was gonna say right at 70 hours ish, then I have to start paying attention more.
Jennifer Smith, CDE 42:01
I've actually personally noticed that when it does, it's not a time factor. It's more of a when my pod gets to about the 20 unit mark, I can almost guaranteed if I continue to use it after that for boluses or anything. Yeah, I will ride higher. Even though the pump tells me I've delivered the insulin. And it's the same way it's the same factors ratio is everything that I've used. It's it's a, it's a dose amount from what I and I've used Omnipod since 2006. So I got a lot of experience of yours.
Unknown Speaker 42:35
Yeah.
Scott Benner 42:37
I was telling Jenny the other day Arden's been using it since 2006. And it's, it's amazing. Like, I have nothing bad to say, uh, you know, a number of people asked, they said, they have the opposite of the feet on the floor up, they have a feed on they wake up in the morning and their blood sugar drops pretty drastically. Have you heard about that? from anybody?
Unknown Speaker 42:57
I've actually not.
Scott Benner 42:58
So so then would we consider maybe that the bazel leading up to their wakeup time is too strong?
Jennifer Smith, CDE 43:05
The question would be first, which is always my question to people are is your wakeup time the same? Please, it is the same. And you're noticing that drop, as soon as you get out of bed in the morning, okay, then the next thing to do would be try to sleep in and see if the drop happens. Because my guess would be the drop is there. Because you're getting up at the same time you think it's because you're getting out of bed. But it's because as you just said, the bazel in the hours preceding that are probably too high, and the drop was going to happen anyway. Um, so If, however, you find that when you wake up in the morning, and or sleep in completely different, let's say the sleep in stays totally stable. And when you wake up and get out, that's when the drop happens. Yeah, that's it. I mean, it's the complete opposite of what a good majority of people see. I'm not saying that it's not your personal experience. I've got friends who have a drop in their blood sugar with adrenaline rather than the typical peak in blood sugar because of adrenaline. So it could be the case, it, I would say that it's going to be a little bit, it'll be a little bit harder to maybe manage a drop. Because if it's related to when you get out of bed and not really wanting to like eat glucose tablets, or drink some juice just to stop the drop, though only a couple of options would be, well, if you can get up at about the same time, you could technically decrease the bazel leading into that time. So the drop doesn't happen. The only thing there is if you if you get up later, then you're not really going to need that
Scott Benner 44:48
decrease higher than listen because of this whole Corona thing Arden has been she shifted her life drastically. She's staying up way later and getting up way, way late. Yeah. And so I know if by 6am, I don't take away the power of her bazel by half, she's going to be low by eight o'clock. Like, because her daytime numbers are, you know, the insulin we use during the day is just different than what we use at night at night. She needs far less. I don't know, I hope that was helpful. Let's say I know I have a drop because I'm not waking up at the same time. Every day when I had a normal work schedule. There was no drop when I wake up. So then Laura, look is did you do you have a stronger basal rate in the time you're supposed to be awake? Because if so then that's it. Your bazel is just building up and building up and you have nothing going on inside of your body that needs resistance from extra insulin, then, at that point, a bazel. could act like a bolus eventually. Yeah, right. Okay, cool. I like the way I said that. Well, Melinda, thank you for loving the podcast. Thank you. This morning, I was 111. Justin says when I woke up later in bed and read the news got up 45 minutes later and went to 72. Hmm. And that's not Justin, it's tough. I can't have a conversation. But was that not bazel related. Somebody here said they have a new bazel program that's called pandemic. So that's a good point, too. Don't just change your settings, you can make a new program so that when this is all over, you can switch back to the way it was. I've had to you know what, I have a question for you, Jenny. This happens sometimes when we do the podcast. Let's do it now. And then I'm going to get to a question about kids and growth hormone. I was interviewing someone today who talked about when they got pregnant, they suddenly needed much less insulin. And I was saying to them, it's interesting, because for three days before Arden's period, she almost needs no insulin to and I'm wondering what hormone we're going to figure this out, I know this isn't going to something you're going to know now. But we're gonna figure this out and talk about later in the podcast, there must be some hormone that's released. For oscillation. That must also exist while you're pregnant. And maybe I'm wrong. But I'm going to find out if that's true. Because those two things like a bell went off my head as Ooh, maybe this is it. Because Arden Will you know, Jenny and I've talked about it privately, Arden will use like almost no insulin for a number of days before some of her periods. Not all of them, you know, just to keep things interesting. But do you think? Did I just say something you've never thought of before?
Jennifer Smith, CDE 47:25
No, it's well, and typically, oops, some reason went off my screen. There you are. Hi, hi, sorry. Um, I was gonna see the horrible and that's present in the lead up to your cycle, as well as the horrible and that's present very heavily prevalent in the first part of your pregnancy in that first trimester up to about like, six weeks is progesterone. Your body is having this ramp up, almost up a hill climb. And when you get your period, because your body's like, hey, you're not pregnant. So then the progesterone kind of like falls off the cliff, right? You come back down to this normal level. So most women, not Arden, but most women have a right up in blood sugar in the days before their cycle starts. And then it calms down. Same thing in those early weeks of pregnancy. Typically, women will actually see a heightened need for insulin in the first about six to seven ish weeks. And then around eight weeks of pregnancy, there is a bit of a dip off for a couple of reasons. Um, you know, hormonal II and what the body is doing, why there would be a dipped in blood sugar prior to the first day of a cycle, or maybe in the first part of pregnancy, when normally most women are experiencing a rise, the hormone, hormone drive there, I can't say that it's different. I would have to research let me give
Scott Benner 48:56
you a number another variable for this story. And I guess this is me ruining an upcoming episode. But what if the pregnancy didn't last much longer than eight weeks? Maybe there was something else going on? Sure. Yeah.
Jennifer Smith, CDE 49:09
In fact, that is if you've had a normal increase in insulin in early pregnancy, and if prior to that eight to 10 ish week point where usually your insulin needs at least stabilize and or dip down a little bit. If that dip happens sooner. Oftentimes, it can potentially be an indication of like miscarriage only because the hormones are not staying steadily, you know, there's not a steady climb. There's also you know, an early pregnancy. If you've ever had miscarriage before and or you're just worried. You can always get this the HCG hormone tested, which is the early pregnancy hormone that's released that actually gives you that positive result in your pregnancy home pregnancy test. So that hormone should add Actually, mostly double, sometimes triple in those early weeks of pregnancy, which is, it tells you is that your pregnancy is progressing the way that it's supposed to. Okay. Um, so those hormones, you know, that might have some indicative factor too. But that would be something I'd had, that's a great way to look into
Scott Benner 50:20
a little more research sound like there's more in there for to understand, hey, I want to go back to Justin for a second talking about getting up and getting low. Justin, I just had a thought maybe you should do a bazel test day, maybe you're eating enough to feed a basal rate that's too strong. And that way you sat in bed, you looked at the news and everything, maybe that is what's happening, maybe it's not, but if you bazel test and find out you're always low, maybe, you know, like, when I talk about, like, you know, manipulating bazel rates, sometimes when you manipulate them too much, Justin, you're in some belong somewhere else. So you can you might be I could be wrong. But you could be in a situation that a lot of MDI people find themselves in where when they switch to a pump, and they realize that their basals way wrong. But you know, people are like, Oh, I switched to a pump, my blood sugar started going up. Well, it's possible, your bazel, you know, before was too strong or too weak, you know, one way or the other. And so, I guess the way I like to talk about it is, so then what's happening? You can't draw a parallel to the things you think they're attached to. So I don't know, Justin, that's maybe worth a shot. Somebody here said I've been diabetic for 31 years, Melanie. Hi. And you guys have changed my life. That's lovely. Isn't that nice? Thanks, Jenny. I feel nice.
Jennifer Smith, CDE 51:33
And they can see a smile.
Scott Benner 51:35
Yeah, because we really do smile. Yeah, cuz I read those two jenine. And you probably think we're just all like, just jaded and like a doesn't matter. But no, it makes everybody really happy. It does. Sabo. Can Type One Diabetes go into remission, I can answer that one. No. That it definitely can't. Oh, what's the proper way to bazel? test? Caroline? In my opinion, that's a long conversation. It's not an easy conversation to have. But Jenny and I have had it in the pro tip episodes. So find the link, go to diabetes pro tip comm and look for the Basal testing episode. I listened to all of them If I was you, but at least to get to that one. Justin says, like, maybe we're onto something. All right. You're good to go for a little longer. Yeah, Caitlin. My toddler has decided to wait, we're gonna go somebody else said something about Caitlyn disappeared, my toddlers decided to pace himself differently during meals resulting in dipping down into the 60s mid meal. I'm concerned about our low percentage has hiked to 6%. and wondering if we should make changes.
Jennifer Smith, CDE 52:43
So if your toddler is now decided to like, pick it things like he'd rather he or she graze like over the next one and a half hours instead of like slamming it all down within 15 minutes. That was the case. You know, kids are different. I've got a three year old, they sort of roll and change without telling you they're going to Gee, sounds like the dose is probably not wrong. It would be again, the timing of the insulin distribution. So if the picking of the food he he or she ends up eating everything, but it's in a slower timeframe. If you're on a pole and extended bolus,
Scott Benner 53:27
yeah, so extended bolus you could do two different boluses if you wanted if that's get that idea scared you. Kenny says try to get them to eat the carbs first or the shorter to help it there's a you can manipulate the food. You know now you're going to get me into my my coma when I'm on stage and I start talking. Too often with diabetes, we think of just one thing, how does the insulin impact the number, but you should be wondering about how the food impacts the insulin, how the food impacts the number, how the insulin impacts the food, like there's all different sort of perspectives you can use to think about it and one of them in there is the answer. And Marcel makes a good point. Maybe the person who asked if diabetes could go into remission maybe they were asking about honeymooning and, and so, so back to that some people really can. Maybe we should go over honeymooning real quick, but honeymooning is a spot where you have Type One Diabetes you have this insulin need. And then sometimes for a day, three days, three months I've spoken to people it's gone on for years for suddenly it feels like their pancreas is shouldering the burden a little more again, and then they call that a honeymoon. Well, I think that's a fairly good explanation of what honeymooning is so it does eventually for most people go away.
Jennifer Smith, CDE 54:45
Right and you're eventually you will return to using insulin completely
Scott Benner 54:50
right for right. If I go away, I mean, your pancreas is gonna, it's gonna give up finally poop out go down like Bugs Bunny eventually. And then for those
Jennifer Smith, CDE 54:57
who are diagnosed as adults or What we call often call ladder. Some adults, it can actually have a very long honeymoon Yeah, where they may very well be able to control even without insulin for months at a time after they're initially diagnosed with just lifestyle changes before they actually start to need to use a basal insulin and eventually a bolus insulin, etc. So
Scott Benner 55:27
let me address this one question. Then there's another one here. I like that I want to go to back to Sabah because he's asking, Is there a cure on the horizon and near future? I don't know that there's any cure on the in the near future. I have a very simple concept around this. I live with a lot of hope for advancements, but I make decisions day to day like they're never coming. Because far too many people I see ignored thinking, Oh, this will be over soon. I can my body can take bad management for a little while. I that's how I feel about it. I act like it's not gonna happen. I hope I'm hopeful. But, you know, somewhere in the middle there i think is the answer. And Jenny, do you know of any cures on the horizon?
Jennifer Smith, CDE 56:08
I don't there's, as there have been long term, there's a lot of research, there's a lot of animal based studies that show some warrants some benefit. But you know, 32 years with diabetes, I explicitly remember my doctor telling my parents not to worry that within seven years, it was seven years when I was diagnosed within seven years, right? You won't have to worry about this anymore. And, you know, even into my teen years, then my team brain even started to tell me, this is like lifelong, right? Just the hope has always continued to be there that maybe there will be some grand discovery, and it'll get through and everybody will benefit from it. You know, I am, I'm hopeful more in technology, and where the technology piece is going for helping management. But I am hopeful, but I don't see it.
Scott Benner 57:06
I agree. I hate saying that. I know it sucks to say it, but I'm on the same page with you. And not for any nefarious reason, just that if you really if you go look, I think as a species, we've cured like eight things. And a few of them are just inoculations. They're not even really cure. So I'd live like, I'd live like it's not gonna happen with my actions around diabetes, but I'm always hopeful. I and here's another thing not to make light of it, though. But somebody said on the podcast recently, no one's going to cure diabetes, and you're not going to know about it. It'll be on the news. You know, you'll figure it out or turn yourself into a mouse because it seems super easy to cure them from type one diabetes. Maybe that's what we should be doing. Looking how to turn people into mice. Hmm, now we're getting somewhere. Yeah, I'm sorry. I feel bad about that. But all right, Mallory says, No, wait, Mallory. I'm sorry. That's not the one I was gonna read. And I'm like, Damn, they almost got the mind. A Kelly said nearly every night after my son falls asleep, he shoots the 300. I've increased bazel by as much as 95%. But once he's there, I can't bring him down. When he wakes up, can I answer first?
Unknown Speaker 58:13
Sure.
Scott Benner 58:16
Hold your thought, I'm just gonna put something on that you can come through with Trust me. Just because your kids bazel rate is I'm going to make up a number here, a half unit an hour and 95% puts into a unit an hour doesn't mean that's how much insulin he needs in that time. So you may have to extend on your pump, the amount of bazel you're allowed to use to get to the point where you can keep him down because there is an amount of insulin that will stop that kid's blood sugar from going up and hold him steady. What were you gonna say?
Unknown Speaker 58:46
What I said, You're so funny. So
Jennifer Smith, CDE 58:48
pretty much along that line? Yeah. One is, you've got data that shows you that this is happening every night, right? You're not like, Oh, this is only two days. And now it's not happening anymore. This is it sounds like it's every night. So one, you know, insulin needs to change to right along with what you said. It's in very low level bazel rates, especially in many kids. If you're turning Bayes a lot by 95% at a bazel. That's point one. You're not hitting the mark, by any means.
Scott Benner 59:21
Remember, you're not going to
Jennifer Smith, CDE 59:23
write it. That's that's not hitting them. You can even look at it a little further if you take into consideration. What what's the climb in blood sugar. Let's say the child is starting at a blood sugar of 91 at bedtime and climbing up to 303. Right? That's a huge increase in blood sugar. You can also take a look at Well, what is your correction factor? Most little kids have correction factor somewhere around like one unit changes their blood sugar by 150 points or by 200 points. If your kid is climbing 200 points, that little notch up 2.2 When your kid really needs a whole unit to correct a 200 blood sugar climb, right? That's how much you need to change the base and why
Scott Benner 1:00:08
Yeah, here's the thing, you'll hear me say this a lot. If you listen to the podcast, you need more insulin. That's it. If you have more insulin, it wouldn't happen. And by the way, for the person who asked about the group, and by the way, too, for a little kid, that could be growth overnight. Right? And for the person who jumped in and said, their kids in the teens and going through growth, and they can't keep their blood sugar down. Here's my answer to that to use more insulin. Because there is an amount that will stop it. Trust me, there's an amount like, now the question is, how do you get to that amount in a way that doesn't feel frightening? Especially for somebody who's now talking about Look, it's supposed to be point five, I made it one, how am I possibly going to go higher than that? That feels frightening. I've told the story in the pious, long time, so I'm not going to waste it here. But there's an amount you can do just find yourself being more aggressive cover with a fast acting is used if you've gotten too much, but the truth is Peters bazel up a little too high. He's not going to go from 300 to negative 10. Out of nowhere, you know, and keep in mind too, that if you see arise at midnight, that doesn't mean change the bazel at midnight, it could mean change the Basal at 11 o'clock even or it could be a little earlier a little sooner, depending on how his body or her body reacts to the increase of bazel. Just like you putting in a bolus doesn't start working right away. Putting in a bazel doesn't start working right away. There are more thank yous in here. Those are nice. Thank you. Jen, do you have to go at the top of the hour?
Unknown Speaker 1:01:34
Oh, no. I've got about 15 minutes.
Scott Benner 1:01:37
Jenny's giving you her personal time. That's lovely. The takeaways more instant mirror it always is. Kara? I'm glad you think this is awesome. Okay, so she got correction factors thinking about it so that way. Jeff is saying protein and fat that are hitting around dinnertime. Okay, Scott. Jamie said, Scott, I've heard you say things about being an insulin deficit. From overnight, I'm pretty sure I understand what you mean, I suspect it's a reason why some people go higher than expected in the morning. It was a lightbulb moment for me. So I'm sure others may find it helpful. Anyways, I love you guys to explain what you meant here. I'll let Jenny explain what I meant. So I can drink something.
Unknown Speaker 1:02:27
Yeah,
Scott Benner 1:02:28
I see what I mean, afterwards, just you go first, relax.
Jennifer Smith, CDE 1:02:32
So if you're at a bazel deficit, essentially, you're coming in to a time period when first thing in the morning most people are trying to put food in right away, right. And if you're coming in at a deficit of insulin behind the scenes, then the impact of that food even with potentially a Pre-Bolus, it, you're still going to rise because there wasn't enough behind it in the hours leading up to that meal time. If you're at a deficit of insulin as well, you're likely seeing that you're writing in at a blood sugar that's higher than you want to be or it's higher than the target, you've had your your pump set to keep you at. And that's a telltale sign right there. And that's only then going to lead into that real time, also causing more of a rise up than you want. Because you're already starting higher than you wanted to begin with.
Scott Benner 1:03:26
I would and I think of it, if you want a different way to think about it, it's like eating a meal without a Pre-Bolus. Right, because there's just you, if you don't Pre-Bolus a meal, you start eating that foods gonna win way before the before the insulin starts working. Same idea, like Jenny said, people jump out of bed and they eat. And you know, we just explained to the last person that you turn, you put a basal rate on at, you know, not at midnight for a jump up at midnight. So if you're getting up at seven in the morning and beginning to eat right away, your blood sugar's jumping up, it's possible your basal needs to be stronger, starting at 6am. And you still have to Pre-Bolus it's not all the base, or you're gonna have to Pre-Bolus and you're gonna have to have the base. All right, it's all just the timing and amount. Everything you see with Type One Diabetes, in my opinion, is about the balance of insulin and using it when it's needed. And you have to be able to step back sometimes to see the bigger picture. People get hyper focused on what's happening in the moment. I get up in the morning and my blood sugar gets high. That's it then they stop there. It's not about that. It's about before I've now this is going to be the third time I send everything. Everything you do now with insulin is for later, but remember now is always some other times later. Ah, that's how Arnold Schwarzenegger tried to kill those people in that movie. Right. Time travel time travel.
Unknown Speaker 1:04:47
Okay. Yeah, that's all. I think
Jennifer Smith, CDE 1:04:50
the other part of it too is that there is a very there's a very emotional level to managing your diabetes. Managing somebody that you love. Diabetes, yeah, right. And so, as hard as it can be, sometimes you have to step outside of yourself. And you have to kind of say, especially for the person who's managing their own diabetes, you kind of have to step back, take the emotion out and say, Okay, um, hi. I love being high, but I'm high. Let's, let's look at the information and see what I can do to fix it. Right? Um, sometimes taking that emotional piece out of it also makes you think a lot clearer about what you want to do. I mean, that's, that's the big reason for baseball maker.
Scott Benner 1:05:40
I maintain, I maintain that I'm as good at this as I am, because it's not happening to me. If I had type one diabetes, I wouldn't have this podcast, I'd be a mess. I'd be on the floor with my 10 a one See, God, I gotta know what's happening. You know, but it was for my daughter, right? Like, no, I don't know, like I you know, it's for her. So that I'm able to, I'm able to be more aggressive because I have a bigger fear of letting her down than I would have letting myself down. I think. So a lot of the things you'll hear about on the podcast, which by the way, you can listen to on any podcast app, absolutely. For free, just search for Juicebox Podcast, there's over 325 episodes, the podcast has been up for almost six years. You know, if you don't have a podcast app, they should be free. If you can't find one, go to Juicebox podcast.com. Scroll to the bottom there are links to all your different phones to get you on. And someone just asked a question here, how to manage unexpected activity, but a bunch of people just jumped in and said have a snack. decrease your bazel Yeah, that's it. Now listen, something somebody said was amazing. I'm gonna assume it was me and we'll just move on.
Unknown Speaker 1:06:50
I don't really know what she's talking about.
Scott Benner 1:06:53
Yet, so they're talking about that they're talking about activity around all this. Also, I want to bring up around you know, a lot of people stress, anxiety, or all of a sudden sedentary lifestyle because you're not going to work anymore. All those ideas somebody in here asked about they said their blood sugar's jumping up at night, not always, since the pandemic has started. And I wonder if when your brain slows down after your days over, do not find yourself thinking or worrying about Coronavirus because stress, anxiety, pain, there are a lot of things that can make your blood sugar go up. So I would I would look into that a little bit.
Jennifer Smith, CDE 1:07:30
In fact, there's it's really funny that you bring that up because, uh, somebody that I work with, she actually just emailed me. It has nothing to do with diabetes, but my brain was right away, like bringing diabetes into the picture reading it, it's all about dreams, since Coronavirus became the thing that it is, yeah. And the fact that dreams are, they are the way that our our mental self kind of manages through things. And we can learn some things, you know, if your dreams are kind of scary, or if they're really scary, or if they're just sort of like hinting at weird things. You know, I mean, it's the way that your body manages to sort of work through some of the thoughts that it didn't have in the daytime, right? Or that were sort of in the background. And with diabetes in the picture. Some of those can be very stress inducing in the overnight time period. So you know, if you're looking at, you know, many of your overnight values and you're thinking Whoa, why is this weird? This night was really weird. I had this strange rise and I woke up high and that's usually not happening for you. Maybe you had a horrible dream about
Unknown Speaker 1:08:37
something that you know, and it's not about never hugging another person again.
Jennifer Smith, CDE 1:08:44
Could be I had a I had after all this started I had a horrible dream about zombies. Did you? Horrible like I woke up in like a panic. And I usually I don't remember many of my dreams. I usually see sleep pretty soundly. Yes. Dream had me like, I was like all levels.
Scott Benner 1:09:03
When Natalie just jumped in and said playing video games makes her teenage son's levels go up. That's adrenaline, I would imagine. And Natalie I bet you they come back down again. Right? And because that's that's another thing. So stress, anxiety, those sorts of things are always going to well always have the ability to impact I'm sure there's some people get stressed out in their blood sugar's don't go up. But it does happen to a number of people enough that it's worth paying attention to.
Unknown Speaker 1:09:27
Yeah, and
Jennifer Smith, CDE 1:09:28
sometimes you can address the rise. If you know that it's not going to come down sometimes sometimes you have to correct for it. Many times adrenaline rises, though. We often don't have to touch oftentimes once that stress factor or the adrenaline like surge sort of passes. You'll see things come back down.
Scott Benner 1:09:46
You know it's funny somebody jumped in as you were making this and said a bedroom could make your blood sugar go up at night, mira said and there people my daughter's goes up with Xbox so if you know, listen, it's not the easiest thing to to Guess schedule. But if you know, Xbox time is going to be in a certain place, you probably could do with Temp Basal increase. Right. And that would
Jennifer Smith, CDE 1:10:08
that would definitely kind of like weightlifters if you know, you've watched enough to know how much blood sugar typically rises during Xbox use, you could technically take an amount of insulin as a bolus to offset the typical rise that you see based on what your correction factor is.
Scott Benner 1:10:23
Let's see if we can get one more thing in, because we have to go so somebody asked about their Dexcom user, and they're talking about Pre-Bolus. And when do you know when to start eating. So for my daughter, in a perfect situation, I like to see a diagnose Down Arrow before she starts eating. And you also have to get right in your head what's high and what's low, too, you know, for me, I don't want my daughter, I try very hard for our not to go under 70. That's my goal. And I try for not to go over 120 do we always do that we do not always do that a number of times a day, she ends up higher, it just happens sometimes. Okay, all the things that you just heard about happened to us to my daughter's a one C has been between five two and six, two for almost six years. But she got out of bed didn't have enough insulin going because she slept in try to eat something with a lot of carbs and her blood sugar's 200 right now. And it's and we're going to get it back down as fast as we can without it getting well it's not you're not shooting for perfection. You're just shooting for as much time and range you can get in there. But back to the initial question, I like to see a diagonal down arrow. But now I know how fast the food is going to hit or just you just have to practice right like, started 100 put in the blood sugar when you get to 91. Diagonal down, eat, see what happens? Did you go up to 150? But then level back out? Cool. Maybe you could have waited till 85 diagonal down. Maybe that would have taken you do 130 c? It's just trial and error. You have to go over and over again.
Jennifer Smith, CDE 1:11:53
Experience teaches you? Yeah, a fair amount.
Scott Benner 1:11:57
JOHN, I don't know that. Jenny knows this answer. But I'll ask before she goes john wants to know if you know what factor? What factors affect the hypest hypoglycemic risk value on the dexcom clarity app, you know what it takes into account to come up with that? I don't,
Jennifer Smith, CDE 1:12:13
it I don't, but my assumption is that it calculates the percentage of time that you've been low, within the timeframe that you're looking at, to classify what your risk is, you know, if you're, you know, 1% of the time low, I guarantee that your risk factor for most is not high. Whereas if you're pretty consistently at 10%, low, even if it's not really red low, it's just that pink low, right? Because there's a different designation. There's a 55, red low, right? But I mean, if you're really low, pretty consistently, that risk factor obviously goes up. I don't know exactly what parameters they're using to establish that percentage value for you. Um, but
Scott Benner 1:13:09
Alright, so let's roll through these last three, Jamie brought up that if she waits for a diagonal Down Arrow for her credit goes lower, so it's gonna be different for everybody. Yeah. Lisa is saying hello to us from Sweden and said, we've both been very helpful in her first six months of being a type one mom. Hi, Sweden. That's cool. And Sue asks, do we recommend the in pen which I think we both though?
Unknown Speaker 1:13:29
Yes,
Scott Benner 1:13:30
yeah. If you can't pump, you can get a lot of the knowledge that a pump has from in pen pairing with their in pen app and your your glucose monitor and even a meter. Not as much luck and Jenny's holding one right there.
Jennifer Smith, CDE 1:13:42
I've got the pink. You can get them in different colors.
Scott Benner 1:13:44
Yeah, I've got blue in here somewhere. But it's a demo. So. Yeah. Okay, so listen, Jenny was only supposed to be here for an hour. It's 409. She got to go back to her life. I want to say that at one point. This was up to 120 people and it never got below 80 even 15 minutes after it was supposed to be over. So awesome. Really appreciate all you guys. Thank you so much for listening to the podcast. If you enjoy the podcast, please share it with somebody else. It's the only way it can grow. I do not have money to to do any kind of meaningful. You know, advertising for the show in the last comment here again is Jenny's email address. You can hire Jenny. She works at integrated diabetes services. You can have one on one calls just like this with her. Check it out. See if your insurance has covered it or if you want to pay cash, whatever you want to do. Jenny is very cool. She is 100% my diabetes spirit animal. I've never heard her say one thing that I was like that's wrong. But as I've mentioned on the podcast before, that might just be my narcissism because she agrees with me. I think she's terrific. But who knows exactly, you know, this will be available on the podcast soon. And it will be running on Juicebox podcast.com as well. And it stays here on Facebook. So thank you everybody very much and Hope you guys have a great day. And Jenny, I really appreciate you doing this. Thank you.
Jennifer Smith, CDE 1:15:02
Yeah, no, this was great. Thanks to everybody who commented back and forth to each other as we were answering. It's a great way to help each other. Yeah.
Scott Benner 1:15:10
Very cool. All right, guys. Wash your hands. Stay safe.
Unknown Speaker 1:15:15
I why.
Scott Benner 1:15:19
Don't forget even though this episode was not sponsored, the podcast does have sponsors like Dexcom. The Contour Next One blood glucose meter, touched by type one and Omni pod. There are links to those sponsors in the show notes of this episode, and at Juicebox podcast.com. If you're not looking for those types of things, go into your podcast app and leave a glowing review of the podcast. It would make my day and Jenny would smile about it too. Alright, let's turn off the music and we'll dance our way out of this
This is a bonus episode and was not sponsored. That said, these are the show sponsors.
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About Jenny Smith
Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com
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#327 Dr. DeSalvo has T1D
Dan DeSalvo, M.D. is a Pediatric Diabetes Endocrinologist
Dan DeSalvo, M.D. is a Pediatric Diabetes Endocrinologist at Baylor College of Medicine and a person living with type 1 diabetes. Dan shares his story and talks about how the Dexcom G6 is being used in hospitals for Covid-19 patients.
You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Alexa - Google Play/Android - iHeart Radio - Radio Public or their favorite podcast app.
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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.
Scott Benner 0:00
Hello friends welcome to Episode 327 of the Juicebox Podcast. Today's show is with Dr. Daniel disalvo. Now, Dr. disalvo is a pediatric diabetes endocrinologist at Baylor College of Medicine and Texas Children's Hospital. He also has type one diabetes himself. Now, you know me, Dan came on the show to talk about how decks coms were being used in hospitals during the current coronavirus. But then I started talking to him. And I think we got to that part eventually, just I enjoyed Dan's conversation. So we didn't, you know, I don't make a bullet list and be like, talk about this, then this then this. I don't know how to do that. If you want that, go to another podcast, which I'm betting will be boring. Anyway, this one is interesting and fun. And you'll still learn about how Dexcom is used during the current Corona crisis in hospitals. So you know, all the information gets out. But you're not put to sleep by a boring host and stagnant questions that have been written down on a piece of paper. This episode of The Juicebox Podcast is sponsored by the Contour Next One blood glucose meter by touched by type one Dexcom and Omni pod. Now you can go to Contour Next one.com right now to find out if you're eligible for an absolutely free meter. Why would you want to do that? Well, one reason is, it's absolutely the most reliable and accurate meter that I've used in well over a decade. So that's a pretty good reason to check into it. I'm also going to ask you to check out touched by type one.org. In these trying times, organizations that are doing good work for people, they need your help. So check out touch by type one.org. And of course, you can get a free no obligation demo of the Omni pod tubeless insulin pump at my Omni pod.com forward slash juice box. And to check out the people who put these continuous glucose monitors in the hands of the people helping those who are suffering from COVID-19. Check out dexcom.com forward slash juice box.
Podcast something here. But first, let me remind you that nothing you'll hear today 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 or becoming bold with insulin. I'm going to read to you now from Dan's professional statement. It says Dr. disalvo joined the faculty in pediatric diabetes and endocrinology at Baylor College of Medicine Texas Children's Hospital in July of 2015. Previously, he was a postdoctoral fellow at Stanford University, where he was an active researcher in diabetes device technology, including closed loop artificial pancreas systems. His overarching goal is to provide compassionate and comprehensive treatment to children entrusted to his care, and to advance the field through clinical research. It says some more here, but what I'm going to tell you is as a serious guy who knows how to have a good time while he's given an interview. And now, Dr. disalvo.
Dan DeSalvo, M.D 3:35
My name is Dan DeSalvo. I'm a pediatric endocrinologist at Texas Children's Hospital and I'm on faculty at Baylor College of Medicine. And I have been pediatric endocrinologist for I guess about seven years now. And my inspiration started when I was 19 years old as a sophomore at Baylor University in Waco, Texas. When I was diagnosed with Type One Diabetes, it was through that personal journey, and his desire to help others that I sort of had this epiphany about halfway through my sophomore year, where I realized I wanted to become a doctor for kids with diabetes, not realizing the journey that would lie ahead. I switched over to pre med and never look back. And here we are 20 years later after my diabetes diagnosis. And now I have the incredible joy and privilege of being a pediatric endocrinologist where I can walk with and Shepherd families on a diabetes journey. And I feel like I learned as much from them as they probably do for me. And you know, I'm really glad to talk to you Scott because a lot of my patients actually listen to your podcasts, read your blogs, and I've really found a lot of inspiration, hope, practical kind of tips and tricks, and also community so thank you for the work that you're doing.
Scott Benner 4:49
diagnosed in college. What were you thinking of majoring in before you made the switch?
Dan DeSalvo, M.D 4:56
So I was actually a political science major and I was thinking that I Maybe he wanted to go to law school, didn't know exactly what I wanted to do. And really, it was through my my diabetes diagnosis that sort of led to this, as I called it an epiphany. My best friend, or one of my best friends growing up was Eric paslay, who I think has been on your show before. So Eric paslay is a country music singer now. But growing up, he was just a good friend of mine who had type one diabetes. And so I learned a little bit about diabetes from Eric, and, but really had no idea that that would be what I would want to do with my own life until my my personal diagnosis, it's kind of a funny side story is that I had, I had for a moment, I thought maybe I wanted to go into medicine. And when I was a senior in high school, there was an internship where I spent about a week in a pediatricians office. And at the end of the week, I decided, you know what, medicine is just not for me. But, but I'm happy to say that, you know, through my personal journey, I've decided to go on this path. And I cannot be more grateful for the opportunities that has provided me in terms of being able to edify my own knowledge, but mostly just be able to, through my clinical practice, pass it on to others, and also, as a clinical researcher, helped to really advance the field of diabetes.
Scott Benner 6:16
Before I asked my my big question, was type one. A surprise? Like, were there people in your family who had it? Or did it come out of nowhere?
Dan DeSalvo, M.D 6:27
Scott, it was a total surprise. I, you know, I was that kid who never miss a day of school, always won the awards for for attendance, no family history of type one that we're aware of, in my family, some type two. But no family should type one. And yeah, I bet the summer after my freshman year of college, I went on a medical mission trip to Africa actually was just a mission trip, not a medical mission trip on a mission trip to Africa. And on the tail end of that got really sick. And when I came back was just continuing to lose weight, had to excessive thirst and urination, this similar story to so many have the diagnosis of diabetes, but was kind of in denial. And finally, it was my roommate, who was a really light sleeper, who every time I woke up was waking up. And finally I said, Dan, I don't know what's going on. But you've got to go find out what's going on, you know, what's wrong with you. So I went to the Student Health Center at Baylor was diagnosed with diabetes, and spend a couple of days kind of learning how to manage diabetes had a sister who was in college, about two hours up the road in Dallas, who actually came down to Baylor where I was, and such an amazing advocate would actually come to my classes with me, because she was so worried about me, you know, having a low blood sugar, this was all brand new for us, and would help me kind of talk to my professors about this in diagnosis and what to expect. So having advocates like my sister, Sarah was was really impactful. And it wasn't long before I became my own self advocate and develop my own knowledge base. But, you know, to answer your question, this was totally out of the blue. And while initially shocking, really led to, you know, learning so much building community with other people at Kent on campus who had diabetes, and ultimately leading to this sort of career calling for me
Scott Benner 8:20
so what would you How would you describe your, your goals for patients? I mean, we talk all the time here it's interesting the threw me off a little bit by saying that you knew the podcast but you know, we talk all the time here about giving people great tools, good information, so that they can make better decisions so they don't get caught sort of in the backsliding vortex that is being confused by diabetes. And and I hear back from a lot of clinicians who are like keep talking about this please this is how we do it. You know, we share the podcasts with people but I hear back from far more people who have successes after listening go back to their doctors and then are honestly yelled at like scolded in the office, even when they show data, even when they pull out a Dexcom graph and say look, no I don't have meaningful lows. You know, I've only been under 65 2% of the time you know in this 90 day period I'm getting this a one c you know legitimately the doctors you know what I always surmise is either they don't understand or they're just scared and they've never seen anybody with a good a one c before someone make a change that quickly and and that does happen people will listen and in the span of one a one c measurement sometimes dropped their their number a point or some people too, and it scares Is that what it's happening to them? Can you can you kind of put yourself in their shoes if you see somebody with an eight nine who all of a sudden has a six nine, and they tell you I heard this on a podcast. What would that sound like to you as a doctor if somebody came in and said that
Dan DeSalvo, M.D 9:59
Yeah. So a couple of things on that, Scott, first of all, you asked about sort of my my personal mission for caring for patients. And it's really, to help empower them to live well and die with their diabetes, to really take ownership of it. And I'm not only looking for improved clinical outcomes, but also less burden of diabetes. And I think part of that is, is being really tight in the community, and having a sense of purpose. And I think that's where the diabetes online community, your blog, your podcast, has really helped inspire them. I also think it's those nuggets of truth in terms of being able to have the self initiation to manage diabetes, having the confidence and the skill set that comes with time. And I think hearing other stories, what you've done with art in with so many of the parents who brought on what so many of the young adults, living with diabetes, their stories, I think, is really helping helping to empower others. You know, I think my sense, as a, you said, at the, at the onset and a younger physician, it all kind of takes the the what how I view this, for maybe some of my really amazing experience overheard colleagues, I think were from where they stand is that the diabetes control and complication trial was published in 1992. And at that time, you know, which really was in many ways, now, the Stone Age is a diabetes, having a lower a one C was associated with a higher risk of having a severe hypoglycemic event. having a seizure or loss of consciousness passing out, right to be clear with the tools that technologies that we have now, that is no longer the case. In fact, if you look at the T Wendy exchange data, which is sort of a cross sectional look at a one sees and the US, having a lower a one C is not associated with a higher hypoglycemic risk. In fact, those with the highest day onesies have a higher risk for having severe hypo, probably, because in many ways, they're managing their diabetes in the dark, maybe they have a lot of struggles with, you know, maybe their adherence and sort of where they are in their diabetes journey, it could be from a tough place, maybe it's the social determinants of health that don't allow them to have access to technologies that others may have. But you know, what I've heard on your podcast, but I've certainly experienced in my, in my clinical practice, is that so many families who have a one sees that are dropping, dropping, at the same time having less hyperglycemia on their CGM, that's sort of the holy grail diabetes, right, there's, I think, three things. One, a lower average glucose associated with the low re one C, two more time and range, the percent of I use in the 70 to 180 range, or 70, to 140. And then three less hypoglycemia, percentage values below 70, or below 54. And that can be achieved that can be done with a dynamic approach today to diabetes, with the technologies and skill sets and the self initiation. So in my personal practice, you know, my goal is really to help help to lift up and inspire my patients and their families. And really, to be sort of, in many ways, a coach and a guide, my hope is, is that they'll reach the point where they're just as self empowered and self initiated, as you and Arden are. And I do see that with so many of my patients, and it is a journey, everybody's on a different pace of that journey. And for some, they require a little bit more guidance and coaching. But they do often reach that sort of Zen state and diabetes, where they've got it, and they've got the confidence to do it. And they reach a place where it's less burdensome. And it's just so amazing to see the kids living well and thriving as students, as athletes as musicians. without diabetes getting in the way,
Scott Benner 13:42
I honestly the feet, you know, I've been doing this now for quite some time. And what I'm seeing coming back from people is that it doesn't really matter, your level of education or social status, or any of the ways we you know, quote, unquote, measure people, everyone can figure this out. And it's not as difficult as we make it seem, or you know, as others sometimes make it seem I'm not saying that taking care of diabetes is simple. I'm just saying that there's some basic kind of tenants, if you follow them, through experience trues are you know, on earth, and all the sudden you see them, and then it doesn't matter the situation I always kind of chuckle sometimes when people are like, Hey, what are you talking about on the podcast? Would that work during a soccer game too, and I was like, it works doing everything. It's it's the idea of putting insulin where it's needed. It really is all it's about I joke all the time. If you all figure it out, I'm not gonna have a podcast anymore. It's timing and amount, put the right amount of insulin at the right place. That's it. It doesn't mean there's not much more that there's other variables. Of course, that can impact those things. But you start to experience those variables and then before you know it, when something goes wrong, you just know what to do. I don't know another way to put it like when something happens with Arden's blood Sugar, I don't stop, put my hands on my hips and start thinking, Oh, okay, well, you know, I guess so she was outside, actually, I just, I can look at that graph on that Dexcom screen, I think for a brief second about what's going on, and I know what to do next. And that just comes with repetition, you just have to get your 10,000 hours. And once you have them, it's I hate saying this, but it's kind of easy, at some point and easy, not that it's not impactful and horrible. And you know, all the other things that diabetes is, it's just your time involved in it becomes so much lesser that it's sort of just a throwaway to me like it. We don't really talk about diabetes around here that often. You know, it's just something happens. We adjust, we keep moving, we don't look back. I don't know why that can't be. Well, I'm gonna I'm gonna rephrase, I believe that can be taught to anyone. But I think it's the same thing. I think the reason the podcast works is because of the repetition, the conversations around the ideas, because it's not something you can just sit and tell somebody, you know, one time how to do and write them down a rule, which is, you know, everybody wants, you know, tell me when tell me how much that's that's not how this works. So given that, I believe you believe you believe in that, too. My thought on this end always is if I can do it here, right? Like if you've ever you've never heard me speak live somewhere. But I guarantee you, I can talk for an hour an hour and 30 minutes, and a large percentage of the people in that room will leave and their agencies will go down by a point a month. So what if I can do that? Because Doctor, Doctor it Can I call you doctor Damn. Doctor Dan, I'm almost a more like an idiot. I know college barely got through high school. Okay. If I can do this, why can those even those silver hair doctors? Why can't they like were anybody like, why is every wire? Why are there a mass of people just going with you didn't die today? And that's a good day. Like, why is that the? Why is that the bar we're trying to get over?
Dan DeSalvo, M.D 17:04
Yeah, so. So you know, one is, is I think I think you're exactly right that your life experiences and sort of learning from cause and effect is something that can really help to inform the next way you do it right. So using CGM is what I call it heuristic learning tool, meaning something where you can sort of learn from cause and effect. Yeah, so with the breakfasts that you eat, or the activity that you that you do, or the you know, your favorite meal at your favorite restaurant, once, you know God willing, we can all go back to doing that, again, you know, really paying attention to it. And and the approach that you took with your insulin, the timing, how is delivered, you know, the adjustments you make with your temp basals are the carbs that you take, before exercise, make taking mental notes of that, and the next time trying to do it just a little bit better, and eventually reach that sweet spot where you can do it really well. You know, one of the joys I have is to be able to sort of watch families as they progress through this process. And you probably remember it well from monogamous first is when she was a little one and how daunting that was and how you wonder how you can ever do this. And then you start to gain a little bit more knowledge and a little bit more skill. And you eventually reached that, that that sweet spot where you realize I've got this, and I can do this, and I can really become an expert, I think with physicians, I you know, I think there, there are so many also who are nimble, and who do change and who were here during dcct, way back in the early 90s. Were before and who really had advanced, so to where, you know, we are now with leveraging technologies and taking an emic approach to diabetes. I think the nature of medicine, though is is that there are others who may be a little bit less resistant to change. They're still practicing the way that they were trained. And I think the other thing is, is as providers, we can all have the humility to sort of learn from our patients as well, you know, maybe there's a new tip or trick that they've learned. And if we kind of step back, and learn from that, it might be something that we can help to impart to another family as well, in the case of diabetes, and so i think that i think that's just a matter of being, you know, willing to sort of change to have an open mind to really advance one's knowledge and to be able to take the learnings from others. And you know, if it makes sense to help to realize that everyone is different, to be able to help to take those special tips or tricks or pearls so that others can can use those to improve their diabetes improve their quality of life as well.
Scott Benner 19:41
Yeah, well, I I just listened. I I agree with what you're saying. I I would like to put myself out of business here right Joe quit, you know, after I put my kids through college, but I would like to put myself out of business. I would like it that one day. This is how doctors across the globe talk to people about diabetes and I've had private comment sessions with some who will say, Well, you know, there's some people who don't get it. And I'm just thinking, I always think, no, you just, there's a way to explain it to them. You know, I, I fall back to a conversation I had a long time ago on the phone with someone, someone online connected me with this young mother, and she was struggling helping her daughter. And I got on the phone with her. And I was like, Oh, I can help her. And I started talking. And it became kind of evident to me that I was speaking with someone who had to drop out of high school to have a baby. And that maybe wasn't on track to go to college to begin with. If that, that, you know, I'm trying to be kind. And, and she just wasn't the she wasn't the brightest person I'd ever spoken to in my life. And I was explaining Pre-Bolus thing to her, the way I explained it to everybody forever, and she just wasn't grasping it. And in that moment, I had this horrible kind of dire feeling like, I have to get off the phone, I can't help her, I'm going to put her in a situation where she's going to hurt this kid, and you know, blah, blah, blah. And then I stopped and I thought, how am I gonna do that? How am I gonna just tell her Oh, well, good health isn't for your daughter, and and get off the phone. And so in that moment, I made up a story about a tug of war. And I put insulin on one side of the rope and carbs and body function on the other. And I started telling a story about this tug of war. And now I sometimes get notes from people who say, Hey, I was in an office the other day, and my doctor explained Pre-Bolus thing to me. And I said, Do you listen to the Juicebox Podcast? And the doctors said, Yes. And I thought, that's just such a wonderful thing. But it's because I didn't listen, I'm not trying to give myself credit, I'm trying to say that you can't give up on people that everybody has the ability to understand this, this is, it's not that difficult to understand. You just have to find the words that they need. And I think that, you know, Jenny and I were talking the other day on the podcast, and I said that sometimes, you know, it's not that we're bad students, sometimes you're not a good teacher. And and you know, that, that should be it, and I get the rest of it, man, like, I get the office hours, and you got to get people in, you got to get them out. And there's this minimum amount of time. Like, I can't imagine that that seems like a heart to me. But I don't think this is, um, I don't think this is how we're going to end up helping people with diabetes, I, you know, 15 minutes at a time every three months, I think the conversations where it happens. And and, and I think they can get it. I think everybody can get it at some point. I just I'm very excited by the idea that you heard about the podcast, and that you've apparently listened to it. That's really cool. I appreciate that. It's made it out like that to people. It's a very, it's very encouraging. When someone sends a note and says, Hey, I went in with my agency, I showed my doctor my graph, he looked at the graph and said, quietly, they always whisper for some reason you listen to the Juicebox Podcast, it looks like you do buy your graph. Like that's weird, man. You know, they mean like I, it throws me It gives me chills, you know. But anyway, I just think that people like you being out there, I find it very encouraging. I really think this concept of talking to people, like they can understand should just be commonplace.
Dan DeSalvo, M.D 23:18
Anyway, I agree. Yeah, no, I agree with that. I mean, I one of my favorite parts about my job is I get to interact with such an amazingly diverse group of people from so many different backgrounds, cultural backgrounds, races, ethnic backgrounds, education, socio economic status. And I think you're right, and I think everybody can get it, I think it might take a different approach, and really meeting people where they are. But if we take the time, the effort, the energy to do that, then then we can get there. I mean, everyone, you know, all these parents, they love their kids, they want their kids to be healthy and safe and to thrive. And if we take the time as a team to teach them how to do that, it's helpful, I think, something that you hit the nail on the head with is, is that it can all happen in the walls of a hospital. So finding community, and whether that's online or with with a podcast, or, you know, we have a lot of different community groups at our hospital to get families together, I think there can be shared learning there that can really help with others so that, again, we can transport this knowledge and we're not just keeping it with one family, but we can really share it, among others. I think it's also helpful for the for the providers, so the diabetes care team, and it can be there as well. Because again, we learned so many tips and tricks around diabetes management around how to use which adhesive to keep the CGM on or, or the pods or you know, how they you know, whether it's Pre-Bolus seeing or managing diabetes and exercise. And we all have a lot of learning there. And again, that knowledge can be transported to the masses
Scott Benner 24:51
being agile like that is so it's incredibly important. It's just like you said if forever allowed to travel again, I'm supposed to head out west to talk to a group of doctors About how I talk to people about diabetes. And that's, that's a cool thing, because they're those are a group of people who are going to leave their ego behind, get in a room, and, you know, stupid maze gonna walk in and say, Look, here's what I've learned about how people hear this. And that's, that's very, very exciting to me. Because, you know, listen, I have friends who are doctors, and one of them told me once he put an age on it, and he said, I'll never go to a doctor over that age. He's like, because they just stop learning. And, you know, now all the sudden you're being, you know, you're being treated 25 years ago, and that's, you know, not valuable for people. And I'm like, Wow, so everything we you know, but are plenty of doctors who are older that keep up to and that's just,
Dan DeSalvo, M.D 25:48
I don't know, man. Absolutely. Yes. In fact that a lot of my mentors so people like Bruce Buckingham at Stanford, who I trained under, people like Laurie lafell, at Joslin build terrible in at Yale, who have been doing this for a long time are not only incredible mentors, but they are, you know, at the cutting edge of diabetes. And there's so many who, you know, might be might have started this journey a little bit before me, but are way advanced in their knowledge and constantly have that agility to change and are really at the cutting edge of this. And so yes, I mean, that I wanted to specifically call out a few of those who've had such an impact for me and my training and mentoring me my career. But there are so many people like that who are out there,
Scott Benner 26:34
it can't get lost if we're talking about the problem where you know, but it can't be lost in the conversation. There are plenty of people who stay behind didn't mean they learn this thing, and then they don't run forward and keep it for themselves. They stay behind to share it with somebody else. And that's how the idea. Yeah, you know,
Dan DeSalvo, M.D 26:51
yeah, and I think that that gets back to being one's advocate, as a patient as a parent, where if you have an interaction with the diabetes provider, where you don't feel like you're learning where you don't like they're supporting the, what you're doing and managing diabetes, when you know, it's working. There are others out there too. And I don't think it's always an age thing. I think it's partly just an openness, and being really adept at taking cutting edge approach to diabetes care, a dynamic approach with Pre-Bolus. Seeing and, you know, dosing based on trend arrows and leveraging technologies like CGM and closed loop systems, you know, that that's what you want to learn from, that's you want to be in your corner, so to speak. And so if you don't feel like you're getting that, then you know, there are others out there, hopefully, depending on where you live, who can can who can be of more support to you.
Scott Benner 27:47
I just want to be a cheerleader for organizations who are out in front and thinking in a modern way. And for the rest of them who through fear or whatever. The reason is that they keep good information from people, you know, Shame on them. You know, I just I don't have any time for it. Okay, yeah, we had you on for a reason. It wasn't this, although I'm really enjoying this. I wanted to talk to you a little bit. If you have type one diabetes, you need a blood glucose meter. Even if you're using the Dexcom, g six, or another CGM, you still need a reliable and accurate meter. It's easy to transport and use. And that meter for me, is the Contour Next One blood glucose meter. Now there are links right here today in your show notes, right in the podcast player, where you can go to Juicebox podcast.com, to find them. But what I'd like you to do is to go to Contour Next one.com and check out the meter. I mean, I know it's a blood glucose mate, and you're thinking what could it possibly do? Scott, you put a test trip in it, you poke your finger. I mean, they all do that. Yeah, they all do it, but some of them do it better. So right out of the gate, the Contour Next One, accuracy is insane. Top of the level, right at the top, right there, right at the pinnacle of the mountain. If you picture a mountain and up the side of the mountain, there's different blood glucose meters, in order of how great they are. Contour. Next One, right at the peak. I think you understand it's good because of my amazing description. Now, test trips offer a second chance, which means if you hit the blood and don't get it right, you can go back in, try again without ruining a test trip. It's got a great light that works at night. It's small and easy to hold on to without being so small or slippery. You don't mean that you can't handle it. I just love it. Absolutely 100% the best meter I've ever used. Contour Next one.com Check out the link at the top of the page. You might be eligible for a free meter. When you're done there, please check out touched by type one org wonderful people doing amazing work for people living with Type One Diabetes, they need to now more than ever touched by type one.org. And of course, if you'd like to check out the Dexcom g six dexcom.com forward slash juice box, and to get a free no obligation demo of the Omni pod tubeless insulin pump, go to my omnipod.com forward slash juicebox. All these links are in the show notes of your podcast player. We're at Juicebox podcast.com.
You know, I was talking to Dexcom. And they were discussing with me a little bit about how the sensors are being used during the current coronavirus crisis. And I found that idea in chanting and I wanted to know a little more about it, and they said you were the one I should talk to. So can you tell me how cgms are helping during this time?
Dan DeSalvo, M.D 30:56
Absolutely. So you know, I think the main reason why CGM why the FDA is allowing CGM to be used during this unprecedented time with the public health crisis of COVID-19 is that it came out of the need to really preserve personal protective equipment or PP, and also to reduce the frequency of staff exposure with COVID-19 positive patients. So you can imagine without CGM, if someone with diabetes who also is connecting positives, you have to have pretty frequent blood glucose checks. And every time there's a bug, because check, the staff is having to dawn TP to wear peepee to walk into the room to check a glucose, that's another that staff exposure to the person with with COVID-19. And, and furthermore, you know, of course, with with blood glucose, it's just snapshots in time of what the blood sugar is doing as well. As opposed to CGM, which really is the full, comprehensive picture also with the trends and the alerts. And so in step CGM, with this ability to have this cloud based technology, where if the person with diabetes, who asked COVID-19 is using CGM, with the Dexcom g six system, the transmitter can transmit up to 20 feet. But also, if it's on a cell phone, which Dexcom is supplying Android phones, for the user to have the patient who's hospitalized via x com share a follow feature. Those CGM data can be tracked remotely by the healthcare team so that the nurse who's no longer at the bedside, can receive an alert for low or high glucose on her phone or her hospital issued device to that that the doctors, the medical assistants, whomever are part of that care team can receive those timely alerts. And also, depending on hospital protocols, you could use CGM, in some cases to supplement or even in place of a normally scheduled blood sugar depending on where that that level is. So again, you're reducing the need for PPV, reducing the staff exposure to patients. But you also have this this real time CGM, which can aid in glucose management medical decision making. So that's where it came was really out of the need to limit PE and staff exposure with patients. But I think that there will be a lot of lessons learned on how CGM as a tool can really help with keeping one safe and healthy during hospitalization. For someone with diabetes,
Scott Benner 33:34
that's a second thing. I thought when you were saying this, the first thing is I wondered what the process was like. And, you know, I guess the the FDA had to say yes to this in a quick fashion. I guess that that is interesting. But I'll I'll bug Kevin about that when I get him on. But the idea that all of a sudden, nurses and doctors are going to get to see this technology that they maybe don't know about. And I know it's easy to think of course they do. They're doctors, they live in hospitals, you know, this is this is their life. But Arden had a cyst removed, you know, just a little cyst. This is a short surgery she had to have a number of months ago, and you know, had all the conversations in the world with the surgeon. This is what Arden wears. we'd like it to stay on her while she's in there doctor was like, Oh, yeah, sure, sure. I got yesterday. That's no problem. I get to the hospital on the day of the nurse comes in the room to prepper the prep nurses like oh, yeah, that's no problem. If the doctor said it was okay, it's fine. Well, then the nurse, the next nurse comes in the one who's going to be in the procedure. And I start you know, now at this point, I've set it to the doctor, I've set it to the prep nurse, everyone's Yes, me to death for a month about this. So I'm now I'm just talking to the third nurse and I say, Hey, you know, this is great that you guys are doing the shoes. Oh, that's not hospital protocol. We can't do that. Just like that. I was like, Wait, what? No, no, I've been talking to the doctor and I started explaining it to her, showing it to her and she's like, Yeah, it's great, but we can't use that. a nother nurse walks in the room. And I just I wish you could have seen me down I pivoted right from the one nurse to the other Other ones, like the first one wasn't there anymore. I was like, Hi. And I started explaining again thinking like, let me take another stab at making this clear to somebody. Well, that nurse says, Oh, my friend has type one diabetes. That's cool. Let me see. Oh, she has this too. Oh, yeah, yeah, we'll use this. I'll keep her phone with me. Just like that. The tiniest bit of understanding, when I made that conversation go from, oh, no, there's a hospital policy. We can't do that to no problem. Give me your daughter's phone, I'll take him to the operating room with me. And that's the understanding that this kind of technology needs throughout the medical community, because a podcast shouldn't be one of the main ways that people find out about Dexcom. Like, why that hell does that have to be the case? Do you know what I mean? Like, and by the way, don't don't get me wrong, Dan, I need my ads. Okay. But, but I, but what I'm saying here is, what I'm saying is, is that this should be something people just think of not something that they're scared of, or say I don't know about this. So this is a great, it's a great opportunity for them to see it live fire, and really help spread the word to other people with type one. Because until it's thought of like that, you're still going to run into situations where insurance companies say stupid things like you're a one sees too low for CGM, as if those two things in any way have anything to do with each other. You're going to get me upset, Dan, I want people to have Dexcom. So so that that is that is very cool. So what you're saying to me is now we're keeping we're saving equipment or saving exposure, and probably giving people I would think greater care than they were going to receive. The other way. I've seen friends in the hospital with type one it it doesn't normally go very smoothly. Well, have you ever been in the hospital and been hospitalized with your diabetes and have the experience of having to manage like that?
Dan DeSalvo, M.D 36:48
No, but you know, there was Adam brown from diatribe wrote a really, really interesting piece on this his experience in the hospital, somewhat diabetes, I've seen and you know, you're right, it's it can it can be there can be some challenges there. You know, that's one of the things that Dexcom is doing here is since Dexcom has or CGM has not been approved by the FDA for in hospital use previously only for in home use. There may be less knowledge or experience with it. So they're really doing a nice job of of providing training to those healthcare teams who will be deploying it. The other thing that hospitals are doing is looking to who are the experts, for example, diabetes educators, or maybe the the diabetologists, or their teams to help train the trainer so to speak, to help to teach and empower the the hospital staff to use these systems and also how to sort of set up and operationalize what that remote monitoring would be like. And then also, it requires a little bit of a new protocol. Right. So since in many cases, this will be the first time that CGM is being used by those care teams. What do you use for your low and high alerts? And what do you use for low and high alerts in a hospital setting may look a little bit different than it would be at home. For example, a hospital might decide that they would use a low alert of maybe 90 or 100, so that they can intervene in a little bit more timely manner, or a high alert of something more like 200 or 250. There have been some studies that have looked at sort of health outcomes as it relates to blood sugars. And actually in a hospital or especially an ICU setting, having a blood sugar that's more in the 100 to 100 to 100 range is associated with improved clinical outcomes, as opposed to running really tight like you might, when you're otherwise health and safety, health and safety in your own home. And so developing the systems and protocols is something that a soldier having to do. We've been talking for a while just as a industry about how we really need disruption in health care, right, so that we can do things a little bit more and a little bit more efficient. And I think technology forward way. And while COVID-19 has been such just a terrible tragedy for our country, the countless laws lives, lives loss, the impact it's had on our economy, how it's impacted almost every one of us personally in some way or someone we love has been so horrible. You know, one of the one of the silver linings, I think that may emerge is that we will see things like the plane these technologies and a a smarter, safer, more efficient way and move to telehealth where we can you know, instead of having families being disrupted from their their normal, you know, job or education having to do with traffic be able to do things by telephone, and diabetes, where we have cloud based CGM technology, where families can in some cases, download their pumps from home or at least provide a log of what their doses have been, actually lends itself nicely. So my hope is is that many of these lessons learned from this really horrible crisis can be used going forward too. deliver healthcare deliver medicine in a much smarter and better way for patients.
Scott Benner 40:06
It is normally in emergency times that medicine leaps forward, it's, you know, it's hard to think about, but wartime brings all kinds of revolution to medicine, because you put doctors in a situation that isn't perfect. You give them, you know, you give them less tools than they might normally have in a hospital. And all of a sudden, they've got to be MacGyver, and they figure something out. And some of that stuff ends up, you know, becoming commonplace in in practice. And I'm just, I'm excited about this, I'm, I'm imagining a nurse, getting an alarm on a CGM at 100, like you're saying, and intervening, and then watching the blood sugar bounce back up, and having that thought, like, wow, maybe I didn't need as much glucose drip as I thought I did here. And maybe next time, that'll stop them from driving some poor patients blood sugar to 250. Because, you know, because of fear, maybe you'll it'll teach the the fine tuning ideas around diabetes to them, you know, and, and then who knows where that goes from there? Like, where do they take that information? And where does it spread to next? This is the stuff to me, that's macro very, very exciting for people with diabetes. If you have no idea what's going to happen to that, that nurse in that, you know, made up situation, goes home becomes a, you know, the parent of a kid, but Type One Diabetes five years from now. And then that kid becomes a doctor like you 20 years from now, and blah, blah, blah, and where do we end up because of this? You know, I, I just I can tell you that where I am now, in my understanding of Type One Diabetes was held back by the direction I was getting from my daughter's doctor, I was seeing things. And I was having thoughts and desires about changing practice. But everything I heard on the doctor's office side, was telling me I was wrong. And I had to break out of that feeling that Oh, no, I am doing it. Right. This is just what diabetes is. I don't know man, like I'm very excited for people to not live the way some people do now in the way my daughter did for a number of years when she was first diagnosed, I just don't think there's a need for it. And I think that anything that moves us towards that is exciting. And this is particularly interesting and how it came about. Do you happen to have any numbers on how many people are actually wearing it? Who were infected with? COVID-19? Do you know?
Dan DeSalvo, M.D 42:30
I do not know how many it is. And I can tell you I've been hearing from a lot.
Dan just disappeared.
Hello, this is Dan. I'm back. Yeah, what happened? I'm wondering as zoom kicked us out, I don't know.
Scott Benner 42:44
I sang while I was waiting for you to come back, which I'll take out. Because I can't say
Dan DeSalvo, M.D 42:48
you were slacking picked up with your last question, which was in regards to how many people are using it right now? And I don't know the answer to that I can tell you from speaking with my colleagues, from all across the country, we're all eager to use this in our hospitals just because of the reasons we mentioned, in terms of being able to preserve PP to reduce staff exposure, but also to have that helpful tool for aiding diabetes management. You know, to your earlier point, one of the things that is helpful with CGM, in addition to having the comprehensive glucose stream to having the the alerts, it's having the arrows also, and in many cases, this will be the first time that some of the hospital staff will see that. So you know, I always describe glucose as being like a vector or an arrow has both a current level, but also direction. Yeah, glucose that's 150. And headed down is different from a glucose that's 150 and double arrow up change by more than three milligrams per deciliter per minute. And so to be able to kind of, you know, and in the case of daily management, you know, and leveraging those trend arrows for daily diabetes decisions is so important. And I think that that can play an important role in a hospital setting as well with managing insulin doses, or insulin drips, or IV fluids and dextrose, concentrations, and so on. So it's another one of the things I think will be born from this. This use of real time CGM during the covid 19 pandemic.
Scott Benner 44:17
That's a great point I talked about stopping the arrows I consider not just the, you know, the direction and the speed, I call it the momentum, like you have to stop the momentum of the blood sugar. And you know, you know, talking to people about I don't know about a Pre-Bolus idea. I'm like, you know, you you count your carbs, your blood sugar's 90, you put your insulin in, but you don't Pre-Bolus now all the sudden the food starts impacting your blood sugar before the insulin has a chance to before you know it, your blood sugar is 180. It's 190. It's 200. It has momentum, you only have enough insulin in there to cover the carbs if you're if you're lucky. And you know, the glycemic load of this food actually matches up with your carb ratio that's set up Right. And so now, you're staring and watching this, this number go up and up and up, you don't realize you need the insulin for the carbs you need to be, you need the insulin to stop the momentum, and you need the insulin to bring the number back, you know, you're sitting on one third of the insulin now that you need, you know, one third of the picture. And, you know, most people stare at it and stare at it, they think, Oh, I counted the carbs, right, like they're back at that point. That's not, that's not even a tiny bit of the picture. It's, I couldn't do what I do for my daughter, and what she does for herself, and what the people listening to the podcast end up doing for themselves. Without the data that comes back from the Dexcom. Like, it's just it's no bowl, you know, like I, I, there's a lot of people I could have, as advertisers on the show, there's a reason I chose the ones that are here. I was wondering about your management, do you have like, like, what are your goals day to day for yourself?
Dan DeSalvo, M.D 45:55
Yeah, you know, I think for for me, it's, you know, I live a pretty busy active life, professionally, but also as a father of two young kids. And so, certainly, for me, being able to watch my glucose and trend arrows closely is important. And, you know, I aim for pretty tight control. And so I have pretty tight thresholds on my low and high, you know, that works for me, it may not work for some of my patients, depending on where they are, and their diabetes journey. And so, you know, I pay, I pay pretty, really close attention to the trend arrows and a lot of what you're talking about in terms of, you know, stopping the glucose in its tracks, looking at the momentum of whether it ties or lows with insulin or carbohydrate, respectively. And really trying to sort of guide the glucose and, and sort of hone in on on that, that maintaining the time and range, and you guys seem strange that the range of, you know, for me, I'm aiming for 70 to 140, typically. And I also, you know, I do a bit of, you know, nutritional approach diabetes, for me as an adult works, you know, it's not, it's not necessarily advocate for my patients, but I tend not to eat breakfast on weekdays. And so I need to sort of ride my basal rate, usually, and within range glucose in the morning. And then for lunch, I usually fairly low ish carb lunch and get most of my carbs at dinner. And so I don't have to worry about blusher quite as much during the day. And then in the evening time is where I tend to have my largest meal. It's also when I exercise and so that can present some challenges with management. And so just like, the patients I care for, I'm always learning in my own diabetes on how to how to best manage it.
Scott Benner 47:39
Have you ever taken information from a patient and applied it to your own life?
Dan DeSalvo, M.D 47:44
Oh, yeah, I mean, absolutely. I mean, they're their little tips and tricks that I pick up from them that I might use my own. You know, I'll give you an example. Sort of a concrete example is with the adhesive that I use for my Dexcom you know, I run cycle and swim, I lead a pretty active life. And I have two kids who like to wrestle with me. So, you know, for a while I was having some challenges and keeping an eye out for 10 days. And, you know, some patch, this was a while ago, but some patches adhesive that's available on Amazon and other places. And it's also hypo hypoallergenic. And so that was something I was able to use to really buttress down the CGM, the sensor transmitter to prevent it from coming off. And, you know, I've really not had any trouble keeping it on for 10 days. And I usually wait until it starts to maybe on the edges start to come up just a little bit, and then apply the adhesive. Okay. And with that, it's really works well. And so that's something also for my patients who, you know, they may be athletes, or, you know, Texas, it gets really hot in the summer, people do a lot of swimming, using these sort of things can be really helpful. So that's just one of many examples I can I, you know, I can share, you know, that I've learned from from patients,
Scott Benner 49:01
I just thought you have a even interesting, you know, opportunity for yourself. Do you think that having Type One Diabetes is a benefit for you in what you do? Or does it give you an advantage? I mean, if I'm looking for an endo what I I want them to have diabetes.
Dan DeSalvo, M.D 49:22
You know, I think I think anyone can do this. And I think I think it really takes having a passion, but also having the kindness and just the the willingness to go the extra mile in terms of having the knowledge and skill set and diabetes management. I don't think you have to have diabetes to do that. I do think that living with diabetes does give you a way to really connect in a really powerful and impactful way with patients and families. And so I i do some time and I do oftentimes share that I have diabetes and and i don't really talk about how I manage my own diabetes as much But I do try to convey a message that, again, you can live well and die with your diabetes, you can become absolutely anything. You can become a professional athlete, a movie star, you can become a US Supreme Court Justice, a lawyer, a doctor, really whatever it is that you're passionate about, you know, I used to say there's only two things you can't do. One is become a commercial airline pilot. And the other is join the military. Well, the FAA has now a law now allows with a doctor's letter, the potential for someone to become a commercial airline pilot with diabetes. That was a huge win.
Yeah. And yet with Yeah, go ahead.
Scott Benner 50:39
I'm sorry to mean to cut you off. I had Owen Lieberman on the other week, and he was talking about this. And now I'm starting to see people holding their letters from the FAA. All of a sudden, in the last couple of days on social media. So it's happening, people are getting their their pilot's license back, and sometimes for the first time who have type one,
Unknown Speaker 50:57
it's super amazing.
Scott Benner 51:00
And, I mean, honestly, that's in no small part to Dexcom as well. I mean, that that's a that's a an ability for someone who doesn't understand diabetes, to be given a visual way to understand it, and then be able to make that leap like, Oh, you know, we just, you know, the government just thought people randomly get low. And that's what we were talking about earlier, doctors 20 years ago, we're telling you keep everyone see higher, you know, keep your blood sugar higher. You don't want to randomly get low. And now there's, there's real concrete ways to stop that. Listen, last night. Last night at 1130 Arden's blood sugar started to trend down. And I couldn't figure out why. So we're talking and I was like, hey, it's holding, but it's like it's at 70. And I'm like, if you look at the line, I don't think it's going to, I don't think it's going to hold up for us. So we started taking bazel away to see if we could get it to rise and it wouldn't rise. So we're talking, I'm trying to find out what's going on, she see she pulls out her period tracker, and there are days prior to her period where her blood sugar, just that she just doesn't require that much insulin. And so this is where we're at, right? So from 1130, last night, no light or three in the morning, I kept Arden's blood sugar up using the dexcom. And without it, I can't tell you how low I think she would have gotten because I was able to, with confidence, take away the basal insulin in a way that held her up in the 60s, which is, by the way, the best we could do for a couple of hours, even with food intervention and everything else. I'm just trying to imagine if we were blind there, I would just see a low number I would treat her and then that, you know, I think oh, it's gonna come back up again. But for for four hours last night Arden's blood sugar just didn't want to come up. And I had the comfort of knowing that that was true and being able to manage her through it. And, you know, eventually, obviously, it started to move again. And then we were able to re add the insulin and bolus with confidence. After four and a half hours of not eating any insulin, I was able to look at a trend and say, whatever that was, is over now. And you need your insulin again. And so because we were able to bolster confidence, she didn't get high, you know, all the sudden when her body had different needs. And she had a, you know, a reasonable period of time where she didn't have very much basal insulin. It's just It's magical man. Like, it just is, you know, so?
Dan DeSalvo, M.D 53:25
I don't know I love Yeah, I think it's essential. I mean, yeah, for people who have busy professional lives, no matter what it is having that real time data on your phone or on your wrist. And I only know where you are, but where you're headed, so that you can actually, you know, as Wayne Gretzky said, it's not enough to know where the puck is, you got to know where it's headed. And really think 123 steps ahead. I think that that is absolutely essential for being able to do all the things we do to have that that information that helpful data, you know,
Scott Benner 53:55
the genesis of that story was Wayne Gretzky.
Dan DeSalvo, M.D 53:59
His father was something he was his dad, right? I don't remember the exact details.
Scott Benner 54:03
His dad was teach him to play. And he always seemed like he was behind the game. And he told his son, you got to skate where you got to skate where the puck is going, not where it is.
Dan DeSalvo, M.D 54:12
And it's just an analogy.
Yep. So So, you know, perfect for diabetes management, right?
Scott Benner 54:21
I tell people all the time, the insulin you're using right now is for later, it's never it's never for now, nothing you're doing with your diabetes. In this moment is for right now. It's always for later and more importantly, and it's a weird distinction that might seem like it's not a distinction, but it is if you really think about it, it's not so much the insulin you're using now is for later it's the insulin you used in the past is for now, and I know that seems like the same thing. But if you really kind of like really go into a Wavy Gravy plays and think about it for a minute then it's um, it's different. It's, it's more about it's about controlling the energy of the inside the power of insulin that's coming at you. It's about it's about being in It's, I know, I don't know, maybe you'll have to wrap your head around it. And other people will too when they're listening, but it's not so much about now for later, it's about before for now. And if you can wrap your head around them, this is kind of easy, you know? Anyway, Oh, dude, I'm really thrilled you did this, I didn't expect to have such a great conversation with you. I thought we were going to just be like, Hey, COVID-19 Dexcom That's cool. And then you'd be gone. But uh, but this turned into an excellent episode. And I'm really excited that we did this. I might have to ask you to come back on again sometime, and maybe talk more about your personal story, if that's something you might be interested in?
Dan DeSalvo, M.D 55:37
Absolutely, I'd be more than happy to. And Scott, thanks again for the work that you're doing to advance the cause that people living on thriving with diabetes for the community built and for getting this message out there. You know, again, it's it's so I think important for using real time CGM in this area of COVID-19. And I think that there will be many lessons learned from this, both in the hospital setting as well as with telehealth that will be propelled forward as we one day reenter normal life. It's hard to imagine that right now but we'll all be there and so my thoughts and prayers for everybody out there and hope you and your family stay safe well, and I'm adding sane to that list because it can be mind numbing sometimes to be stuck at home, but you know, my my best wishes for for all your listeners as well.
Scott Benner 56:23
I really appreciate that. Then, you know, we last weekend ended up I staked my entire family and we played poker. I played poker to get my own money, just to just to try to pass the time. I said to my kids, I'm like, Here's 25 for you. 25 I gave my wife $25 I took $25 like Alright, this pots worth 100 bucks. We played for seven and a half hours.
Unknown Speaker 56:45
No one wanted to give the money away.
Dan DeSalvo, M.D 56:48
Yes, we need distractions these days. Absolutely. I saw
Scott Benner 56:52
a woman online say that she spent four hours yesterday watching a truck get towed out of some mud. She said it's the most exciting thing that's happened to her. So Alright, man, wash your hands stay safe as well. I really appreciate this. Huge thanks to Dr. Sabo for coming on the podcast and sharing his story and telling us more about how the Dexcom g six is being used in hospitals to aid with the Coronavirus fight. Huge thanks also to the Contour Next One blood glucose meter for sponsoring this episode. Don't forget also, sponsors like touched by type one.org Dexcom and Omni pod. They make the podcast possible. So check them out, use the links support the show. I'm still here. I'm so bored. I don't know what to do. I mean, once I finish this, I'm just gonna go downstairs and like clean something or make something or put something away. All my options. Here's my here's my day. I sleep and then I wake up and take a shower and work on the podcast. cook something clean something. cook something clean something. Take out the recycling. cook something clean something. Watch Ozark and go to bed. That's it. It's the whole thing. It's my life. It's your life. It's our lives, but not for much longer. Hang in there people. Stay strong. Wash your hands. Cover your cough. You know what I'm saying? Don't be disgusting. Say
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#326 Medtronic 670G Insulin Pump
Jenny Smith RD, LD, CDE & T1D talks about her time using the Medtronic 670G
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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.
Scott Benner 0:00
Hello everyone and welcome to Episode 326 of the Juicebox Podcast. Today's show is sponsored by the Omni pod tubeless insulin pump, and the Dexcom g six continuous glucose monitor, you can check out dexcom@dexcom.com forward slash juice box and find out everything you want to know about the Omni pod, including how to get a free no obligation demo of the pump sent directly to your home at my Omni pod.com forward slash juice box.
You know the podcast is about a lot of different things surrounding type one diabetes. And very often we talk about management. When we do we kind of speak about it on a macro and a micro level right? You know, the idea of using a Temp Basal increase or decrease for instance, that works with every insulin pump. But when you hear me speak specifically about a pump, most of the time, you'll hear me talk about Omni pod, because that's what my daughter has been using for 14 years. Same with CGM, my daughter's had an Dexcom. Since I don't even remember what the first one was called, but a really long time. So when I talk about CGM, you might hear me talk about it macro how to use the data to make good decisions or micro how Dexcom works. But we've never been able to talk about the Medtronic 670 g in a micro way, because I've never used it. So what I did was, I brought Jenny Smith on, because Jenny's worn the 670 G and she trains people on how to use it. So this is Jenny's experience. 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 are becoming bold with insulin. Of course, you know Jenny Smith from the diabetes pro tip episodes here on the Juicebox Podcast or defining diabetes episodes. We do ask Scott and Jenny together as a matter of fact, this Thursday, there'll be a live ask Scott and Jenny on my Facebook page, that's going to be Thursday the 23rd. He says because he's not 100% sure what today's date is, I'll look for you hold on Thursday, the 23rd at 3pm. Eastern Time on the bold with insulin Facebook page, Jenny and I will be doing a live hour of ask Scott and Jenny. Jenny is a certified diabetes educator. She's had Type One Diabetes for well over 30 years, she works at integrated diabetes. And Jenny is adept at walking people through using different pumps and cgms. And enough of you have asked about 670 G. And I thought well, let me get Jenny on. And we'll find out what her experience was, while she was wearing it. I would like to talk about and do an overview of how it works and how to use it. And what's good about it. What's bad about it about the Medtronic 670 g Ah, so this is not meant to, but start off like this. I think we all know that Jenny doesn't love the 670 G. Like she doesn't hate it. But when you talk about it, there's not loving your voice is what I'm saying. And and but there are plenty of people using it. And they should know how to use it as best as possible. And that's sort of what my goal is for this. I started off by familiarizing myself with the system a little bit online. And I was surprised to see immediately it's going to sound like I'm I'm not a fan. But I don't mean this in any judgmental way other than, you know, ardent users. And on the pod, I open up a little plastic thing. There's a pod inside of it. And that's the entirety of what we use, right. So I'm looking at this and there's a pump itself. There's a reservoir, glucose monitor and infusion set inserting device, there's an infusion set, and I was like, wow, that seems like a lot of stuff. But I get it like you know, it's it's a different situation, a different setup and everything. So anyway, so those are the pieces. There's the pump, the reservoir, the CGM, which is a proprietary Medtronic CGM. Correct?
Jennifer Smith, CDE 4:24
Yep. Got Now today's it's called the guardian. It used to be if you're still using it, you could potentially maybe still have the enlight and the old old one, I think it was called the soft sensor. Okay. So they've had quite a number of up updates. Um, yes. So current is guardian. That is,
Scott Benner 4:46
that is the exact lack of love I was talking about. So then there's the infusion set for people who aren't pumping or using an omni pod is a it's an adhesive thing with a plastic thing on top that Yep, you know, it's like a port. I guess the goes to a piece of tubing, the tubing goes to the insulin pump and you can disconnect that. That set right like to take it you have
Jennifer Smith, CDE 5:07
to take a shower to get in the pool to do all of those things. There's also a little piece that whether most people use it or not, there is a little extra piece that you pop into the infusion site, once you disconnect from the tubing that's supposed to and you you pop it, it's almost like a cap. Yeah, it's you're supposed to technically put it in, in order to prevent extra things from you know, getting in there.
Scott Benner 5:33
So when I disconnect that cap, I'm supposed to cap this like,
Jennifer Smith, CDE 5:36
okay, yes, you're supposed to cap it. Yes.
Scott Benner 5:39
So those are the pieces. And then there's the I'm sorry, the insertion. So it's sort of it to me, it looks like it's maybe palm size, sort of like a cup, I guess you set it on your skin and press on it or squeeze a button or something. Yeah,
Jennifer Smith, CDE 5:51
that would be for one of their one of their infusion sets. In all the pump. companies that have tube pumps have different types of sets dependent on you know, your body type. And what works well for you the one that you're talking about, it usually works with their, it's called the Quick Set, you kind of it comes with this little like, almost looks like a little pod, sort of like a like an alien UFO, almost as what I call, okay, and you open it up and you pull, there's like a little like a lever inside that you sort of pull back and you caulk it essentially. And then when you squeeze the buttons on the side, it pops the infusion set or the in the Yeah, the infusion set underneath your skin. There are other ones like the silhouette, which is more, it's an angle that's not 90 degrees, like the Quick Set. The Neo is another one, that's a 90 degree that they have. And the silhouette is an angled one that does come with an inserter I would say a good a good 75% of people, though, who are using the silhouette are self inserting, they're just pushing that infusion set underneath their skin. They're not actually using the insertion device. I myself when I when I was using Medtronic, I had tried using the silhouette and I wasn't using the inserter I was just doing it myself.
Scott Benner 7:14
So you just Fried my brain a little bit as a person who's never used the tube pump. So you're telling me at some point, there was an infusion set, and it still exists now that I press into my body, like metal with the covering canula on it. Yeah. And that's how it's meant to be used.
Jennifer Smith, CDE 7:33
It is so in two ways that that set in and of itself is it comes with an inserter the inserter. In fact, I think as a visual for people who can't see us talking, the insertion device looks much like the old g five inserter for the sensor. That's what it looks like. It's like it's almost like a thick pen. The infusion set goes into the end of it right. And then the button on the end, you press and it pushes the infusion set under your skin. The big thing with it is that you really it's meant to go in at a certain angle under the skin. And you know, with that device, it's like a very fine rocking of your own hand to keep it at a 45 degree angle. Okay, so you could technically insert it too shallow. Or you could insert it too deep. Not the way that the infusion set is technically supposed to be inserted. I myself found that the inserter did not work well for me. Okay, so I, even my husband, he was like, What are you doing? Now? I'm like, I'm putting my infusion set in. He's like, that's a really big needle. Thank you very much. I'm quite aware of that. So yes, it's a selfie. And it does. I mean, for people who are using it, they get used to it. I can say it's not my favorite thing to do. And of all the set. My favorite set of all, even compared to Omni pod, which you don't get a choice in a sec, right is just what it is. It's built in. I've never had any problems with Omni pod set, thankfully. But my favorite for any tube pump is the one that's called it's a steel canula so it's almost like a thumbtack that sits under the
Scott Benner 9:25
skin. Okay. And you Why do you like it? I like
Jennifer Smith, CDE 9:28
it because it goes in at a 90 degree angle. I had so many problems with kinked bent, problematic tubes that were the typical like Teflon type of canula under the skin. I never I've never in my almost 15 years of using Omni pod now, I have had maybe two kinked sites, maybe two with the two pumps, however, I have had my supply of way more than I've ever wanted. So the nice thing about the steel canula for Medtronic, it's called the shorty for if you're a tandem user, it would be called the true steel. So they both make a completely steel canula pops under the skin like a thumbtack popping into a cork board. There is no hassle to using it, it stays in place. No kinking at all. There's a lot less site irritation for many people with it. There are a lot less site infections with using it. Um, so yeah,
Scott Benner 10:40
I can say that. I know Arden has had one. One Candela problem in the entire time she's used on the pot and I was doing the math on it the other day. She started when she was four, she's gonna be 16 so Wow, it's been wearing
Jennifer Smith, CDE 10:54
almost as long as me
Scott Benner 10:56
Yeah. Arden's been wearing an army pod for 12 years every day. You know? And so we and we've had one and when I look back on it, it happened like it was a pump we put on like at a pool side. And I remember it all being a little like, like I want to get back in the pool. Like you know, like it wasn't
Jennifer Smith, CDE 11:14
like Quick, quick, quick, quick.
Scott Benner 11:16
wasn't, it wasn't it wasn't being done maybe exactly right. But you know, it was obvious the CGM made it obvious that it wasn't working. So right. Actually, it was funny. The CGM made it obvious it wasn't working after we got our away from the pool. It actually turned out that, you know, I think her exercise had kept her blood sugar down for the for the couple of hours away from the pool, then all of a sudden, you could tell, hey, this thing's not working. Right. So anyway, okay. Now, that seems like a lot to me. I'm not here. I'm not here to critique the, I really want everyone to understand it. It's tough, because there's the side of me that feels like um, I don't know, I A lot of what you just said, I think, Wow, a lot of that doesn't seem necessary, but okay,
Jennifer Smith, CDE 12:02
you know, well, and I can say to from, from just giving credit as well, of all the pumps on the system on the, you know, on the market today of which there are only three brands that are out there right now FDA approved, with Abi mipad is the easiest by far. So if you're going to rate them in ease of like, filling using even a canula and a reservoir, Omni pod is the easiest. Medtronic honestly is the second easiest, okay? As cumbersome as it looked to you having never really done it yourself or needing to, it's actually the second second easiest tandems is it's a weird system. I mean, and I say that from the standpoint, it just has a lot more steps in the filling of the reservoir, the filling of the tubing, and every it just takes longer. Yeah. So, um, there's some credit to Medtronic there.
Scott Benner 12:57
Hey, Medtronic, you're not as bad as the tandem when it comes to use. Congratulations. Put that on a box,
Jennifer Smith, CDE 13:03
reservoir and filling.
Scott Benner 13:06
Excuse me, specifically reservoir and filling use that. Wouldn't that be a tagline? Medtronic, we're not as bad as control IQ for filling the reservoir. This is getting out of hand already. I'm sorry, Medtronic. users don't leave. We're gonna get to the good stuff.
Unknown Speaker 13:20
Yeah, yeah.
Scott Benner 13:21
I do. I would, I would be remiss to say that, to not say that I could change it on the pod in about 45 seconds. Like it really doesn't take any time at all. I am. Jenny has a pump changing story that she won't let she won't tell on the podcast. But apparently, you can do it almost anywhere. She's like, I shouldn't tell people that I've done that. I'm like, Okay, well, sorry. You keep that private then. Anyway, Alright, so what the goal of this system and this was, and I I do say this all the time. This was the first like, closed loop system out the door, right? Like, this is the first one that got, you know, FDA approved. Yep. And, and on the market. So points for being first because, you know, just like in the military, or firefighting or anywhere else, stuff first guy through the door doesn't usually end up so good. So. So the point here is, is that, you know, this was early on, how long has this thing been available now?
Jennifer Smith, CDE 14:25
Oh, gosh, um, I even I'd have to check online exactly when
Scott Benner 14:30
it's gonna be a number of years now. Right?
Jennifer Smith, CDE 14:33
Correct. It has been a number of years, I would have to look exactly, but I feel like, gosh, it's got to be at least three. At least two, if not three years, because I'm trying to remember when I did my 670 training, and I feel like it was very soon after my three year old was born. Okay. So that would be about at least three years, I would say,
Scott Benner 15:03
Okay, let's call it. So first things. First. It's a it's a system that's making decisions about insulin on and off, right? does it increase? bazel? It does, it does. Okay. So
Jennifer Smith, CDE 15:15
from Yeah, from that like, kind of like hybrid closed loop system? Yes, it does that, as your glucose changes, it will temporarily increase or do these incremental adjustments up in insulin delivery, as your blood sugar changes and drops, it also does an incremental adjustment down. It also will temporarily suspend based on, you know, where glucose is going to get to it will do a suspend for you. It does not, it does not do, like an automatic Bolus, Bolus Bolus kind of thing. Um, it's it's bolusing. structure is truly around food.
Scott Benner 16:03
Okay. And that's still on you to tell it how much you're eating and all that stuff.
Jennifer Smith, CDE 16:10
It is in fact, that's the only, that's the only setting in the two modes of use of the 670. Pump, which you can use in manual mode, which is just like your normal conventional pump, use all the features all the settings everything you have set work as they normally would, you're the controller in auto mode, when you slip that on, then the only setting that is used for true calculation or exact calculation from a math standpoint, that the user can figure out his carbs, their carb, the insulin ratio stays true to what is set in the pump. So if you have set a one to 14 ratio, the pump is going to use that along with the glucose value to suggest a bolus for that food.
Scott Benner 17:04
Okay, can you adjust the bolus? Can you say, Oh, I would like this to be No you can't. Okay. So in a situation where, you know, you know, like, say the glycemic load of food is going to hit you heavier than the carb count. What do you do then?
Jennifer Smith, CDE 17:21
So that's the there are no longer temporary Basil's there is no longer in extended bolus. And on Medtronic pump, their extended bolus is referred to as either a square wave or a dual wave, right. None of those features are now available once you are in auto mode. So you're right. The hard thing is that for a meal, such as and we've talked about it so many times, but like pizza, right, right. I mean, a lot of people are not going to get the hefty management in the afternoon. And in the aftermath, for fat that they've been used to getting, when they're using maybe an extended bolus for fat or a temporary bazel to offset the later impact of fat, that feature isn't there. As an option with the auto mode, now, as glucose does start to change, you will get those microscopic adjustments in insulin dosing off to accommodate for the change that is happening. But it's not going to be like your very robust, temporary bazel of 60 plus percent above your normal in order to
Scott Benner 18:38
take care of experimental and smaller,
Jennifer Smith, CDE 18:40
correct and correction boluses it's another place to kind of bring in correction boluses are there they're very difficult to navigate within auto mode, okay? Because the system is it's more conservative, right? its target that it's aiming for is 120. And it doesn't really start to adjust or aggressively navigate blood sugars until you're higher,
Scott Benner 19:07
what is higher mean?
Jennifer Smith, CDE 19:09
Right, like the 161 80 range
Scott Benner 19:12
that it starts to crank on the bass or
Jennifer Smith, CDE 19:14
and then it starts to crank based on the trend and you know, it is referring to the trend and glucose that's happening, right. But overall, you're not getting an aggressive enough nature to assist so you know, many people are many people are learning when to potentially shift out of auto mode when to potentially shift back into manual mode or a you know, back into auto mode. So there are some tricks and or tips to using the system to your advantage
Scott Benner 19:51
right I think we'll be talking about that. So I just I I'm trying to understand just one more thing. So yeah, take some when I put a bunch of insulin in For something, right? I don't know how it's going to know. Is there a way to tell it? Hey, this is pizza, it's not really going to hit me for an hour. You can't You can't tell it timelines of food or absorption rates or anything like that. Okay, so this thing throws in, I say I'm gonna eat two slices of pizza. I tell it, it's 60 carbs. It throws all the insulin in, does it then work with the bolus? Meaning does it take the bazel away to let the bolus work? Or is this the basal still stay? in play?
Jennifer Smith, CDE 20:34
kind of depends on what the shift in glucose? Is situation? What's happening? Yeah,
Scott Benner 20:40
so we could so it could take away the bazel. If it thinks you're gonna get low, and then let the bolus try to work. But then that doesn't feel
Jennifer Smith, CDE 20:49
right. Yeah. And yeah, and it does it along with, as I said before, the only true setting that's sort of carried over from your normal setting mode is the insulin to carb ratio, and then it also utilizes the active insulin time that you have set as well. Okay, so that's a piece of, you know, how long should this insulin really be working? If you've got it set for two hours? Well, then the pump is going to think that two hours from now you're clear of any active bolus insulin. So it may allow you to take some correction within the automatic mode. But yeah, it doesn't use your current basal rates, it doesn't use your current sensitivity or correction factor. Again, it targets a blood sugar of 120.
Scott Benner 21:37
So you just said if the action time is short enough, then you know, say two hours than two hours later, you'd be eligible to make a correction bolus,
Jennifer Smith, CDE 21:46
then potentially depending and it'll only suggest correction boluses if your blood sugar is above 150.
Scott Benner 21:53
Okay, so I can't decide. I'm 130. I want this to stop, I'm gonna give myself some it's, I have to be over 150 40 even allow that. Yes, but I could go out of auto mode, and then do whatever I want, then it's just it's all
Jennifer Smith, CDE 22:10
good, then it's just an insulin pump like you're normally using. Yes.
Scott Benner 22:14
But I just thought the problem with that is that it's been making decisions about insulin based on what it thinks is going to happen. And then I come in and make different changes. How do I get back into auto mode without a problem? I don't know about you. But here we are five weeks into our social isolation. I don't think I've been out of my house more than a few times, except the wander around in my yard. And it's starting to get a little weird. It's starting to be difficult to care about things. I don't know how I mean that exactly. Let me let me think it through for a second. I didn't comb my hair yesterday. And I didn't care. And I went outside and my neighbor saw me and my hair was sticking in 16 different directions. I just thought, whatever. I'm worried though, that that attitude is gonna bleed into other parts of my life. And I'm worried that it might for you as well. For instance, were you just about to find out more about ways that make yourself healthier right before all this happened. And now you just feel like you're on pause, just waiting for the world to pick back up again. Well, I know that's true for some things, but it's not for everything. For example, right now, with very little effort, you could get on the pod to send you a no obligation free demo of the on the pod right to your house. It's amazing Miami pod.com forward slash juice box. You go there you fill out your information, and a box will arrive at your home with your Omni pod. Now you'll probably like you know, it'll be on the front step and you'll be shooting it with Lysol and stuff like that. But after you do that, inside, you're going to find an omni pod. And it's all for you to wear to try to test to shower when you can find out how the Omni pod looks on you while you don't comb your hair. For a while you're sitting in a chair, staring off into space. Once you understand how that's gonna work, you'll be ready to wear your Omni pod as you launch yourself back into the world with your new insulin pump, ready to make these kinds of adjustments that you hear us talking about all the time on the podcast. Temp Basal increases, decreases. Extended boluses not having to disconnect your pump for a shower, being able to set up bazel programs which sounds really difficult but isn't but just think of it this way. If you're on MDI and you get low overnight, but not during the day and you think I don't know if I take away my insulin, my basal insulin, so I don't get low overnight. I'll get high during the day but on the on the pod you don't have to worry about that. You could set up one bazel program for the daytime and One for the night time. on time, you need more insulin. And one time you need less. You can keep that pump on while you're showering, swimming, walking around in your backyard, trying to remember what it was like to go to the movies. And then, you know, once everything's back to normal, all the other things that your life is Miami pod.com, forward slash juicebox, get a demo pod sent to you today, you're not doing anything else anyway, please don't put your health on pause. Now, when you get done with that, here's the next step dexcom.com. forward slash juice box. Find out today, why I love the dexcom g six continuous glucose monitor. So very, very much. The information that comes back from the dexcom is not just to keep you safe, it's to keep you healthy, it's to keep you ahead of the curve, that is your blood sugar, you can stop the blood sugar curve a lot easier than you can flatten other curves. By just Pre-Bolus Singh a little bit more understanding where you need more or less insulin, or how some meals impact you differently than others. You can get all of that, and so much more@dexcom.com forward slash juice box. Examples are from my daughter's life with Type One Diabetes, your results may vary links available at Juicebox podcast.com. And right there in the player of your podcast that their show notes look around, you can just touch on it, boom, you'll be right there. At the link you want. It's magical. How do I get back into auto mode without a problem?
Jennifer Smith, CDE 26:35
Yeah, it's a and that is the that is the difference. Sometimes it is just a button push right, it's a turn the auto mode back on. So it seems as though it would be an easy like fix. But when you go back into auto mode, it's then looking at the sensor data for like an accuracy. And then it's evaluating. And it may require some additional information it may ask you to calibrate, it may ask you to add a glucose, which isn't really a calibration, all it's doing is requiring a glucose value to be added. Which kind of goes into a lot of the alarms and things that people get annoyed with within the system. Because it just needs to see that glucose value and reevaluate where things are at this point. So you may get going back into auto mode, some of those some of those alerts and alarms, before it starts doing things. And then they're also limit, you know, to how much in auto mode, the basal insulin will be allowed to increase. And it does, it's interesting, because it does vary sort of person to person. Um, it's about from what we can kind of tell it's about like, two to two and a half times your average izle rate, excuse me, is what it'll allow, as far as an increase in the bazel adjustment that it's giving. And again, remembering that any temporary bazel increase isn't really like a bolus to correct. So if you're seeing a trend that's going up, and you're waiting for the system to kind of kick in, that temporary adjustment is also going to take time to start affecting that blood sugar. So it's like, it doesn't really adjust quick enough. And it's only a portion of how much you would put in if you were making a bolus in that situation. Right. So not only is it a fraction of what you need, but it's going in is bazel. And probably taking up to an hour for to actually be an impact potentially impactful. Exactly. And you're
Scott Benner 29:00
130 is gonna make it 200 by the time it's there. And it's not going to be enough by the time it's there to begin with. Right. Okay.
Jennifer Smith, CDE 29:07
And then and then on the opposite end to you know, if you're looking at like lower blood sugars. And this is true, even in conventional pumps, if you're low, now you need to treat the low, right, you don't expect that a temporary bazel adjustment or even one that's being augmented by an automatic system like this. If you're low, you have to fix it, you can't expect that a temporary adjustment down is going to offset where you are now my blood sugar's 50, it's 50 a bazel off isn't going to turn a 50 into 100 and any kind of reasonable amount of time right now if I ever if I ever right.
Scott Benner 29:41
So when I correct that 50 do I tell it that I did that? Do I tell it carbs? Because I find that to be an interesting problem because they're such quick acting carbs. You know that, you know, within reason if you're if you're you know if you're if you're reasonably good at correcting You're gonna take in enough fast acting carbs to get your 50 back to 80 or 90 or 100. Hopefully, you don't want any insulin for that, because it's that little, that little bumps not going to send you to the moon. So you don't want all of a sudden, I've just taken in 10 carbs, because will it then when you get to 90 start bazeley at the carbs. You're I mean,
Jennifer Smith, CDE 30:23
it's basically not based on any of the carb information it's giving you in fact, if you entered carbs, if it didn't, if it didn't think that you needed a bolus based on where you are, it would offer a bolus, but it's only really, it's not intuitively looking at that carb stamp and saying now I need to change the dosing because there are carbs in the picture. It's only looking at the change in glucose. So if
Scott Benner 30:47
that if that fast acting carbs did cause a rise, then it would start affecting it but not based on the carbs, it would be based on the the sensor data
Jennifer Smith, CDE 30:56
based on the sensor data. And again, based on where does the glucose start to be adjusted by the auto mode system, it has to be a certain height in order for it, or a certain like trajectory towards a high number, that it would start to offset things.
Scott Benner 31:13
What is that number? Where does it start to? Correct? You know,
Jennifer Smith, CDE 31:17
I'm trying to remember whether it's, um, I haven't used the system like personally in a while. And I have to think and I'd have to look that up, actually, and see if I can find that because I can't remember the exact number that it starts to correct. Like, at or above. I do know that you know, if for corrections, as we were kind of just chatting about to some, some users might already be thinking, well, gosh, I just I just enter some extra carbs when I'm high even though I'm not going to eat them. And so it generates the Bolus for me.
Scott Benner 31:54
Okay, so they're
Jennifer Smith, CDE 31:55
doing and a lot of people are calling that like, like ghost carbs, carbs that you aren't eating, but you're just putting them in because, hey, I know if I enter 20 grams of carb, I can get that one unit Bolus that I really need because my blood sugar is higher than it want it to be. But the system isn't offering anything outside of this. So I'm going to enter it in the problem is that it can offset data analysis then. Right. So when a practitioner or a caregiver or somebody is looking at data using it can get very confusing with where to make adjustments. So you know, if you if you did use that strategy, the one thing that we would really recommend doing is making a note in whatever your logging system is. tide pools a nice place to make notes like that, because they pop up right on that daily trend, to be able to say, Hey, I see a 10 gram entry here with a bolus. Yeah, that was a ghost carbs. I've got some people just enter ghost carbs. As a take note, you know. But again, it's it's also kind of, in practice, it's kind of discouraged, even though people do do it very often, well,
Scott Benner 33:10
is it a problem in inside of the system? Because you've now told us that carbs exist that don't exist? So what happens an hour from now if you've right? If you do, yeah, or you vote, right. But you know, your your examples better if I do want to eat, it believes there's carbs in there, and now it's going to change the Bolus somehow, either more or less, or
Jennifer Smith, CDE 33:32
because it'll be insulin on board for a purpose. Right? Right. So it will have effect on you know, auto mode for hours after putting in that corrective ghost carb entry to generate it and it is accumulating, then, you know, if you do that at three o'clock in the morning, you're not going to eat until nine o'clock in the morning. That's not really going to have any major impact overall, other than just hopefully navigating you down safely. If you're trying to stop a rise an hour before
Scott Benner 33:59
dinner, then right? It's gonna get messy
Jennifer Smith, CDE 34:02
and everything gets messed up. Yes. Mm hmm. I mean, and this all kind of goes back to the beginning of what we always educate is get your settings right also, right, before you go into auto mode. Okay, make sure things are good. And it's really I think, in in the the hybrid closed system, that the 670 is, this is even more important. Mainly because before you switch on auto mode, and all the system is gathering like insulin dosing data in the days before you switch on auto mode. So it essentially we'll update its algorithm of insulin use at midnight every night based on your amount of insulin you've used over the years. about the past week, okay, so we've found that it's best. And I'm not quite I don't remember exactly what Medtronic says, I think that they're saying two or three days, we've found that it's most advantageous for people to be in manual mode of normal insulin dosing with well set settings for about a week, before turning auto mode on.
Scott Benner 35:25
You're not gonna buy this thing, slap it on and be like, fix me, right?
Jennifer Smith, CDE 35:28
No, no, it's not. And that's where it is very different comparative to tandems control IQ. Okay, control IQ, you put your settings in all of your settings, work in control IQ mode, you can slap it on out of the box, put in all your settings, turn control IQ, and you're off
Scott Benner 35:45
and running just starts working. Okay. Not so with 676 70 G's actually trying to learn is that it fair statement are now
Jennifer Smith, CDE 35:55
in a very, in a very beginning sort of rudimentary way.
Scott Benner 36:01
Yeah, so it's just collecting data, like you used 50 units on Tuesday, 45 on Wednesday, but all of a sudden to end it. Somehow that's helping it make decisions.
Jennifer Smith, CDE 36:11
Correct. Now, there are there are also some drawbacks to that. Right.
Scott Benner 36:16
I see them as you're talking, but go ahead.
Jennifer Smith, CDE 36:19
Yeah, and and you probably do, I mean, you're intuitive about all of this, because of the years of experience that you have in managing with Arden. But you can see where this leads to, especially from a female point. Right? If you are in that time, potentially, before your cycle start, where you have these high insulin needs. And everything needs to be ramped up. Then what happens when your cycle starts and all of your insulin needs plummet to sometimes for women 10% less than what their standard profile is running for a day or two of their of their first two days? And this thing's made a decision based on when you've been resistant for a whole week? Correct? Right? For people who've been using steroids because they're sick, or people who've had like, an unbelievable amount of stress for the past three days because their father passed away or whatever, well, that could be two things being in auto mode, more aggressive really
Scott Benner 37:19
is so the thing that that is pretty common. Within You know, how people talk about diabetes that I completely discount, I don't pay attention to it, and I don't believe in it. 100% or even maybe 10%. But the idea that, you know, three days makes a trend. I'm like, okay, it makes a trend, it doesn't mean it's gonna keep happening. For all the reasons you just said, like, okay, I finally figured out I need my base, it'll be point five an hour. And then I get that set up and something changes. There's too many variables to say that any one trend is an indicator of the month. Do you mean? Like it just that doesn't make any sense? Male or female? I don't like buying into that at all. What if I just, what if one week I decide, I don't know, man eat more vegetables than red meat? Or then you know what I mean? And then the next week, it's different? I don't know, right? Like, there's just too many, there's too many things, I work a little harder at work this week than I did last week, I get a little more sleep a little less sleep. If you're looking for that, if you're trying to find a repeatable pattern in that. I don't imagine that exists. And if it does, it's well beyond what an insulin pump or me can figure out, you know, so I'm just more well, even
Jennifer Smith, CDE 38:35
for the people who have done the testing. And let's say they'd have for the most part figured out like, I always need about this much more for this time period, or this much less or whatever. Well, for the again, of the woman who sort of figured out her monthly, like cycle changes and how much more she needs and what bazel profile to set on and whatever. Well, what if you start training for a marathon? Or you've decided to now you know, go swimming for an hour every morning? Yeah, that is going to create a difference in need into this next month. And so it probably will look like, well, gosh, everything's different again. Well, you brought a variable into the picture that wasn't there when you were doing the testing to begin with,
Scott Benner 39:17
right? You can't turn to your pump and say, Hey, pump, listen, just you and me this week, I got a report, do it work, a lot of pressure here, my bonuses riding on this, I'm probably gonna be a little jacked up just so you know, 20 more percent. You know, I think I'm gonna have some stress, high blood sugar, there's that doesn't exist. So you need to be able to be flexible. For those things. I don't know, it, just it. I've just never been a fan of the idea that, you know, three days is a rule. It's a rule for those three days. It's not, you know, and so and so, if that's the case, what people always end up doing is spending three days trying to figure out what's going there. Stare at high blood sugars or stare at low blood sugar trying to find out if it's gonna be Um, uh, you know, it's gonna become a thing that they can count on. I'm always just like, I think you should deal with diabetes in the moment. And then whatever happens is now gone. And I don't I mean, don't get me wrong if Arden's needed less insulin on Saturday, and it looks like that's how it's gonna be on Sunday. I remember that. That's part of being flexible, right? Yeah, but I don't but but if I wake up on Sunday, and all of a sudden she needs more insulin. I don't say to myself, well, that's not true. Because yesterday, she didn't need a lot. So we're just gonna watch your blood sugar be 300 all day today? Like, I don't, that's not it. Like, I think diabetes is a in the moment situation. But, but okay. So I've got my, let me ask you this. I say this all the time. And maybe maybe it's not true for this one. And maybe it is I'm going to get your opinion. I think that for most people living with Type One Diabetes, these systems, you know, the 670 g that's available now. And obviously, it's been out for a couple of years, the the tandem system and the, you know, the forthcoming horizon from ami pod, which we should be seeing pretty soon from hope. Well, as long as the code that Coronavirus doesn't keep their own things. So, so those things exist. And for most people living with Type One Diabetes sorted up to like 1.8 million people now and like that habit, for most people, slapping the systems on is probably a huge improvement for them, don't you think?
Jennifer Smith, CDE 41:26
Yes, in fact, we've had quite a number of, I wouldn't say quite a number. But a good enough number of people that we work with who the 670 has smooth things out considerably. It has, you know, they were they were up down roller coasting consistently day to day high to low, high to low, no assistive management to help with that variance in their blood sugar. And overall, while there's weather still probably averaging a blood sugar of 140 to 150, the system has smoothed out the variants, and it's kept them more stable. That's a beautiful thing. Yeah, and, and for most people that that's the case, they're happy with it, getting them to a target of 140, it targets 120. But for the most part, they talk to most people, they're really achieving an average somewhere between 130 to probably 160, give or take, um, but again, stability there. That's a huge piece, right? So
Scott Benner 42:29
if you've gained stability, and you're an average of 160, instead of 220. It's an incredible improvement for you in the moment and probably for your entire life as well.
Jennifer Smith, CDE 42:39
And a lot of people still even in auto mode, they're still reaping the benefit of these, these hybrid kinds of systems, especially in the overnight. Most people without food in the picture, a system like this is a huge advantage for the overnight,
Scott Benner 42:56
get some sleep and you don't get lowest. You're not you don't get those crazy highs overnight is right. What about, I feel like we were missed if we don't mention the Guardian sensor? So yeah, obviously, we're I, my daughter uses the Dexcom g six, they're sponsors of the show. You use the Dexcom? Yep. The the, you know, the scuttlebutt for me from what I see on the street from the kids, is that people don't think the guardians as accurate as the dexcom. Is that Is that a fair statement from what you've seen? Or how do you even I
Jennifer Smith, CDE 43:32
think that's a very fair statement. It is, I mean, even from my personal sensor use of two of their sensors I tried the enlight years ago, I all when I was training, you know, on their pump to begin with. And then when I trialed and the 670 with their guardian, I would say that it's definite, it was an improvement from what I had had with the enlight it was it was definite improvement, but it was still not for me, anywhere near the accuracy or the consistency in accuracy that I get with my dexcom. In fact, when I was using the 670, I wore my Dexcom at the same time, okay, to compare, I mean, when you're wearing like, several things, and who cares about another site, right, like, I'm just gonna be the ultimate like robot person. Right. Right. Right, exactly. So, you know, and I, I mean, I follow there are certain you know, things to definitely make sure that you're getting the sensor to work as well as possible to begin with, from the Guardian standpoint, because it is, I would say the best word for it. It's finicky, comparative to Dexcom. And I personally tried all those tips, tricks, things that could possibly be done, and it never really worked well for me, and I think that that's the biggest hang up then that I had with it in automotive. It is that it drove me crazy with all of the requests for additional glucose entries and calibrations. It wasn't accurate. And thus, in any of these hybrid systems, if you have a sensor that is not accurate, the adjustments in something like auto mode or in control icube closed mode, you're you're not going to get accurate adjustment because your sensors not accurate to begin with
Scott Benner 45:29
when you say it asks for calibrate, so it knows well enough that it's not okay, but it doesn't know where okay is, is that.
Jennifer Smith, CDE 45:37
So for the most part our our go to recommendations for getting your sensor to work as well as possible. We recommend calibrating that sensor. And it does require calibration on like g six for Dexcom. The Guardian does require calibrations. But we recommend calibrating about three to four times a day, at more regular times of day. But the biggest thing is really to ideally do it when your glucose is more stable. In order to avoid what we know, in all of the sensing systems, there is lag time, based on if something is trending down or trending up right now. There's lag that's happening, your finger stick is often either lower, or it could be higher based on what's happening trend wise. So the goal is to try to calibrate when you've got a horizontal kind of angled trend happening. Also, the accuracy of the glucometer that you're using to calibrate with is a big deal too. Yeah, that's a huge deal. I mean, if you're using some off the market, like, well, not off the market, but like random, generic brand. Don't take out, right? Hey, that's easy. It just just don't, don't I and I know that some people it, it's based on what their insurance is able to cover, right? Right, or what they can afford, I get that. But then also understand that your calibration of these systems may actually mess up the natural sensing of what it sees as being
Scott Benner 47:20
you're wearing, you're wearing a state of the art glucose sensing system and calibrating it with something you got out of a bubblegum machine, it's not going to go well, because then you just confuse the sensor by by telling it, you know, let's say the sensor thinks you're 110 you're really 120 and your meters like no, no, we're at, and you put that information in that the sensor is going to go there, and it's not going to know what to do. And it's gonna confess it, you know, and you have to be careful.
Jennifer Smith, CDE 47:48
The thing with Medtronic, it does come with a monitor that connects with the pump, which is nice, it's the best one that's on the market, it's the Contour Next One, if you get it with the pump, use it, because that is the best rated as far as accuracy on the market. And that goes for anybody that's out there.
Scott Benner 48:06
If you want to know why the Contour Next One is sponsoring the show. Now it's because Arden's experience with the Contour, Next One meter has been head and shoulders better than any other meter she's ever used. As far as consistency, ease of use, portability, and end how closely it agrees with the G six is fascinating. I don't know if that speaks well, for the G six or for the meter or for both, maybe honestly, but it's I've never seen so much consistency between technology before. And you know,
Jennifer Smith, CDE 48:40
according to I mean, one of the last conferences I went to, when I was able to fly and actually be within six feet of somebody else. I stopped at the actual the the Roche were accucheck their guide or guide me is also one of the highest rated accuracy on the market. So if you can't for some reason, insurance coverage wise, use the contour that accucheck guide or guide me it is also not very good. Yeah. So but that that goes along with sensor, any sensor that you're calibrating, but definitely one that could have some finicky component to it for The Guardian, try to make sure that your glucometer is a good one. So and then, of course, you know, any sensor, it's the insertion of it. Are you putting it in the right way? are you cleaning your sight? Are you making sure that you're the transmitter for The Guardian needs to be charged? And so unlike Dexcom, which you just slap it on, and it continues to work every time you put it with a new sensor until it's dead at 90 days. The transmitter for The Guardian has to be charged that's just confused me
Scott Benner 49:49
can I try? I can't charge it while it's on my body right Oh no. Then how does so I have to pop it out and charge it. How often do I have to do that?
Jennifer Smith, CDE 49:57
Oh, the charging Another one that I'd have to look back and see exactly, it doesn't take long to charge it. Okay, but I know that it's at least it's at least every five to seven days. But don't, don't you know, directly me on that. But yeah, it is it requires charging and there's like a little, you know, that comes with the system, there's a little charging like, port that you pop it into, and it charges and then it's ready. And then, but if you're, if your transmitter isn't well charged, or it's kind of at the end, you know, don't put on a brand new sensor, and then you're gonna have to pop it out and it just weirds up the system.
Scott Benner 50:37
We're selling the hell out of this thing, aren't we? So? Geez. Alright. So being serious, like, that seems like more work. I so I have to take so every
Jennifer Smith, CDE 50:50
number of days, if you do want a positive, good, it lasts longer than your transmitters. Okay, that's a huge positive. So right in
Scott Benner 50:59
place the actual devices frequently,
Jennifer Smith, CDE 51:02
you don't have to write this set at the transmitter is there you've got it until it's no longer working for you. And that's a nice thing.
Scott Benner 51:10
It's a great point. I only ever have our experiences, I've I've never experienced a gap where we didn't have Dexcom supplies. But I you know that very well, maybe because I'm on top of ordering them or because my insurance doesn't argue about I don't know why there's probably a number of different reasons. But okay, so there's there's the good and bad, so you have to recharge it, but it lasts longer,
Jennifer Smith, CDE 51:32
it lasts longer, it does require some taping, oh, it
Scott Benner 51:37
tries to fall off does it?
Jennifer Smith, CDE 51:39
Well. And all I think all the sensors on the market, depending on body type and what the moisture level and you know, everything in your skin is everybody's a little bit different. I mean, I occasionally in the summertime need to, you know, need to tape down or put up a thing around my decks calm as well. But the Medtronic sensor specifically has to be taped down. It's not a, I could choose to do it. It's kind of a funny, I wish we had like visual. But once the transmitter is popped into this little sensor piece, the transmitter bounces. Like it's like if you imagine a beaver with its tail. The tail is the transmitter
Scott Benner 52:23
Jenny, Jenny is making a hand motion that's making me feel like Has anyone anyone ever been driving in like snow, and you're the back of your car gets like a little light and starts bouncing around. And you know, so she's she's basically saying that, uh, that the back of her tail, the back of the transmitter is bouncing?
Jennifer Smith, CDE 52:43
Yes, if you don't take it. And obviously, you don't want it bouncing because it could easily come disconnected. It's pulling out the adhesive and it's pulling it the sensor wire and all the other stuff. And then that decreases accuracy. So Medtronic supplies you with all of the adhesive tape that you do need to tape it down and keep it in place, they give you directions to tape it the right way and pop it in and everything. So again, it's not extra stuff that you have to remember, it comes with your supplies, but it's an extra piece of use that isn't there for the other sensors.
Scott Benner 53:14
I'm holding in my laughter because I'm trying not to be a hater on this situation here. But my brain is going maybe don't design it to do that. And then or when you design it, you go, Hey, this thing's bouncing around, like who's the person that was like, we'll give them tape? Not maybe we should redesign it.
Jennifer Smith, CDE 53:31
Right, right. Well, the question in my mind, honestly, always comes and this is not specific to Medtronic, but it's any product that comes out on the market. People with diabetes, get it? And they're like, why did they do this? Why is it designed Like this? Like, did they not ask people with diabetes, how their life would work if we did this weird part to it? Right? Yeah. So I I just, I don't know, I'm always like, well, I guess somebody thought it was a good. Yeah.
Scott Benner 54:05
Well, some engineer maybe who doesn't have to wear it, right? Thought about the usability of it, and it works like it works. And that this shape, we can make it rechargeable. And you know, all that I listen, I'm imagining it wasn't by mistake. I don't think they were just like, I don't care, you know, but there's sounds like there were trade offs made. And you know, as we're having this conversation to, I don't know what the date is for g7. But g7 is going to become disposable, right? Like you're not
Jennifer Smith, CDE 54:32
I that's what I've heard as well,
Scott Benner 54:34
yeah, that you're not going to have that transmitter with the battery, you're gonna put it on and when it's over, the whole thing's gonna go in the garbage and you're going to start over again. And it's, it's gonna have enough battery life in it for the life of the sensor. Right. And that's it. So, yeah, I mean, things are moving forward quickly. I think I think from a personal perspective, as I watch Medtronic and their pumps, it feels to me like they're Like they're making a five pound bag of cereal, you know what I mean? Like, it's mass market. Like, like, like
Jennifer Smith, CDE 55:09
the ones that cost like $2 on the very bottom bed, and you're like, well, that's the best deal.
Scott Benner 55:13
But she gets so much of it, right? Like, I feel like they're just, I feel like they're the, they've put themselves in a position where they're giving pumps to more people than the other two companies, right. And so what they're saying is quantity over quality, like, that's how it feels to me, like, we're going to serve these pumps to as many people as we can, it will work for most of them, and it won't work for some of them. And that's just the price of doing business. I don't know I could be wrong. It's just how it feels from the outside. Because of all the things that I mean, listen, Jenny's just been sharing her experience wearing the device, and she's not, you know, and she hears people talk about it as well, and she's doing her job. But there's a lot here that seems fixable. Except it doesn't change ever, it's just sort of like they won't change this thing till they change the system, they're not going to come back and make an adjustment to it or anything like that. They are making them they're pumping them out, no pun intended. And this is what they are until they're done. We're just going to give people tape and then we'll fix it next time, I guess. Right.
Jennifer Smith, CDE 56:13
And we do. And there are I mean, speaking to that, specifically, from what we know, clinically, and the bit that's been shared, they are already on it, as your as a company there, there are products that should be coming out in the future, when I don't have any idea or not privy to that information. But there are, there will be a new sensor that will be more accurate, more user friendly, from what I remember and understand it will not have that beaver tail transmitter kind of piece to it. It will be much simplified. And their next iteration of this hybrid closed loop system that they have, will be more finely tuned with a lot of these pieces that are they're kind of a pain to have to deal with. Right. So they are working on it, as are all the companies out there, right? They're continuing to build and, you know, yeah, make changes and listen. And
Scott Benner 57:18
I meant what I said, when we started out that I think it's, it's not a great position to be in to be first. You don't I mean, because you probably had to do a lot of things to get through the FDA. And that's been softened for the pod and tandem now you know that that stuff is that past been cleared out a little bit for them. So there's a lot of good, you know, somebody's going first is and to be honest, if it was going to be anybody, it makes sense that it was Medtronic honestly because they're well,
Jennifer Smith, CDE 57:44
they're the oldest on the market. Honestly, of all of the pump systems. They are the oldest that is still around. I mean, all the rest are pretty much gone. Right? There are lots of people who love their, their combo pumps and their animists and things so
Scott Benner 58:03
they're all gone. They're all gone. Was it cosmo? What was that one that people? Cosmo's no pump, right. Yeah,
Jennifer Smith, CDE 58:09
yeah. In fact, another Scott Scott Johnson, who has his own little like diabetes blog, and he works with the my sugar group now. Um, he was like, he Bade his Cosmo and
Scott Benner 58:24
as long as he should
Jennifer Smith, CDE 58:25
hoarded supplies in order to keep it going, as long as he could, he could, he probably I don't know what he's using anymore. But he probably go back to because he really loved
Scott Benner 58:34
his cosmos. That's a nice person I've met. Awesome. So what's the overview here of this, if you have the system, and it's not working the way you want it to? You're going to have to go out of auto mode sometimes to address some meals, but not all, or you're going to have to understand that your blood sugars are going to be higher than maybe you want and just let it be.
Jennifer Smith, CDE 58:59
You have some kind of standards of when to go out of auto mode. Honestly, you know, the the initial question you asked a while ago about, well, what if I'm eating this really slow digesting or really high fat meal or, you know, my normal peek is going to be way out here and whatever. And you were used to using a square wave or a dual wave Bolus before you know what it might be best to temporarily switch back to manual mode, use what you knew work from the get go. And then when it's done, switch back to your Mac to your auto mode. I mean, that's, that's really one of one of the settings of switching out of auto mode. Another one might be honestly sick days, high stress, those kinds of things or even like I said, high fat meals etc. Where you really, let's say you always know that when you've got this really nasty, like cold that you use 25% more insulin, you've got a temporary, you've even maybe got a profile set for sick days. Right? You know what, don't hesitate to switch out and go back and use that because you knew it worked.
Scott Benner 1:00:11
Does that system allow for me to set? Could I set up multiple? Like profiles? No, but so I can't have a pizza profile on a regular profile. But see, that was because that would fix it. If I if I suddenly made the sensitivity, and the you know, the insulin on board times differently and changed, like my carpet is
Jennifer Smith, CDE 1:00:29
remember why it's gathering data over the past several days of insulin sensitivity, I keep changing it
Scott Benner 1:00:36
around because it will. Correct. Okay.
Jennifer Smith, CDE 1:00:40
Yeah. But that's a that's a great question. Again, you know, days, I even think of days, like, my brother in law works for Disney. And so we've gone down there more times than I can count. And we've enjoyed the parks and whatnot. And I know that a full day of getting up. This was pre kids, my husband and I were just enjoying the parks as adults like running around like crazy kids trying to get to everything, right. I had to use not only a temporary bazel all day long, but also overnight to avoid running too low. Well, you know, what auto mode would would not benefit me in that scenario. Because I would just be running too low, it would be consistently trying to probably suspend me not just temporarily decrease things. And that is also a limiting factor to the system that is different than the coming hybrid systems that are going to be on the market or are already, there's only a certain timeframe that it will high temp, your bazel for or Low Temp or suspend for before the system kicks you out of manual mode and say, Hey, this is all on you now, okay, you're and it will alert you. It's not like it's all of a sudden gone. And you're waking up at three o'clock in the morning. Great, I would have loved to know that you kicked me out. There's an audit, there's an alert that tells you you are out of auto mode you are back in manual mode. And it's because either you've reached the max amount of insulin delivery in a time period that's divined or you've been suspended or decreased bazel for a certain amount of time as well.
Scott Benner 1:02:23
Interesting.
Jennifer Smith, CDE 1:02:24
So in a day, like I was describing, yeah, that's to switch out of auto mode, go to your Temp Basal that worked. Mine was always setting a Temp Basal decrease of 15% for the whole day that we were the year and into the overnight. That worked beautifully.
Scott Benner 1:02:39
That's it's a great advice. And it also feels like it's, it's a little sad, because you're telling me that this pump that I'm I'm thinking what's gonna stop me from getting high, it's gonna stop me from getting too low, it's gonna be great. It's gonna take my mind off of blood sugars, blah, blah, unless I go to Disney and run around all day, and then it's back on me. Or I have pizza. Or you know,
Jennifer Smith, CDE 1:03:04
and remember, if you are going to Disney today, and the last four days, you were in some type of horrible business meetings that had you all jacked up and insulin needed, it's gonna crush you insulin. sensitivity is Yeah, exactly. You can't whisper and be like, Hey, 670 on vacation. Now I got
Scott Benner 1:03:22
a Fast Pass today. So keep up, right? So keep up with Oh, it's gonna thank No, for the last three days, you've needed more insulin?
Jennifer Smith, CDE 1:03:29
Correct?
Scott Benner 1:03:30
Exactly. So you go from I've needed more situation to I need less situation and it can't, it can't
Jennifer Smith, CDE 1:03:35
adjust it. It can't adjust again, fast enough is kind of the issue, right? And then I guess one of the last ones truly, which we've all experienced on every single pump is an infusion site problem, or a site failure or something, you know, and if you're in that high blood sugar, and you know it's a sight problem, and you go ahead and you change it, it really is best to switch back to manual mode, change out your set your tubing, maybe even your insulin, give a bolus we usually recommend via injection instead of through the new pump site. And then once your blood sugar is back in range, switch back to auto mode, right?
Scott Benner 1:04:15
Okay, I am at pump changes. I do something very similar pump changes. Like I don't rely on the new site right away like I tried to. And I also do not stare at bad sites like when sites no don't. When you know, you know how I say when when when an insulin pump site stops doing what I expect it to do. I do not stare at it for 10 hours wondering if it's gonna get better again, you know, right to bosses. It doesn't do what I want it by time. Yeah, right. Yeah. And it doesn't have it's not like you know, doesn't happen constantly. I'm just saying when it happens. I don't look at a pump and think oh, I have three more hours left on this one. I can't wait. That's an that's a rookie move. Right? Like that idea of like, oh, there's three more hours. Here, I don't want to waste those three hours, there's five more units here, I don't want to waste those five years, I mean, money aside, I understand insolence expensive, you're gonna have diabetes, for abs, you know, I mean, so like it just trying to cheat two hours here and three hours here and four hours here, you might think oh, I'm, you know, I'm saving myself an insulin pump set or something like that every month, what you're doing is you're costing yourself three and then two, and then four, and then six. And before you know it 20 and 25 hours and 30 hours a month of high blood sugars, by trying to sneak an extra two hours out of your pump. You know, I think, I think you have to, if you can afford to, you have to think about it the other way or supplement with injections, if that's crass, not working?
Jennifer Smith, CDE 1:05:40
Correct, or something like you know, a frezza, or something that works very rapidly, and you know, that it's going to work and it's going to get things down, or, you know, whatever, I don't get
Scott Benner 1:05:48
a 180 going, Oh, it's only for eight more hours until the right, come on. You know, don't do that. Just
Jennifer Smith, CDE 1:05:54
don't do it to yourself. Yes, yeah, yeah, exactly. Health is what your
Scott Benner 1:05:59
health is, first health is the goal.
Jennifer Smith, CDE 1:06:01
And I think you're talking to you know, you're kind of like hiding from a situation that you can, you can visibly see, it's there, and you're like, we're just gonna like, it's gonna fix it, kind of like even you know, going along with like the auto mode, we really try to recommend not hiding things from auto mode, too. Right. And one big one that is often forgotten, especially if you've gotten into this routine before having auto mode. And if you were an omni pod user switching to this system, you wouldn't even really think about because you've never disconnected. But when you disconnect from the pump, in auto mode, suspend your pump, so the system knows that you are not receiving insulin, okay? Because if it thinks you're receiving auto mode based adjustments of insulin counts, when you're really not getting them pumped into your body. It may, it will then continue once you do plug back in, it'll continue to think that there's insulin there that wasn't
Scott Benner 1:07:07
okay. So you have to tell it up if you just connect to bathe or something like that.
Jennifer Smith, CDE 1:07:11
You suspend your suspend
Scott Benner 1:07:12
the pump so that it realizes nothing's happening, correct. Okay. Yep. And I'm assuming that's an easy thing to forget to do. But do people forget,
Jennifer Smith, CDE 1:07:21
I would say it's an easy thing to forget to do. I, you know, some people, especially in conventional mode, coming from conventional mode into using an automated mode like this system has, because I'd say probably 50%, at least of people who disconnect from their pump, because their system isn't connecting with a CGM to do anything with that insulin. They're just disconnecting, letting it pump. They reconnect when they're done with their shower done with their swim or whatever. Maybe they're maybe the really meticulous people are remembering to suspend their pump and then remembering to resume their pump. Once you reconnect.
Scott Benner 1:08:03
I used to be surprised by the number of people who would tell me I took my pump off to get a shower and three hours later remembered where I forgot. Yeah, yeah. And I guess and like I said, buy used to be surprised. They used to be surprised because Arden uses a pump you don't disconnect from I never considered it. But you know, after you think about it for a while it's reasonable. You can be rushing around or right doing whatever it's you know, I don't know. To me, it's a selling. Yeah, no, I hear you. Okay. Well, alright, I don't know what we've Do you think we've done anything valuable here, like if a 670 g person heard this, but they'd be like, I've heard something that might help me.
Jennifer Smith, CDE 1:08:38
I think if you're a person currently using it, there are some there are some tips if you didn't know about them already, to maybe put into action to make it work a bit better for you, especially if you're somebody who is using auto mode, pretty much 9095 maybe 100% of the time and you feel like there is something to tweak but you're not quite sure where to start maybe some of these tips. While we spoke about some of the drawbacks, I think the tips that are in here for people who are using it could be an advantage if they're already not trying them. Um, you know, I think another another big one that often times again, with these hybrid types of systems is often a forgotten piece of teaching someone when they start on it is how to treat lows.
Scott Benner 1:09:30
So you're not over treating your lows,
Jennifer Smith, CDE 1:09:32
correct. The age old 15 grams every 15 minutes kind of thing. A lot of people are still following that and on a conventional pump, especially if your settings aren't really dialed in very well. Maybe it does work quite well for you. Maybe you even need to use 20 grams are 25 grams because you're really not sure how much insulin is there and that's always seems to be brings me up and I don't get low again. So I keep using this well, you can guarantee that on any of These hybrid system systems that are augmenting the insulin delivery, right, you have to remember that in auto mode, if your blood blood sugar is decreasing, the system is has already seen that. And if it's decreasing, and you're going to get below a certain value, or to a certain value, depending on the rate of trend, the system is either temporarily decreasing, or it may already be suspending.
Scott Benner 1:10:32
So it's already created a void of basal insulin correct with the food in. And once you stop the drop, there's nothing else there to help with the food.
Jennifer Smith, CDE 1:10:41
Correct. Because that bazel deficit, remember how long into the future that can make a change? So think about under treating your lowest?
Scott Benner 1:10:52
No,
Jennifer Smith, CDE 1:10:52
I think easiest way to say it,
Scott Benner 1:10:54
I think those are the little pieces that that get lost, especially in a low situation, because there's a panic, I got a really lovely note from a person today, just this morning, who said how much the podcast has helped them just with that idea, you know, they used to get low, and then eat a bunch of food. And then just let whatever is going to be be after that instead of recognizing some of this food was for the low. And some of it was because I'm ravenously hungry, because I'm low and I'm scared and all these reasons that this food needs insulin, you know, some of this food needs insulin, right. And the person said that just that idea from the podcast has really changed their, like their days, you know what I mean? Like they're not spiking and dropping and spiking and dropping all the time. And that's the stuff nobody talks about. And it's tough. And not to put that on a pump company, either.
Unknown Speaker 1:11:40
No, no.
Scott Benner 1:11:41
I don't know if people understand like the pump companies, through FDA regulations can't tell you how to manage your diabetes, they can tell you what the pump does, and how to technically make the settings like how to use it. They can't tell you when to use it. They're not allowed. You know, I mean, and that's supposed to be for your doctor, but then your doctor is busy telling you, you know, just keep eating 15 carbs and 15 carbs and fat and carbs. And then you know, see what happens afterwards.
Jennifer Smith, CDE 1:12:07
And along with that, you know, we bring into the picture technology, right? Our technology today using CGM, you have to remember that CGM is leg, especially in times of lower blood sugars or in times of rapidly changing blood sugar values. So if you've treated your low, especially on an automated system like this, if you've treated it, you've you've got to wait, yeah, unless you're willing to do a finger stick and a finger stick to see that things have now up they've stabilized up I'm rising, my blood sugar's coming up. But look at that my sensors still reading at 52. But my finger stick is at three, stop eating your 15 grams every 15 minutes,
Scott Benner 1:12:47
you have to stop caring about this. It's an interesting situation, you've corrected the low. And now you're going to wait for your body to respond, your body begins to respond with a blood sugar that's rising. The sensor doesn't figure it out quickly enough. So you're still looking at the 52 going, I probably need more food. If you fingerstick you might be 65. Right? If you wait 10 minutes, you might be 74. And the CGM might believe you're 74 too. But it's that panic time right in there. Yeah. And I I'm a fan of testing. I like testing in that spot.
Jennifer Smith, CDE 1:13:18
I do too. You know, I do too. In fact, when I you know, in a conventional pump sense, I usually enter the carbs into my PDM. Because when I do that for a low blood sugar, if I enter too many grams of carb, the PDM will tell me I need to Bolus and if I have a certain amount of carbs and it's recommending a 0.0 Bolus, I know that it's at least offsetting enough to bring me up. And potentially if I've got insulin on board, it'll allow me to actually then take in enough carbs to compensate for insulin on board. And the low blood sugar without recommending a bolus, yeah, if you enter it, and you're like, I'm gonna eat 49 grams of carbs to treat this low and your pump is like okay, well you need 2.2 units of insulin. I guarantee you probably need that 2.2 units of insulin even though your blood sugar is sitting too low. I will tell a story sometimes when I'm speaking publicly about the time it It struck me like when I finally figured it out and Arden had a bad low. It came out of nowhere in the middle of the night. And you know, everything you described like she's falling
Scott Benner 1:14:34
so fast that the CGM this is years ago. She was falling so fast. That CGM didn't pick it up right away. It was also I think, two generations of Dexcom ago, it was probably the g4 right, and so she's falling fast. And I catch it. I test she's really low. She's like 36 she takes in 65 carbs, right and the 36 I finger stick it holds wait five minutes the longest five minutes your life you stick again. She's still 36 Okay, she's not falling. You know, you're like, Alright, wait again you wait again you wait again fingerstick 42 going up. All right, the CGM still just yelling low, low, low. Yeah. Because it's just waiting. Yeah, it was. It's a little behind now, right? So I'm like, okay, 36 went to 36 went to 42. I'll wait. And I wait. And then I saw 54. And it was that time it was this one time that I was like, god damn, you know what I'm gonna do. I was like, I'm gonna Bolus. It was like, so she had like 65 carbs. And I think
Jennifer Smith, CDE 1:15:42
you were like 65 carbs was a lot of carbs.
Scott Benner 1:15:46
But the leap is, first of all, you have that adrenaline. You just saw 36 blood sugar. The CGM is yelling low at you. All this is happening. But she's clearly coming up. I didn't Bolus Roth 65 cars. But if I remember correctly, I think I did 40 of them. And I stopped her blood sugar like 170 because trust me, 20 minutes later, her blood sugar started shooting up, right. And even that gives you this anxiety because the CGM is catching up, you know, it's telling you low now she's 54. Now the sudden she's probably 65. Now all of a sudden it goes ooh, 40. And then it shows you arrow straight up and the arrows panicky, you're like, Ah, you know, but because I was testing, I knew what was happening. I was like, Alright, forget this first second, I'm gonna stop paying attention to the glucose monitor for a second. And I'm going to go back to knowing what I know is going to happen. She's got food. She's clearly not low anymore. She's moving up. This is no different than a bad Pre-Bolus at a meal. Like it's almost like I Pre-Bolus too long. Like, right, that's all that's happening now. So like, what do I do next? And what I did next was insulin. And I'll tell you, if you've ever seen me speak, speak live like sometimes like I do. I go out into my my hallway afterwards that I leave Arden's room, and I'm like, hey, my arms over my head. I'm like, Oh, I killed this. Oh, my God, I did such a good job on this. And then I go to bed. And that was it. But yeah, you can't if you over treat Lowe's, especially in these auto system, this one specifically, you're just gonna bounce forever, they get it, then it's, then you're not letting the system do what it's there to do for you either. Right, you know, all right. Well, I truly believe that, you know, Medtronic next system will be an improvement over this one. I 100%. Want to give them credit for doing it first, because I think it's a I don't think that I don't think they had a chance for an outcome any different than the one they got being first and probably I'm guessing, dealing with the restrictions from the FDA that they put on a first, you know, hybrid system. So
Jennifer Smith, CDE 1:17:48
absolutely, I'm quite sure that the that the restrictions and the parameters they had to stay within were outrageous to actually get a system on the market. That could actually, I mean, the first step really was allowing CGM to replace fingerstick. Yeah, it was 100%. And once that was approved, and they were like, okay, now that that's approved, now, we can actually have a system that doses insulin based on CGM values. And that was the huge first step. So I mean, they put a lot into place I, you know, I would not like,
Scott Benner 1:18:26
we all need to appreciate that we all need to appreciate the speed in which things are moving through the FDA now that they did not used to. And I mentioned this to somebody personally, last night, if you go back a couple of years, and the CEO, Shea see from from Omni pod is on the podcast, I'm asking her about like, hey, am I ever gonna be able to control my daughter's pump from a phone? And her answer a couple years ago was like, I mean, we would love that. But I don't know how we're getting that through the FDA. And now the horizon is going to come out and it's going to be controlled through your phone. And it's a couple of years later. And so for new people who are used to like Dexcom, being like, here's the G four, here's the G five, here's the G six, the G seven is coming. That's not how diabetes has worked. Historically, getting new technology to market, so things moving so much more quickly than it used to. It's really yeah, you know,
Jennifer Smith, CDE 1:19:16
and it's making a big difference for people. I mean, really even considering just the 670 system, and some of the pivotal trials and the things that Medtronic came out with even years ago. I mean, they really proved that people who used it with a lot of the strategies of applied management to using it mean they can achieve an A one C, kind of shortly under a 7% sort of in like the 6.8 6.9% range. I mean, a good percentage of time in range. I mean, if you were falling short of that 40% 50% if you're using the system well and auto mode, most often you can get 70 75% in range, with that range being like you know that 70 to sort of 180 ish kind of plays such a
Scott Benner 1:20:01
big but yeah, for a lot of people
Jennifer Smith, CDE 1:20:03
for that that's huge for many people. So you
Scott Benner 1:20:07
have to remember where you're coming from when you listen like when you say, an eight, one c like in the low sevens. It My mind is like, Oh, that's a point and a half higher than I want it to be. But that's for me, a person who's got to see in a one see who's nine is like, wow, just saved my life.
Jennifer Smith, CDE 1:20:23
I'll take it. Yeah,
Scott Benner 1:20:24
yeah. No, 100% No, I, I believe I really do. Like I like to tease Medtronic. Mostly, I like to tease them in case they're listening. Because I am not a fan of what you do in Washington, around insurance and the way you throw your weight around and limit other pumps. So it for that, and I'll bleep this later. I think you're a bunch of it. But you know, for the rest of it. We're just here talking. I agree. Yeah, that's all let's Scott Johnson have his goddamn Cosmo pump. It wouldn't have been that bad. Damn, it. wouldn't know he wasn't taking that much money out of your pocket. Medtronic, he could have let it be. Alright.
Unknown Speaker 1:21:01
Right. You can
Jennifer Smith, CDE 1:21:02
all these other products off the market right here.
Scott Benner 1:21:04
Okay. Huge thanks to my sponsors, Dexcom and Omni pod. You know, we never mentioned it. But the opinions expressed on this podcast are not those the advertisers probably should say that once in a while to take that thought a step further. I'm an idiot. I don't really know anything. So, you know, grain of salt, though. And I'm sure there's a ton of wonderful people at Medtronic. To find out more about the dexcom g six continuous glucose monitor, go to dexcom.com forward slash juicebox. Please use my link, click on it. You know, you can do it right there and your podcast player right now. And to get a free, no obligation demo of the AMI pod sent directly to you my Omni pod.com forward slash juice box. Don't forget Thursday the 23rd of April 2020 at 3pm on the bold with insulin Facebook page. Alive Scott and Jenny. Jenny and I are gonna answer your questions right there on the Facebook machine. And later, you'll hear it on the podcast. It's actually at bold with insulin on Facebook. So I don't know how you do that Facebook calm. There's some slashes in there but you'll find it. What else? I don't know. I hope you guys are being safe and find the things to pass your time and all that stuff. I am recording this right now in a pair of shorts and it's too cold to be in shorts, but doesn't matter because I'm not going anywhere. So at least I'm wearing the shorts
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