Scott Benner 9/23/23 Scott Benner 9/23/23

#1016 Diabetes Pro Tip: Long-Term Health

Scott and Jenny discuss optimizing long-term health with type 1 diabetes.

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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:04
Hello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right, you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CD and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisit double. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. While you're listening please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have an amazing offer for you right now at my link only contour next one.com forward slash juice box free meter you can get an absolutely free contour next gen starter kit that's contour next.com forward slash juice box free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries G voc hypo pen. Find out more at G voc glucagon.com. Forward slash juicebox Hello, everyone. Welcome to Episode 311 of the Juicebox Podcast. Today's episode is a pro tip. So you know that means it's not just me today and a guest it's me and Jenny Smith. Today Jenny and I are going to talk about long term health as it relates to type one diabetes. This one's a little less pro tippy and a little more conversational. The information rises to the level of pro tip. But the style of conversation is more like Jenny and I got together as friends. And I said, Hey, tell me your thoughts about this. And then we chatted about it a little more laid back a little more conversational. But the information is definitely something you want to have in your tool belt. And that's why this episode is part of the diabetes Pro Tip series that begins back on episode 210.

Unknown Speaker 3:18
What are we doing today?

Scott Benner 3:19
We are going to do a protip episode that you suggested and prevention of long term complications you said and you said What does optimizing glucose long term do for keeping things healthy? So I feel like what you meant by that is low less variability not low but in you know, lower than what a lot of people go for less variability, lower standard deviation, how is that going to help you throughout a lifetime? And so I feel like between that, and some other safety ideas that I'd like to bring into the conversation. I think we're going to have a good a good talk here. So I guess first, why don't we talk about a little bit through time, right? Where does everybody? Am I everybody? I mean doctors, where do they get the information that they put on their patients? You know, I'd like to see you have an A one C of x. Does that come from the American diabetes Association? Did they set the tone who sets the tone for what we should be shooting for? For somebody does it

Jennifer Smith, CDE 4:22
as far as targets? You mean? Yeah. Yeah. So I mean, well, targets count. It's funny. I just had a conversation with somebody who listened to the podcast, and I had a first visit with her just before this. She asked the same exact thing. She's like, I'm getting all of these different targets from different people. And she's like, I don't even know what to believe anymore for target. She's like, I know where I feel good. I know where I kind of want to be but what am I aiming for? And I said, well, there are a couple so the American diabetes Association aims for post meal target under one ad that comes from the American diabetes Use Association through research and gathering of all of this information and you know, whatnot and looking at complications down the road. Cumulatively, they aim for what less than 180. Now, the American Association of clinical endocrinologists recommends less than 160.

Scott Benner 5:19
So less than 160, less than 160.

Jennifer Smith, CDE 5:22
Okay, so there are two high in the ranks of diabetes management that are different already. Right. And then we bring into the mix well, what are recommendations even further than that, like pregnancy? Pregnancy recommendations, you know, are for the most part under 120, fasting under 100. And post meal no higher than 140.

Scott Benner 5:51
So, um, is what I'm hearing good, good for the

Jennifer Smith, CDE 5:54
Fusion. Yeah, right. Confusion entirely. And then I had a woman in a couple of years ago postpartum, I had her visit with her. And she's like, so I was aiming for all of these targets in pregnancy to keep my baby growing healthy, and myself. And she's like, and then my doctor tells me to loosen up my target in my palm, and tells me I don't have to be so you know, quote, unquote, tightly managed. And she's like, she's like, I want to ask your opinion, Jenny? Like, why wouldn't I want to stay this tightly controlled if it was good for me in pregnancy? And these are targets that people without diabetes, maintain? Because their body does what it's supposed to do? She's like, why wouldn't I want to maintain this? Whether I'm pregnant or

Scott Benner 6:34
not? Yeah, yeah. So here's right here. Exactly. And here's what it's making me feel like, so much like, with everything about diabetes, when you try to give someone like this just, I don't know, this is how things are right? Like it 181 6120 whatever anybody ends up saying, That's not personal. And and personal between should be considerations should be you, your intent, your involvement, your intellect, your understanding, than it should be, am I injecting? Am I using a long acting insulin that was made 20 years ago? Or am I using one of them that's been made more recently that people find more stable? A lot of the times? Am I using a pump? Do I have a glucose monitor? Is it a, you know, is it a libre? Or is it a Dexcom? Is that the G six? Or is it the g4 Like, it would seem to me that all of those variables would would make it more or less likely for me to be able to maintain targets that are lower or higher? Right? And so then you get the doctor, like what you just said about the pregnant person? I feel like that doctor was like, Look, you must have had to have killed yourself to keep your blood sugar that low. Right? Like, obviously, it ate up 99 months of your life, you did nothing but keep your blood sugar in check, have to pay and watch television, that must have been your whole nine months, right? Like, like you're talking to a guy in 1920. It's like, you know, you didn't even have time to make me my pot roast. Like that. Fake, right? You're getting old time idea, right?

Jennifer Smith, CDE 8:12
And now you come into the office and you look like you've got baby spit hanging off your ear, and you look like you haven't slept or combed your hair. So let's loosen things up.

Scott Benner 8:20
Right, right. I think that what would make your day easier is if you were less healthy. But it's not it becomes about and I get that right? Like, I think that out away from the ideas that we talked about on the podcast. Maybe that's real. Do you know what I mean? But when you start telling people, we I, when I started asking people, you've been at this for a while now six months, eight months? Is it that hard? They say no. Like most of the Pete I don't want to say most of them everyone I've ever spoken to who's picked up the ideas of the podcast, put them in practice, and gotten to the point where it's just second nature. They don't think about diabetes very much these these targets are meaningless because you get to a spot you stay at that spot. If you leave that spot, you know how to get back to that spot. Right? That seems like it to me, honestly. Right.

Jennifer Smith, CDE 9:12
And from the standpoint of, you know, prevention, I mean, that's the that's one of the biggest things that brought out beyond Well, here's your insulin, here's how to inject it. And oh, by the way, insulin can cause your blood sugar to go too low. complications are always within the first like, new onset diagnosis, discussion. There's always something about complication, right? Always, like you have to control things. I love that word control because like, like a moving target of control.

Scott Benner 9:42
That, by the way, gives you the impression that you're going to be out of control and it's your job to control the chaos. Correct. Right.

Jennifer Smith, CDE 9:49
Exactly. It's like your job to herd all of the million cats in your yard with no fences, right?

Scott Benner 9:54
What if I just didn't let the cats in? How would that be?

Jennifer Smith, CDE 9:57
How would that be? Exactly? Yes. Exactly. So you know, the prevention of complications that I mean, there's no, there's no set solution, really, on how to 100% prevent complications. In research, we've seen people with many years of diabetes, some of them poorly, you know, manage, some of them tightly managed. And complications can start for people at different points of time. And that makes it seem like, Well, gosh, I'm just gonna throw my hands up in the air if I can't 100% prevent anything. But what we do along the way makes you feel good. On a day to day basis with tighter containment of things overall, yes, you are likely 99% likely avoiding the complications down the road. Right? That 1% That's something could happen. Sure, it could be there. But I don't think there are many things in this world that are 100% Perfection. And so

Scott Benner 11:01
to your point, it's, it's presented incorrectly to people. It is like right away, like, you know, it's not your goal not to die, right. It's your goal to live really well in till you die. Right. Right. And if you can extend those years. Wonderful. But you know, it just and you just said to about how people feel? I've been talking about that a lot lately. I don't know why people don't think about that. Like just how they feel every day like, you know, are they tired? Are they sluggish? All the stuff that we've spoken about over and over again? Why is that not important to them? And I don't think it's not, I think they find it to be something they can't impact, which isn't true. It just isn't like there are times there are times genuine, I'm afraid people will realize that when I keep saying over and over again. It's about timing and amount and common sense. They're gonna go, Hmm, I don't think I need to listen to that podcast. That guy might be right about that. Like, why don't I just tie my insulin better? And when I see something happening, go, Hmm, that makes sense. I should do this now. Yeah. Right. Because I mean, honestly, there's no point if you guys all figure it out, the podcast is over. Basically, I, you know, obviously there will always be newly diagnosed people who are going to get this terrible information and start down the wrong path. I just I want I want people to think more about how they feel. And I spoke about this in my talk this weekend. And I've said it here before, too, but you have to, you have to believe that if your blood sugar is constantly high, you're altered. You just are like there is a person with a short term and long term. Yeah, there's a person you would be intellectually articulately that you don't get to be when your blood sugar's higher, or crazy low or bouncing around, right? Because your brains always just, it's just, it's not where it needs to be. I don't know within

Jennifer Smith, CDE 12:58
that, even within that day to day feeling, are those behind the scenes. Unfortunate what's happening in the body that you aren't feeling? Like, we know how high blood sugars make us feel. And if you're paying attention, you know, the containment of them, you get out of that you can think better, you can act better you can do the things you enjoy doing. But behind the scenes, internally, what's happening with better management is you're not causing damage to cells. You know, I mean, especially heart disease. I mean, heart disease is a huge component that we have to take into consideration. But it's not like it has to be there in your brain every single day. If you are managing the blood sugars, you're also managing a healthy heart. You're also managing healthy kidneys, healthy nerve cells, healthy eyes, you're managing those internal pieces that until they are damaged enough and give you indication that there's a problem. You're managing that along the way so that you don't get to the end of the road and have heart disease or kidney problems or whatnot, right? Yes. So

Scott Benner 14:09
and where do you stand? Have you ever heard me explain how I think of it with the sandblasting? Have I ever said that? Because here's the place to say it if I've never sent it to you? Okay, so the way I think about high blood pressure, high blood sugars, and back when my kid was little, and I was looking for motivation, like seriously, like, what? What's going to get me up at two o'clock in the morning to correct a 150 blood sugar. When my doctor is telling me that's okay, like, what's the motivation? And whether I'm right or wrong? Technically, in my mind, it feels like this. My body is built to withstand a certain amount, a certain content of sugar, glucose in my bloodstream. And when there's more there, on a cellular level, glucose is still sharp, right? It's like, it's like if you take a sugar and he spilled on the table, you look at it It's a course and you know, it's sharp and even on the molecular level, like smaller, smaller, it's still sharp. So when you pack too much of it into your veins and your arteries that run through your heart, and your eyes and your legs and your fingertips and everything else that sharp does is scratching at the inside of that soft tissue and those veins and those arteries, and one day, it'll wear through a little hole. And if it wears through a hole in your heart, you have a heart attack, if it wears through a hole in your eye, you have vision trouble, if it starts wearing through in your feet, you might not be able to feel your feet, and on and on. And again. So all of the diabetes complications that are on a list somewhere in your doctor's office to scare the hell out of you. What it really means is, if your blood sugar's too high, you know what inside of your body, is it going to rub through first and create a breach? And you know, and will that breach, you know, and that breach will hurt. You might you know, we talked recently about my friend Mike who passed away, he was on dialysis. So the first thing that it rubbed through was his kidneys. And then as he was on dialysis, the second thing it rubbed through was his heart. And then he had a heart attack and he died. And that's it. And he'll he'll his death certificate says he died from complications of type one diabetes. So that's it right.

Jennifer Smith, CDE 16:14
And that's a great, it's a very layman's, a way to understand it. Because I think that the textbook explanation is, it's too clinical. It's too medical. And I think that's why for the most part, people are aware of complications. But when you explain it such as that damage piece, and I used to explain it in the class, the type two classes that I used to teach is that high sugars caused damage to the inside of your vessels caused damage to the the outsides of the nerves and everything and almost like eat it away. So like a sandblast. Yes, it's like cutting and cutting and cutting and calling causing small abrasions, writes, scratches, scrapes that the body actually tries in your body is a it's a, it's a self healing. Like organism, right?

Scott Benner 17:07
It just happened to you right away in fixing little making little patches. It's like your road crew in town filling potholes, when you think can you just repave the whole road, they're like, nope, best we can do is pop in a little patch in this hole.

Jennifer Smith, CDE 17:20
And it's more inflammation, I mean, long term, those little holes are really from inflammation in the lining and along the cells and whatnot. And over time, I mean, if that inflammation causes a tear, the body tries to patch the tear. Well, if more and more tears happen, and more and more patches get placed into the vessels, you know, and I know visually, this isn't a podcast, people can see. But as you can see, my hands get closer and closer together to indicate the constriction and the narrowing of vessels. So then we have heart disease and potential for stroke and problems with blood flow, getting two kidneys to do what they're supposed to do, and circulation to your fingers and your toes and everything see.

Scott Benner 18:03
And Jenny, the way I think of it is I was just there one day in my house trying to talk myself into not giving up before I understood what was going on. Right? So what do I need to do to not give up and this is how I put it, it's really no different than a football coach who just has a player has three brain cells in his head, and he goes, Look, see this line right here. Don't let that ball go past that line. And that really is how I dumped it down for myself. I was like, I can't let that ball go past that line. Like I have to try to figure out how to stop that. And I think everything that everyone's listened to since then, is born from that idea. Like how do I stop this from happening? Right. And I've had that moment where I realized I may not be stopping it from happening to like, maybe my kid genetically is just the one who can't withstand having type one diabetes. I don't know, you know what I mean, but she certainly has a better chance, the way the way she lives right now than she would if I just listened to, you know, just keep her under 200. You know, don't don't let her spike over 180 or 160 or whatever, after a meal if you right you know if you can. To me that was just that just made sense. In the moment when I was scared and alone and it didn't know what I was doing. I just thought like I need a I need I need a goal. You know why?

Jennifer Smith, CDE 19:25
And blood sugar Oh, sorry. Sorry to interrupt. Go ahead.

Scott Benner 19:27
No good blood sugar.

Jennifer Smith, CDE 19:28
It's gonna say blood sugar is a big piece of it. But you know, the other components to those complications too, are the other factors that also contribute to blood sugar management, right? So the kind of nutrition you take in sedentary versus more active lifestyle, all of those are also huge benefit for long term health outside of just controlling or managing your blood sugar

Scott Benner 19:58
that remastered diabetes This Pro Tip series is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have a unique offer just for listeners of the Juicebox Podcast. If you're new to contour you can get a free contour next gen starter kit by visiting this special link contour next one.com forward slash juice box free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juice box free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen it fits well on your hand and features Second Chance sampling which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com Ford slash juice box free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips you can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now through your insurance. Contour next one.com forward slash juice box free meter go get yourself a free starter kit. while supplies last US residents only touched by type one has the back of people living with type one diabetes. Take for instance, their D box program touched by type one knows firsthand the intricacies of living with type one diabetes, and so their team has created a DI box which is a starter kit that provides important resources and supportive materials to individuals with diabetes. They want you to thrive. The D box is completely free and available to newly diagnosed people. All you have to do is go to touched by type one.org. Go to the Programs tab and click on the box. While you're there, check out all the other resources and programs available at touched by type one.org. Speaking of support, touched by type one.org is available in English and Spanish. Don't forget to find them on Facebook and Instagram too. You do not want to miss what touched by type one is doing. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. G voc hypo Penn is a ready to use glucagon option that can treat very low blood sugar in adults and kids with diabetes ages two and above. Find out more go to G voc glucagon.com forward slash juicebox G voc shouldn't be used in patients with pheochromocytoma or insulinoma visit G voc glucagon.com/risk. And all those things become exponentially more important when you have type one diabetes. They're important to a person who doesn't have it, it becomes even more important when you do like sometimes you just feel like you know like how many how many gunfighters are going to be on the other side before I just I don't have time to get to the mall. You mean like I'm gonna get overwhelmed because there's just so much over there. So you have to give yourself a chance. You know, and aside from the idea that exercise helps you keep lower blood sugars like that aside, exercise does all the other things that exercise. You know, it's funny, it's worth mentioning here that I realized the other day that some people refer to me behind my back is like somebody who pushes carbs on people. And I thought that's odd. I've never considered that before. Excuse me, but I guess more low carb people kind of can feel that way a little bit. But I listened to it and I thought it through and I don't feel like I do that. I feel like this podcast teaches talks about preaches maybe how to use your insulin, like how insulin works. And I say all the time. Once you know how your insulin works, I don't care what you eat, you know, you do whatever you want. But I think you need to know whether you're low carb or whether you're a person who's like, wow, I think I could eat that whole box of hohos. Like Like whether whoever you are in that scenario, you know, one side or the other. If you understand how to use the insulin, you can accomplish it. I'm not saying because I know how to Bolus for Chinese food. You should do it every day, every day.

Jennifer Smith, CDE 24:45
Right every just because they know how to Bolus the chocolate chip muffin and the chocolate milk and the Hershey syrup on top doesn't mean it should comprise every meal. Because Is that better than an apple with peanut butter and nutrition well is probably not. But

Scott Benner 25:01
is there a danger, I found myself wondering of people focusing on themselves so much as diabetes that they forget to think of themselves as person. Like, you know what I mean? Like does does a piece of does a big cupcake not seem unhealthy anymore because you know how to stop a spike from happening when you eat it. And that's important to remember that it's still, it's still a cupcake, it's still something that's, you know, a once in a while thing, not an everyday thing, because I can Bolus for it. And I think that's so I think Jenny's point is important too, is that there's just a lot more that impacts your health than just your blood sugar. And we sometimes we talk too much, not too much. But we're so focused on trying to understand it, because there's so many components that people don't understand that you stop thinking about, like, hey, you know, what else is easy to Bolus for broccoli.

Jennifer Smith, CDE 25:56
It's learning to manage the insulin around what you eat, you decide what you're going to eat, and you figure out how to manage it. It's not encouraging people to eat a high carb diet.

Scott Benner 26:07
Not at all, I don't see it that way at all. I see it as understanding and so on. It's just how it is I, I was speaking somewhere recently, and I looked down and saw a person in the crowd who this has happened to me about three times since I've been doing public speaking around diabetes. But I've looked down to see what I would call like an old school person in the diabetes community. And when I'm talking, I can see on their face, they're just there somewhere between angry and horrified that I would even deign to talk about insulin, and how to use it. You know, like, you can't tell people to you guys, when I'm on when I'm up on stage, I tell people, no different than, you know what I say here, right? I'm like basil is first beat, we have to have your basil, right? Because we can't just start Pre-Bolus Singh and doing other stuff. Because if your basil is wrong, it could end up being dangerous. So first, we get your basil right? Now after that, step two, you have to Pre-Bolus your meals. And that's usually when I look down and see like somewhere like a 60 year old mom whose kids had diabetes for 30 years now. Like, you know, like their arms are moving around, and like, oh, you can't say that to people, you're gonna kill them, you know? And I'm like, Alright, and so I'm like, you're thinking about this in a different way. Before that, you're not considering the technology, you're not considering that these are not the same last lambs that you talked to 30 years ago, right? Like these people are here to find this out. They want to know this.

Jennifer Smith, CDE 27:42
And long ago to bring in long ago, timing was an insulin issue. Long ago, I've had diabetes 31 and a half years, I started on our insulin, and the cloudy what most people started on something called NPH. Or en, I was on L which was Lily's brand, okay. I did no carb counting. I use the exchange diet. I took exactly this amount of starches and fruit portion and vegetable and protein and fat at every meal. And my mom or dad gave me my insulin mixed in a syringe at breakfast and at dinnertime and I eat it strategic times in exactly the same amount of food. There was no other than measuring the food for the right portion. There was no carb counting, there was no insulin based on carb. It was you take your insulin and from the dosing standpoint, my insulin, regular insulin, you know, it's slow. I mean, we call it short acting. It's slow. I mean, it may not have a dose me 45 minutes an hour before I even started to eat in order to curb that post meal, right?

Scott Benner 28:57
Yes. And so everything you just said, is about using the right amount of the right time. Hi, Nick. Yeah, it's timing. It's all timing. Like I, again, I that I figured it out. I mean, we should all be able to figure it out. Right? Really, I know myself, trust me. It's there's not a lot like I'm not, you know, I'm not over here. Figuring out the Pythagorean theory after or a theorem, whatever it's called. I don't know, after I get off the podcast. Yeah, I just don't think I think there's so much fear in now that we forget later. And you know, what we're talking about right now is long term health. And so, let me jump to I can't quote it. I don't have it in front of me. I don't know where it came from. But I think everyone's fairly aware of this article that came out in the last six months that tried to say that lower a one sees aren't necessarily an indicator of health. And that did you see that one they started talking about like, you can have a one seat like this here. It'll be fun. if it tried to give the impression to me that the way I saw it was someone trying to say, Look, I know a lot of you are using this technology to do better, but you really shouldn't do that. Like it's not necessary. And I thought, well, how do you know? You don't even mean? Like, like, I thought the same thing. I thought when I saw vaping the first time I was like, I have no interest in that. But if I did, I wouldn't do it. Because I don't want to be the one to find out 10 years from now what happens? Because no one knows, you know, right? So is there any in your mind? If you're safely at, if you're in the fives, and you're a one C and look, you know what I'm going to do here, I'm going to actually pull up an email. To make my point, hold on one second, it's going to take me a second to find it. I apologize for that. But I got this email this morning from a person I know who listens a lot. And when she emailed I thought, wow, this is gonna work right into what Jenny and I are talking about today. It's crazy. And it's from Laura. And this note from Laura mimics many, many, many, many notes that I get. Scott, I achieved a 5.4 a one see, first time I've ever been under 6.4. But my doctor freaked out at the number of lows. And she's asking, what's an acceptable amount of time under 70? Like, how many times can I dip under 70? And you know, and so I there's first of all, it's it's a two step thing, right? Everybody who goes to any kind of a doctor who's more like the lady in the crowd, who's thrown her arms around y'all and don't talk about it like this, when they get their blood sugar down, and they find a way to keep it stable, and it starts impacting their variability and it starts impacting their agency, the doctors flip out, they make this assumption that they have all these crazy lows, and it's throwing them off. So I know what I'm okay with. But what where do you stand in your personal life? I guess like how often do you find yourself under 70? Do you think?

Jennifer Smith, CDE 32:10
So personal versus professional, I kind of I really aim for the same thing, quite honestly, overall. And this is where I think that that data is very helpful from a CGM standpoint. Because especially when I speak for clarity, the other reports or the other CGM is do give you something similar as far as data. But from a clarity standpoint, clarity always gives you that overview gives you your glucose management indicator there, quote unquote a one see right from CGM, not from your blood glucose, right? It gives you your average glucose, it gives you your standard deviation, it also gives you this little like chart that shows you time in range, right? And it is based on what you have your time and range numbers set for 70 To 180 60 to 140 90 to 200. So you have to adjust those parameters. But clarity has it set 70 to 180, for the most part, right? We aim for the lows specific to be less than 5% of the time. So from all of the gathered data, whether it's two months or two weeks, or one week, or whatever you're looking at that percentage of time, we're aiming for less than 5% to the low and low being less than 70, less than 70. That's, that's the goal is to be low, less than 70. Less than 70, less than 5% of the time. So from the standpoint of overall a one see though, you know, if, if a clinician is coming in saying, hey, you know, wow, that's way too low. And they're looking at data, which proves that, well, gosh, you're hanging out in the 50s consistently, and that's why you're achieving a five point for sure. And if you're low, let's say 12% of the time, okay, there's some work to do to bring that back up into range. So that that 5.4 is actually better, for lack of a better word. Better, right? It's more real 5.4 In a target range that's healthy, safe, and good for you, overall,

Scott Benner 34:23
you're reaching that number with quality decisions, not good. Not with, you know, being low. And just coming out

Jennifer Smith, CDE 34:31
and saying 5.4% As of Oh, my goodness, that's, that's way too low and not even looking at what what is that 5.4 The person could have very low standard deviation, maybe their variability is 20. And they're ranging somewhere between 70 and like 120 pretty consistent or 70 and 100. Great, fabulous. You're, you're knocking it out, have at it, continue what you're doing

Scott Benner 34:59
so When I gave the explanation of a Pre-Bolus this week, this weekend, I used something that had happened an hour before because my wife was at home with Arden. And I said actually my wife did a great job this morning with breakfast. About an hour ago Arden's blood sugar was 70 and it was time for lunch. Now Arden is at school, and I think 70 is a great blood sugar right before a meal. Arden's blood sugar was able to stay at that level for a number of reasons. But those reasons are evident to us as they play out, because we can see her blood sugar in real time with the Dexcom G six continuous glucose monitor. Not only can Arden see her blood sugar right there on her iPhone, but I can see it here at home on my phone as well. Because of that knowledge and seeing the stability that had existed within Arden's blood sugar for the hours prior to lunch, we were able to make a good Pre-Bolus and give her a nice launch into her mealtime. Now that our later Arden's blood sugar is 132. The data that comes back from the Dexcom G six continuous glucose monitor is life altering with type one diabetes, but being able to see it remotely, that takes life altering to another level. So if you'd like to know what your blood sugar is, the speed and direction it's moving, and find those things out without a finger stick. The Dexcom G six is something you should check out. I have a link you can use dexcom.com forward slash juice box. There are links also right here in your podcast player notes and at juicebox podcast.com. But I think you should check out the Dexcom Arden's results are hers and yours may vary. But I'm telling you right now Dexcom is a game changer. Now moving from continuous glucose monitoring to insulin pumping. I'd like to talk about the AMI pod. Until you first I have just as much affinity and love for the AMI pod as I do for Dexcom Arden has been wearing the AMI pod tubeless insulin pump since she was four years old, she'll be turning 16 In just a couple of months. The Omni pod brings so much freedom along with the ability to pump your insulin right no injections all day long. No slow acting insulin and fast acting insulin let the Omni pod take care of your background Basal insulin for you. It does that put your insulin in the pump, you get your Basal insulin from the pump. And when it's time to Bolus for a meal or to crack the high, same insulin, same pump, no tubing, right so not an infusion site on your body somewhere that's attached to this plastic tubing that runs through your clothing out to a controller that has to clip to your belt. You know whether you're an adult or a little kid, you're not looking to have something clipped to you. Here's what you can do. Go to my on the pod.com forward slash juicebox. There you can ask on the pod to send you an absolutely free, no obligation demo of the Omni pod. It'll come directly to your house. You can try it on and see what you think for yourself. You can see the difference between wearing a shirt and not having tubing running down your sleeve. Every time I've worn a demo pod. What I thought first was, it's amazing how quickly I forget that it's there. This is super important. This is something you have to do every day. You don't want it to be constantly bugging you. Check it out my Omni pod.com forward slash juice box with the links in your show notes. Were the ones you'll find it Juicebox Podcast icon, an absolutely free no obligation demo can be in your mailbox before you know it.

Actually, my wife did a great job this morning. With breakfast. She made a Pre-Bolus at like 83. Right. And it was a big kind of breakfast. And Arden drifted down drifted down and she actually hit like 63 for like a split second and came back up. So imagine this 63 probably happened 30 minutes after my wife pushed the button right? And probably 10 minutes after she had already started eating. So if you want to say she missed I guess you can. But it's funny. Had she been at 68 Everyone would have been like That's amazing. But 63 is a number that somehow gotten in somebody's head. So I'm like so she hit 63 one revolution of the CGM and right back again, and I said if she didn't have a CGM, you never even would have known that that happened, right? She's She just wasn't dizzy. Nothing happened like that. I can see it because I'm looking at it that this same person in the crowd, this person who's you know, you know, from a property from a different era with diabetes, you know, fell just shy of, you know, back of the hand on the forehead. Oh, Scarlet, what happened? I've got the vapors, you know what I mean? Like that kind of thing. And I was just like, I looked over second. I was like, You got us like I was thinking to myself, like, just stop, like, don't like the look at the rest of these people. These people are enthralled, they're excited. These are people who are half an hour after they put their insulin in or running around with their blood sugar's 250? And Are you really telling me that that's what you want to say is okay for them. Because when I speak to them privately, when they come up to me as I'm trying to walk around you guys, we're all delightful. But people would come up and be like, hey, look, this is my, you know, my 23 year old son's CGM, the kids like 403 100 all the time. Like, are you telling me it's not worth trying to do better for this kid. And so I think sometimes, both in the community, in people's minds, in doctors minds, in some older doctors minds, there's just more of that idea. And we talked about all the time, like, it's better not to like, like, I don't want you to have a seizure. Like that's it, like when I say don't die advice, like, that's what they're trying to say that I don't want you to have a seizure. I don't want anybody to have a seizure, either. But I don't want your blood sugar to be 300 all day. You know, it just it's, it's not okay. Because we say these nice things out loud, and other people who are maybe well meaning but don't have good information. They're like, Oh, you know, I want you to be safe, blah, blah, blah. But those people you're talking to online, or whatever your whatever that person's ability to get to people is, you don't get to see those people 20 years later, you don't know what's happening to them. And so I'd rather take a bet on what I'm saying being good for them 20 years later, than what I hear some of those other people saying, I think that if you're going to if you're going to roll the dice one way, you ought to roll the dice and try to be healthy, not hope. I hope that your body's the one impenetrable thing that diabetes can't find its way through. Yeah, you know, right.

Jennifer Smith, CDE 41:38
Right. Well, and there's also the safety of bringing those high numbers down to, right. I mean, it's like, you don't want to end up going from an average of 280, which means you're drifting well above 300, and not quite into the low two hundreds to average a 280. Right? So you're not gonna say, Okay, today we're at, you know, an average of 280. And tomorrow, you're gonna be averaging 100, right? That goes, well, that would be a pie in the sky one, it's not actually healthy. She drops you that fast, drop that fast. I mean, you will have significant changes in your body. And you know, I remember when I came home from the hospital for two to three weeks after I was released from the hospital. And I think I started with an A onesie in the twelves, when I was first diagnosed, and my blood sugar was coming down and coming down. My vision changed so much, that my mom had to read me my homework in order for me to answer and she had to write things down. Because my vision was so blurred, I couldn't actually see well enough to read what I needed to get my homework done. Right. So and that was gradual. So again, you can imagine bringing a really high blood sugar down that's been consistently stable high, yeah, it will be problematic.

Scott Benner 43:01
What I said to this group of people was luck. Like, don't go home, I'll shot out of a cannon, you know, and be like, I usually give a unit for this, but now I'm gonna do five. I'm like, no, no, a unit and a half, maybe, you know, and I was like, the next time go, Ha, that could have been more I said, you know, over days, bring it down over weeks, bring it down, not, don't go home and just be like that. Because that's probably not gonna go so well. You know. And, and again, Basil first. And it's funny, no matter how many times I say it, and how many times I preach how important it is. The look on people's faces. When you say to them, I need you to get your Basal insulin right is like, oh, that I give up. Like, it's quick. It's they're so quick to be like, That's not possible. I can't do that. And I'm like, No, of course she can. And that's why I've got it down to like, they're like, Well, how and I was like, Look, there's a great episode on it that you could go listen to them, like, but if you're looking for how I think of it, I think of it like volume, like I turn it up until it's too loud. And then I start bringing it back down. So you turn it up a little, not loud enough, turn it up a little not loud enough. And what I mean by that is turn it up a little my blood sugar's not sitting stable, where I want it to, you know, blah, blah, blah, and then all of a sudden, you get to a spot and you go, Alright, that looks like it. Or maybe it's Oh, I went a little too far. I'll turn it back down a little bit. I'd like but don't you know, one woman's like, by Bezos point nine, you know should but my blood sugars are 250 Should I try one and I'm like, I mean, okay, I'm like but an hour later when that doesn't work, but could you push it up a little more for me like I was like thinking about what you're saying? You Your blood your your basil is holding you at 250 1.9 Like, but you want it to come down 150 points, but you only want to move it up. Point one I was like, that doesn't make sense, right? Like, don't you feel like it might need more than that. She's like, Yeah, I guess you're right. But that but that's a doctor that scared her not to touch her Basal and so on. And so she's it just it's I don't know, I'm a little heartbroken. Like, it's a little It's very exciting and uplifting to talk to people and see them have some ideas they're going to take. And at the same time when they come up to you, and they show you how bad things are, you know, after the fifth, sixth 10th One, you start feeling like, oh, gosh, like I'm not never going to reach enough people to make a difference in the world like it starts feeling mutual to

Jennifer Smith, CDE 45:18
might even have like, from the adjustment standpoint, sometimes comes from the people who had diabetes a long enough time to have actually had a long enough experience with Basal injected insulin. And how long it did take to really see the difference in an adjustment up and or down in the actual dose and the imprecision in which that Basal insulin works on a 24 hour scale. Right. I mean, I noticed an immense difference, going from Lantis to using an insulin pump in immense difference. It was amazing

Scott Benner 46:01
is that where that kind of that that adage is like making an adjustment to your Basal wait three days and see what happens is that what that's from,

Jennifer Smith, CDE 46:09
for the most part because the well, you know, the Basal insulin clears technically within like a 20 to 24 hour time period right from let's save the example of Lantus is supposed to work 24 hours, most people somewhere between like 20 to 24 hours. And so you adjust, you need kind of at least a 48 hour period, at least after that adjustment of incremental change by let's say, two units, to see if that was enough to now hold things level and steady. And then it also depends on were you taking your Basal insulin in the morning? Or were you taking it in the evening, you know, the evening time was a little bit easier to see, because you could notice an overnight with only true Basal insulin there. No boluses no food, no activity component, you're sleeping on that, right? And then through the course of the rest of the next day, how did things look in between meals or after the meal Bolus was gone? Did you kind of get into the next meal on a nice stable level where you where you wanted to be where you still too high, or you're drifting way too low? And then we adjust again, you know, so I, then it is probably where that like, adjust wait three days to see if the adjustment held things where you wanted them and then adjust again, it's kind of where that would have started, I would expect

Scott Benner 47:29
because someone from the crowd asked me, How long is it going to take me to get my basil, right? And I was like, Well, I said, if I think if you listen to that episode, and you really understand it, so maybe a few days, you know, she says How long would it take you? And I was like What time is it now? She goes, it's like, it's one o'clock. I'm like I could have it done by dinner, you know, like so. And then we would adjust off the the rest of the clock moving forward, like but there's, there's somewhere there's a good number. And it's funny because I just I realized that I could just keep looking at the CGM and decide. I said, now if you didn't have a CGM, it take me a couple of days to write, right? Because now we're kind of blind. And we're testing and seeing things and, you know, making sense and seeing if we can see repeating that and stuff like that. It was like But, but looking at it. That's like, that's cheating, almost like that. That's pretty easy. But I also infer things from pitches and lines. And and there's no and then people all the time are like, can you do an episode about how you see that? I don't even know how to talk about it. Like, I wish I did, like I just look and I'm like, okay, that's not enough insulin. That's too much this is here. You don't I mean, like, it's just, I don't know, it pops into my head. But I don't know, I really don't know how to quantify it. If I'm being right. Come on. I'm not joking. Well,

Jennifer Smith, CDE 48:45
you've, you've looked at things enough and you understand, you understand insulin action, I think better because of the way that you've looked at things and the way that you've talked about things. Sometimes it is hard to just nail it down and explain, hey, if this is happening here, this is why and this is how we would adjust more. And that's kind of mean that's kind of what we do. We get people's graphs and information and their insulin here and like basil testing for a pump, especially you know, we'll do a basil test within a time segment. I get the data the next day, I look at it adjust here test again tonight. They do great, that looks awesome. We're perfect. We've got it like checked off, move on to the next time period. So it shouldn't be like six days in a row that you have to test that to make sure that each single one of them exactly was nailed. Because we adjusted it four days ago. Nope. If you adjusted it looks beautiful with the adjustment. Great. We're moving on. We got it. I've

Scott Benner 49:44
learned from talking to people face to face to that. The stuff they want to tell you that they think is going to help you help them is never the stuff I need to know. Do you know what I mean by that? They start giving me like and it's it's not I don't even mean to be funny. about like, they're, they've been paying close attention. And they're like, Okay, like, here's a piece you absolutely have to understand. I'm like, I don't care about that. That doesn't matter. You know, like, like, I'm like, How much do they weigh? How old are they? What kind of insulin are you using? What's your Basal rate right now? You know, where do you sit steady when you don't have insulin, and you blah, blah, blah. And then from there, I'm just like, Okay, turn this up, turn that down, make this this. And then let's wait and see what happens. But it's interesting, because the information they've been given so far has led them to ask almost all the wrong questions. Right? That's the part that I find fascinating, right, is that somebody has been directing them along the way. And now I talked to them. And then I talked to them again, two weeks later. And now they want to make a small adjustment. And they're asking the right questions. It's very interesting. Like, it's just where you, it's who talks to you first. Like it really is, it's like, whoever talks to you first, you win. Or you lose, like right then and there. You don't even realize it. And it's happening. There's somebody being diagnosed right now, in the world, who's talking to a, an endo, who understands, and they're gonna go on one beautiful path, they'll never find this podcast, because they don't need it. And then there's somebody else being diagnosed right now who's being told all that stuff that we, you know, have to debunk, and then reteach? It's just, it's bizarre. I mean, you don't like, do you get cancer and get two wildly different ideas like this one cancer doctor say to you, Hey, listen, we're gonna try a little radiation. And then if that doesn't work, we'll try to cut it out. Is there another doctor that says you should go home, blow up balloons and eat birthday cake, and I'll fix the whole thing? Because it feels like it's that far apart, you know, like, one ideas, right? And one ideas? I mean, I'm sure there's variations in between? Well, I

Jennifer Smith, CDE 51:45
think the extremes truly are the people who still to this day, for whatever reason, will go into their clinical diabetes team, and they get the hand me your pump. It's like handing over like, you know, your foot. I think I said that before and after. So it did nothing. And you're like, that's great. Thank you. Your pump is like, like your foot, like, well, that really my foot, just a body part, right? You hand it over, they like take it away from you. And you're like, Oh, my goodness, you've taken like my body part from me, you know, and then they bring it back to you. If they've dumped this data in, they look at the data, they don't ask you anything, the doctor might actually sit there and actually might push your buttons on your pump. Yeah, physically make all the adjustments for you. And your left, then handed back reconnected with your pump. And the doctors like, oh, we adjusted some of the Basal or we did this and this because I thought I saw this happening here. What's lacking there the education? Why did you adjust? What were the explanation? So the person could go home and say, Okay, I understood the doctor adjusted here, because he was seeing this. I'm gonna now watch this. I'm gonna see did it help? Does it make it better? Did it make it worse? Do I need to readjust this? How should I readjust it? That's the missing chunk. And, you know, I think that that piece of not educating people, nor even letting them push their own pump buttons to make the changes, or add in hay, three days in a row. This past week, I was at grandma Joe's eating like sloppy joes and birthday cake. And please, please don't pay attention to that data. It's not my true trend. But the doctor is basing adjustments off of it.

Scott Benner 53:35
It messing up everything else that may have been working better than that. I brought a poor kid up on stage from the college diabetes network this past weekend. And I just we stood Arm's length apart, we put our palms together, you know, standing side to side. And I said, you know, I'm going to be insulin, and he's going to be body function and carbs. And I was like, right now, he and I are pushing, you know, an equal amount into each other. And we could stand here forever, like this. I was like, but as soon as I don't push quite as hard. And he started like overpowering me. I was like, now the carbs and the body function are winning, which means my blood sugar is going up. And should I push too hard. I start driving that down and your blood sugar gets too low. But as long as we stay balanced, and we're pushing equally on each other, this could go on like this forever. While I'm saying it, audibly I can hear people going. Oh, like out in the audience like, right. Oh, wow. Okay. And they just as I was saying it I thought a doctor couldn't think of that. Like, like, you know what I mean? Like cuz dumb me figured it out. And you know, put it into words. Like Like that was it and just them watching that. And it's something I'd done before with my own hands like palm the palm. I've explained. I've gotten people on the phone and I've made them put their palms together and like and like done it. And I just think like, it's just it was so simple. You could see like nodding going on and people were like, oh, okay, I get it. I found a million ways to talk you added since then I've talked about like, bringing in more blockers to like, you know, stuff like blocks, like in football, like I've talked about it a million different ways. And every time you kind of paint a picture around it, you get somebody else to understand it. I just don't know. It just doesn't make sense to me. So these doctors are telling you, I want you to be healthy forever. But then they kind of some of them don't tell you how. And so. So optimizing your glucose, right for long term is going to keep you as healthy as hopefully possible. Right? Yes,

Jennifer Smith, CDE 55:32
absolutely.

Scott Benner 55:32
What about gaps of fall off? Right? I don't like the word burnout so much. But what if they just stopped paying attention for a week that turns into a month, that turns into six months, is that if I, if I come back from it, no, I'm not trying to give people like, like, I feel like I'm saying, you know, you can go off and, you know, go off and do heroin for six months and come back, and it's not going to hurt you. But I'm saying like, if you have one of those moments that a slip up or your life gets, you know, busy and all of a sudden you start leaving your blood sugar at 140 instead of 120 or 180, instead of 150. Is there any way to quantify what that means to you long term? Or there isn't really right? It really

Jennifer Smith, CDE 56:18
isn't? Because again, there's nobody has kind of quantified exactly what amount of mismanagement equates to this amount of complication down the road. If you don't do this for three years, you will have this amount of heart damage 10 years from now, right? There's no you can't quantify it, but I think you can also not bank control that was optimal. Yeah, for the next month and saying, Okay, I was really really awesome for six months. And now I'm gonna go on like an eat all convention blowout in Italy and just not care or pay attention. detrimental stuff could be happening, could, I don't know what's happening in your body. It's not great for you, but it's, you know, but you you're not, you can't bank on the six months previous being like a code over for smoothing that out and being like, Okay, this whole month of like, mismanagement doesn't really count because I was so good before it's

Scott Benner 57:25
like sleep, you could get great rest six days in a row, and then STAY UP 24 hours, you're still gonna be exhausted, you can't, you can't bank sleep, you can't bank health, you can't like that. That kind of stuff is really super important. Understand. But you know, it's funny, because the same time when I'm teaching people how to get going, like within a one season I started trying to impress upon them that overnight is easier than you think you know. And like, once your basil is right, and you're not bolusing too much or too little, you're not going to get these wild swings. Now you've got this third of the day, you don't as like, so if you see a 160 in the middle of the week, in the middle of the day, you can feel a little better about it, because you had like, you know, you're at five or eight hours last night, right? It doesn't make whatever impact the one at Spike has. And like you said, I don't know what it does or isn't is or isn't doing to your body. But if it is doing something being at all night long, doesn't stop that. Right, you know, like being safe right now doesn't mean that if I burned my finger, five minutes from now, you know, it doesn't make it go away. It's still happening. I think that's really that's good information. So what are we in your own personal life? Is that how you think about it like just I'm gonna do my best and hope this works out?

Jennifer Smith, CDE 58:41
I do because I you know, I I try really hard not to like I go to all my checkups, right? I mean, I get like, my heart checked and I make sure that I go to the podiatrist I make sure that I get my feet checked. I've never had any problems thank goodness but I still go for all my checkups I go on I see my ophthalmologist to make sure they check all the vessels and you know, do the test for the puff of the air in the eyeball, right? Like you always like you're always like an idiot when it hits when it hits like anticipation of that puff of I have puff of air is worse than the actual puff is but you know I do all of those things because I know that they are a check in the long term. And you know what, if something does come up, then the checking is also prevention for furthering problem, right? If he says get a check on something and up now something is happening. Okay. One might beat myself up a little bit of I could have done this better. I could have done that. But that doesn't help. That's past you can't go back and fix it. What you can do is continue to go forward and say okay, I can try to do better here or maybe I need to add This now I just need to see the eye doctor every three months instead of every six months or once a year, or they've got this treatment that could help me and it could make it better. And if I continue to do what I need to do, then I can prevent further complications down the road. So

Speaker 3 1:00:16
yeah, I also want to say that, I think

Scott Benner 1:00:21
I've never met anybody so far, I should say, that has told me, I decided I don't care, I'm going to run full force straight ahead, I'm not going to pay that much attention to my diabetes. And however long I make it as how long I make it, whenever one of those people runs into a complication, they have always said the same thing to me. I wish I wouldn't have done this, like you don't, I mean, like, I wish I would have bla bla bla or tried something else, or it wasn't my fault. Even I didn't know. But I wish I would have kept searching. And and I think that that's the truth like it, whether you make it, you know, till you're 40, when all of a sudden, you're finding out UD dialysis, or you make it to 70. And you're like, I made it to 70. And then all of a sudden, you're having a heart attack, a seven year old type one who's having a heart attack doesn't go at least I made it this far, you start thinking, Oh, I would like to stay alive a little longer, you know, like, like, it's, I don't think many people get to the point of no return whatever it is, and go, you know, I did my best and, and I'm happy with this, I think I think that people really do feel like that, like, Oh, I wish I would have whatever that means, you know, whatever they wish they would have done. I mean, if you're a person who can make it the whole way, and just be like, you know, 35 years old, jumping your car over a canyon and realizing you're not making it the other end to go, oh, well, I did my best. You guys, like that's a special like, that's a special gear you have. But what I'm saying is is that caring now will keep you from that feeling of I don't know what that feeling would be what how to describe it. When people talk about their they are disappointed in themselves. And then they can't shake that feeling for the rest of their life. Right? Like every day, they wake up with a problem. And they have this feeling like, oh, maybe I could have done something about this. And then you have to live with the problem and the guilt. And it's hard, you know, so I say all the time. I think with what we talked about on the podcast, diabetes becomes pretty. You know, I don't like to say easy, but I think it becomes like a second nature thing for you. I would rather put that effort into understanding a Pre-Bolus or, you know, something like that, then I would spending six, eight hours a day fighting with high blood sugars that cause a low they have me eating, that make my life feel like turmoil that I'm not living, I'm just existing through rack. So I don't know, that's how I feel.

Jennifer Smith, CDE 1:02:46
And then I agree and I kind of the way that I feel about my own management is I do the things that I do every day to make it less of a visible upfront in my face, to let it be more of a yes, I have to manage it, I still have to look at my blood sugar, I still have to take my insulin, I still have to count my carbs and Bolus the right way and whatnot. But those are like more second nature things that I just

Speaker 4 1:03:15
do now. And until I have like

Jennifer Smith, CDE 1:03:19
a bad sight or something that I really have to completely put my focus into and, you know, take care of the normal things that I do every day are just, they're part of my day. Exactly.

Scott Benner 1:03:31
And those bad sight moments, because I recognize what you're saying is how Arden's life is in mind with helping her is that most of the time, we are just sort of cruising along. And when something really goes funky, and you're all of a sudden you have to stop thinking about life and you're now you're focused on this diabetes thing. In my heart. I know that some people live like that all day long every day. Right? And that's just because that's an explanation to me, like you're bad cites a great explanation because you're but all that means is you're not getting insulin the way you need to. And if if your Basal is off if you're not Pre-Bolus And if you're not doing all those things in every moment, you're not getting insulin the way you should. And so your life is always going to be you know, I like that.

Jennifer Smith, CDE 1:04:13
And in the instance then of blood sugar's being all over. You never really know unless the pump tells you if you are on a pump, that you have an occlusion and that there is a real problem. You never really know. If there's a pump problem you should be addressing. Yeah, and I know when I know even ahead of an occlusion alert coming, that something's not right. Yeah, I can tell because things are contained. And if I see something odd happening and I know that nobody is like, injected me with like the sugar tube of glucose right, then clearly I am not getting insulin for whatever reason I don't know, change it out, I don't care. Well, I'm going to address it, I'm going to take care of it, I'll just change my pot out and move on. Let's see you and

Scott Benner 1:05:07
Arden have a scenario a life where your expectation is a lower, more stable number that reacts the way you expect to we said this the other day, when we were talking like I, I talked about how I think of the site as doing what I expect it to do. So the minute I don't see it, doing what I expect, or I see a blood sugar, that's all of a sudden 150 My my I start thinking, like, I can look back, if I didn't mess this up somewhere. This is this is I'm not getting enough insulin. So I don't mess with that either. Like there's a moment. Like I think some people end up looking at a bad site for days. And then and then they they'll change their property. Oh, it turned out to be the pump 48 hours later, right? Yeah, I'm not into that, you know, the second or third time I Bolus and what I want to happen doesn't happen. And I'm getting out of it.

Jennifer Smith, CDE 1:05:57
I actually had it this morning. I mean, I wasn't, I wasn't actually supposed to change. My pod out until this evening is when it was supposed to expire. And I woke up this morning. Not at my normal like Ed ish blood sugar. I was like 130 Something is like, that's kind of odd. Right now. Like, that's not where I should be. And I could see all this, like, positive temping that been kind of happening. And so I look at my site. And it's bloody in the window of my pod site. And I'm like, had I not checked, I just got I got about three, though. I'm higher than I normally am this morning. And I'll just correct some insulin, I'll eat for my or I'll take for my breakfast. And hope all goes well. Well, I just I know that that's not the norm for me. So what did I do? I changed out my pod and dealt with it, you know?

Scott Benner 1:06:49
Yeah. Because you're you would have been fighting with that all day. Otherwise, right?

Jennifer Smith, CDE 1:06:52
Correct. And my post breakfast would have been orange. I'm sure I'm sure.

Scott Benner 1:06:56
I bet you for whatever. 220 then in that situation, right, right.

Jennifer Smith, CDE 1:07:00
Yeah. Right. At least. Yeah, exactly. So,

Scott Benner 1:07:04
Jenny, if you and I were one person, we'd be a super diabetes brain.

Unknown Speaker 1:07:07
Oh, my goodness.

Jennifer Smith, CDE 1:07:11
No, in one place.

Scott Benner 1:07:12
Oh, my gosh. All right. I know you gotta get going. I'm not sure if we talked about what we said we were gonna talk about, but I found this to be a really great conversation about, about long term health and, and ideas of how to get to it and why it's important. So thank you very much.

Jennifer Smith, CDE 1:07:27
Yeah, absolutely. It was, it was good. I think sometimes, you know, the stuff about complications and whatnot gets, it gets to clinical. And I think people just need a return to that. That's why I am aiming for just keeping things tighter, or why I'm keeping things more in this range, or whatever. I mean, they know that the complications are out there. But this is the reason I'm doing this

Scott Benner 1:07:54
instead of talking about a thing that seems like it's so far away or so impossible, that there's no real reason to try to plan for it not to happen, because it's so far I will always use this example. My father smoked cigarettes all day long, two and three packs of cigarettes a day and not like not some like Marlboro light thing like Chesterfield kings, no filter, you know what I mean? Like it was left over on the floor of the place that they just roll up and sold the people you know, and in his 30s in his 40s in his 50s, smoke, smoke smoke so 60s, he'd come back from doctor's appointments doctor says I can't even tell you're a smoker and he would wear that with a badge of honor right up until smoking killed him right up until he had COPD and then and then he died. So you know can only you can only you only stay ahead of a charging bull for so long, right? And that's right. You don't want to be you just don't want to give yourself

Jennifer Smith, CDE 1:08:57
rather step off the path and be like let it run by run by.

Scott Benner 1:09:02
My dogs are barking like crazy. I think someone's breaking into the house. I might be killed soon we'll find out. would be cool. Not for me. Kelly. Oh my God finally dating. I doubt that. Oh, I hope not. All right. I will talk to you soon.

Unknown Speaker 1:09:19
Okay, awesome. Have a good day.

Scott Benner 1:09:22
I want to thank assenza diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free contour next gen starter kit at contour next one.com forward slash juicebox free meter while supplies last US residents only. If you're enjoying the remastered episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by Type one.org A huge thank you to one of today's sponsors G voc glucagon, find out more about Chivo Capo pen at G Vogue glucagon.com forward slash juicebox you spell that GVOKEG l u c h ag o n.com. Forward slash juice box. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years, and she works at integrated diabetes.com If you're interested in hiring Jenny, you can learn more about her at that link. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bumping nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low Beegees in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two in Episode 1008 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025, we talked about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active. Took me already from a decent 6.5 A one C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.

#1015 Diabetes Pro Tip: Emergency Room Protocols

Scott is joined by Jennifer Smith, a registered dietitian and certified diabetes educator, who shares her insights on visiting an E.R. with type 1 diabetes.

You can listen online to the entire series at DiabetesProTip.com or in your fav audio app.

+ Click for EPISODE TRANSCRIPT

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

Jennifer Smith, CDE 2:32
Yeah. Which was great. And I think I mean, we've touched on some of these points in like some of the I know we did like up a safety in a hospital preparedness and all of that kind of stuff. But I think this hits a really specific mark of most people that go to an emergency room in an very emergent setting. They don't really know, and why would they know that the staff there is not prepared to deal with type one diabetes. Yeah, they're not in they're not in. I don't say that in like a god. They're not educated they are they're highly educated, they're educated in a million different things, right. But their focus is so much not type one. And because the scope of how we manage type one, especially in the past 10 years, has changed so dramatically. They the staff, they can't keep up with that. They don't they don't have time to keep up with that. So when you come in, you know, on these fancy gadgets and all these things, and they're like, Well, I know an insulin drip and I know how to, to hook you up to glucose and that's what we're gonna do. Like and you step back and you're like, No, no, no, no, that's not how I do this,

Scott Benner 3:53
you you come to realize what they really understand is just how to keep you from having a low blood sugar incident while you're there. That's what they know how to do. So you may or may not be surprised by the number of emails I get yearly from nurses and doctors who have children who were diagnosed or sometimes who have themselves diagnosed. And inevitably, there are three sentences, three sentences in their email that describe I'm a good nurse, I'm a good doctor. I don't understand type one diabetes at all every time. It's just, you know,

Jennifer Smith, CDE 4:30
with a family right now the the father is a physician and the mother is a nurse practitioner and their little child they I mean they came to us and they were like we know diabetes, but we don't know diabetes. You know, I mean, we know the coded book description of this is what you do and that should be cut and dry. When you limit not cut and dry. There is no book anything A

Scott Benner 5:00
bit of nuance just a bit. Right. Right, right. So I don't think Misty would mind her name being used, Misty came into the private Facebook group that we have for the podcast. And she shared that, you know, her child had to go to the hospital. And then she had all of these questions afterwards, and statements and things like that. And when it ended, she said, I would love it, if you and Jenny talked about this stuff. And I said, Okay, you go ahead and put a list together of what you think of, you know, as emergent that came from this experience. And Jenny, and I'll try to talk about it. And she really did. So Misty, congratulations, this, you are the founder of this feast today. So

Jennifer Smith, CDE 5:42
she did a banana, I mean, from the topics that she noted, would be helpful to cover and everything. I mean, quite honestly, it kind of speaks to the amount of medical education you get, yes, it's only in one field. But the amount of medical stuff you learn, when you become either the person with diabetes, or the caretaker for someone with diabetes, I what she has here is very much in a very, very specific way really important, and should quite honestly be like taken to the emergency department heads. And this is what your Doc's should have a list of protocol to follow up. So

Scott Benner 6:23
that's what we're gonna say the real question becomes, excuse me, the real question becomes, what happens in an emergency situation in a medical situation, when you are the most knowledgeable person in the room and have the least power? Right, apparently to you in the moment, right? Doctors lab coats, people bumbling around, you're not a doctor. But it turns out, you do have power, you just need to know how to assert it. And we'll we'll did exactly. So let me read a little bit here. This, this email is not miss these initial post in the, in the Facebook page. This is the email she sent to me. And so she said, Hey, thanks for considering making this as an app. Thanks for considering making an episode about emergency care. Going through the sickness with my son, which was the first time he had had a stomach bug since diagnosis almost a year ago, made me start thinking about how to figure out what else I don't know. In this instance, probably the three biggest mistakes made in the ER, ended up being the doctor turning off his basil. They didn't hang textures, and a refusal, an absolute refusal to call an endocrinologist. And she said, I knew that these things weren't right. But by doubting herself, and assuming that the doctor must know better than she did. You know, she had no idea in the end, how to make him do those things that she knew needed to be done. And she should have been more assertive, she says, and sooner. So she puts she just puts a bulleted list here. That's terrific. I and I think we should just go down the list. Right?

Jennifer Smith, CDE 7:59
Absolutely. Because it's it's a great list. And I think some of the points can actually even be kind of melded together in a way. But it is it's a very well put together list. It's actually in fact, many of the things on here, when we talk to people, the people that we work within our practice, and we give them our information about prepping for a hospital stay, we have not only a hospital stay or expecting like for a planned surgery, but we also have a lot of these things covered so that you do know how to advocate for yourself, because that's really what it becomes. When you go to the emergency room. Unless you are the person with diabetes, and you're completely out. Well, you know what? They're gonna do what they can do to save your life. And you have no control there then. But

Scott Benner 8:48
yeah, and maybe you can get into a situation where you don't end up like you've heard people in the past talk about in the podcast, where they have family members sneaking them in insulin, and they're doing like, you know, like, Wouldn't it be nice if that's not how this went? Right? It wouldn't be lovely for your, your medical doctors to know about the insulin in your body. So I have a couple of experiences that I'll I'll interject if they fit, and I know you're gonna have some. So first question was, how do I know when it's time to go to the hospital or even at least to call the Endo? When it's a specific type one problem, I guess around illness? The when do you tell people to call?

Jennifer Smith, CDE 9:27
Yeah, I mean, we usually tell people to call at least to call their endo or I guess even a step before that is make sure that you've addressed with your Endo, a 24 hour emergent line to be able to contact somebody at because I guarantee that your specific endo isn't going to be there at two o'clock in the morning and everything every time something happens, right. So the step ahead of that is knowing who to call, what's the number, who will I actually talk to, is it just going to be a nurse triage or is it really that I'm going to get to talk to somebody that's going to give me some information mission without playing phone tag

Scott Benner 10:01
sharing services still exist. So you might just be getting a person taking a message, right? Correct.

Jennifer Smith, CDE 10:06
I mean, most systems, most healthcare systems do have 24 hour nursing care within your like, you know, whatever your insurance coverage or whatever system you're in, right? And that nurse should also be the one who can help determine what are your symptoms? What's going on? Or what's happening with your child? Is this emergent enough? I'm going to call the doctor on call and we're going to get some answers for you or no, you need to go to the emergency room there. I mean, we've used it a couple of times for for our boys when they've been like sick fever, like, you know, rolling around, not feeling great. I'm like, Okay, let's call the nurse and see if the time to go to the doctor, you know. But so they're from our experience, they've been very, very helpful and good. So that's a first step, if it's daytime, certainly tried to call your endo office get in a very emergent message that, hey, this is what's going on and have some very good facts to give them, you know, we've checked blood sugar, we've given insulin, we've checked ketones, you know, my child won't take any fluids, or my child can't stop vomiting, or those are very, very important things to be able to give facts. So they know what to do with you.

Scott Benner 11:19
I also think that it's important not to get caught up in the emotion of it, start telling stories and like they need the facts. They don't need, you know, the extra stuff my mother in law was over. And yeah, let that go. That's not

Jennifer Smith, CDE 11:35
the kids friend was over three weeks ago, and had you know, the flu two days later, they don't care about they don't need to know,

Scott Benner 11:41
we've all been around a person telling a story who's telling a story. They're five minutes into it, you're bored out of your mind, and then they go. So anyway, it was one o'clock in the afternoon. Wait a minute, was it? Was it one o'clock? Or was it 130? Right? I you know, I think and you're like, listen, going, it doesn't matter. Just tell me the story. So yeah, and I think to to recall, to remember, is that it's possible, you'll get a really learned person on the phone who can hear you and respond from their own brains knowledge. And you might also get someone on the phone who's just following a flowchart waiting for you to say a key word. So you know, exactly. temper expectations, I guess, too, right?

Jennifer Smith, CDE 12:23
And definitely, you know, like I said, have the facts in order that you can tell them so they can direct what they need to tell you in the right way. And then, you know, if you really just don't know, you know, when is it actually time to just pick up and go to the hospital? I mean, certainly, we usually say if it's, in this case, you know, her son had a stomach bug. So my expectation is that there was a lot of vomiting, or maybe there was vomiting, and the other end as well, kind of coming out. I don't know, stomach bugs are pretty nasty. And for little kids, or kids of any age, even adults, you could be so like, just out of it, that even remembering to take a sip every couple of minutes or remembering to get, you know, some food in or some carbs in or to try adjusting your insulin this way. Some of that may completely go out the window. So I mean, when is it time to go the hospital when you've put everything in, and you've adjusted, and you've tried all the sick date protocol that you've been given to try, and it's not working, and especially if there are more. So that higher ketone level, you need to go to the emergency room, don't play with it.

Scott Benner 13:40
So is the idea. The illness is not fixable, you are ill now you're ill, you're either able to manage it at home in a way that isn't going to become dire. Or you need to be at the hospital prior to it becoming dire. Right, right. That's correct. That's the idea.

Jennifer Smith, CDE 13:57
And a lot of some of the evaluation in this case would be hydration, for a stomach bug, when to go to the hospital, especially for little kids. If they haven't been able to even take anything in fluid wise or fluid with a little bit of carb. It's it's time to go hydration is a really, really, if you get dehydrated, it's hard to

Scott Benner 14:19
get to recover from that and pay attention to your ketones. I would imagine when you're sick, yeah. Okay. All right. So then she says, What do I take with me? Maybe you should talk about the stuff you have prepared in case you're too sick or unable to speak for yourself a list of medications, outlining of what your normal type one care is like what hospital is best for you to go to if you have a choice. She she lives very far from her hospital, which is interesting. I live in a metropolitan area. I never think about that. Like I never I don't realize that some people have to take an airplane to an airport to fly somewhere else. Like that's not the life I live. I wanted to go to a children's hospital right now. I could go to Five of them if I wanted to, right? Yeah. Right. So, but that's not everybody's situation. So what should you I mean, you've talked before though about having a go bag for yourself, yeah.

Jennifer Smith, CDE 15:10
Next to the door or even if you keep it in the car, as long as doesn't have any psych meds or anything that'll freeze, you know, if you live in a cold place or way too hot place. But I mean, some of those things that should be in a bag, a bag, especially if you're on a pump, things like extra reservoir, tubing, infusion site, even a bottle of water, extra batteries, tapes, adhesives, you know, all those kinds of things, even some extra like glucose, glucose gels, and bull sugar uses simple sugar, all the things that you would pack to potentially take along on like a vacation, let's say, could be in that bag along with and I love that, you know, she pointed out things like a list of meds 100% Because you know what, when you're bringing your child someplace emergently like that, while you may the back of your hand know exactly what the rates are of Basal delivery and what they get, and maybe if they're on injections, how much and when, when you're in that emergent situation that may completely go out of your brain. And you may be fumbling to remember. So having that all, you know, written down, even, you know, if you upload your pump, do a printout once a month of the changes that are in your rates, ratios, you know, time of action and everything that's available on every pump load site, right, download it, put it in the bag, that way it's there. Yeah,

Scott Benner 16:36
yeah, I think too, as you were talking, it made me realize I'm going to do something. So Jenny, and I have topics for some of our episodes. And we just keep them in a simple note in an iPhone, right. And it's a shared notes. So I type in a list, Jenny goes back and strikes things out or adds things we go back and forth. And as we make changes to it, the other person can see the changes, you could just simply have a note in your iPhone that is shared with your husband and your mother and and those people, that is a list of medications, what Basal rates are stuff like that, so that everybody has access to that information in a second.

Jennifer Smith, CDE 17:10
The other really good like I'll like I never take off my ID bracelet. But many ID Bracelets like mine on the very back of it. Now of course I can't get it off. But on the very back of my ID bracelet is actually a an 800 number and a website, that's it's free. All they would have to literally do is look at my ID bracelet. And login to that and all of my medical history is there. So if your child wears a necklace or a bracelet or something like that, many like American medical ID does a really good job. Most of the other websites. I don't know if they offer that as a free service when you buy a bracelet, but it's a nice way that again, you don't have to have that list, like printed out. It's there.

Scott Benner 17:58
That's excellent. Okay. Okay. Misty says what are the universal non negotiable things once you're at the ER, like for your safety? She says that in their case, it was not shutting off the pump. You know that hanging dextrose not saline by that's why that one's interesting, isn't it? They gave him because the saline drops your blood sugar, like well,

Jennifer Smith, CDE 18:22
and the dextrose versus the saline may, you know, in her circumstance, she's right. But in other circumstances, depending on where blood sugar was, you know, hanging saline versus dextrose. If somebody's coming in, in DKA, obviously feeding them more glucose, at least initially, you know, you're going to actually you need hydration, right? So there are some pieces that go along with the illness that you've come in for to pay attention to. But I think what she's really saying here is asking what's being hung? Right? Right. It's it's knowledge to say, Okay, you're hanging saline, he's come in with a stomach bug, I understand that you're trying to provide some hydration. But let's look at where blood sugar is. Let's look at all these things, then she's, you know, again, also very correct. And it's a big thing that I go over all the women and men and parents that I work with. If you go to the emergency room, do not let them take your pump. Do not let them take your pump. I mean, like if you have to like scream and yell and whatever, then advocate and don't let them take your pump. If you come in because you've had a pump malfunction. Obviously your pumps not gonna be doing what you needed to be doing.

Scott Benner 19:36
Take your busted pump. There's a

Jennifer Smith, CDE 19:38
difference in the story, right, but definitely not shutting off the pump. The other thing here too, is they don't necessarily know pumps well enough to even be able to know whether you've shut it off.

Scott Benner 19:51
So Jenny just brought something up. Interesting.

Jennifer Smith, CDE 19:53
Okay, so I kind of I kind of sugarcoat that in a way like that. They don't know.

Scott Benner 20:01
It's like, it's like when my kids were little, we used to go into a spare room, pull the sofa away from the wall a little bit and hide Christmas presents behind the sofa. And the kids never knew where they were because they just didn't know to think about that. So So I have two hospital experiences with Arden. And they both come within the last year. So they're fresh in my mind. One of them is an emergency room visit, where our son had abdominal pain. It was bad. We went into the ER, the first thing I started doing and now keep in mind that this ability to do this comes from a confidence standpoint, like I was confident when I got there, so you know what you're doing. So I got I said to the nurse, and anybody who walked in Arden has type one diabetes, she's wearing an insulin pump and a continuous glucose monitor. Her continuous glucose monitor is reading her blood sugar live, here it is I held it up and showed it to them. And her insulin pump is giving her Basal insulin and Bolus just in case she gets larger. We want to keep these devices on her. Okay. Now you would think they'd be like, Oh, I don't know. But when people realize, you know, and they realize they don't know, they get a little smaller in the conversation, if that makes sense. Like someone's in charge and someone's not. Now it is not the you're not trying to lord it over them. You don't want them to be like, you're not like, Hey, I'm here, I know what I'm doing back up. It's a very symbiotic thing you're trying to set

Jennifer Smith, CDE 21:25
up because you've also come in for help. For something else, respect what they

Scott Benner 21:29
know, right? Respect what they know, try to get them to respect what you know, it's very important not to come off crazy during those initial conversations flustered, like you don't realize it. But if they look at you and your hair on fire, they read that as I'm not listening to that person, right? You know, and that's good on them, they shouldn't. And also keep in mind, that emergency room, people deal with a lot of crazy people. So they don't know if you're crazy or not. And so you have to build a little quick rapport, simple conversations, ask questions. And I also found that I'm was kind of in my mind scoring the people. What did they understand? What, when did they get a blank look? Or when did they have a response that made sense, you know, and try to figure that out, then sometimes, there were people in the scenario I just stopped talking to about diabetes, I directed it more towards the nurse who seemed to understand what I was saying, the one who wanted to give me a little space, and did and that's how I did that. And, and it worked out really well.

Jennifer Smith, CDE 22:31
And I think at the same time in your scenario, kind of bringing in until she she mentioned a little further down, not until the nurse really was like, I need to set you straight. And I'm going to call in somebody else to talk to you and set you right and whatever. And she called it an endo konsult. Quite honestly, when you go to the emergency room, and you know that you may have a stand up and put your hands up and say I got this I know. And you know what you can call an endo bring them in, because I would like another advocate for what I'm doing. Right up front asked for them. There's always an endo on call. There's there's always a specialist on call that will come.

Scott Benner 23:16
And if I can play psychologist for a second when the nurse says that the misty that's the nurse saying, Well, I really don't know enough to write to be the stop in this situation. I think that woman should stop telling me what to do. But I don't have enough facts to Stop or I'll go get a person with facts that come in. And then we'll see later that the person with facts came in and, you know, told the nurse instead of Mr.

Jennifer Smith, CDE 23:39
Kelly, you know, hopefully overall the nurse may have learned something in that setting too. You know, everything is kind of with diabetes, I find it's if people are willing to listen, it's a teaching moment. So you know, hopefully for the next person who comes in or the next parent with a child who comes in this nurse will be a little bit more in the know and be able to say you know what, I don't know enough about this. I do understand that you feel like you know what you're doing? I'm going to call the endo let's just make sure everything is is is good. Everything is the way that it's supposed to be going based on what you came in here for you know, three.

Scott Benner 24:14
Yeah, exactly. One second, I gotta tell ya. The remastered diabetes Pro Tip series is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have a unique offer just for listeners of the Juicebox Podcast. If you're new to contour you can get a free contour next gen starter kit by visiting this special link contour next one.com forward slash juice box free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juice box free Meet her head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen, it fits well on your hand, and features Second Chance sampling, which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash juice box free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips, you can use my link and save time and money buying your contour next products from the convenience of your home, it's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now, through your insurance. Contour next one.com forward slash juice box free meter go get yourself a free starter kit. while supplies last US residents only touched by type one has a wide array of resources and programs for people living with type one diabetes. When you visit touched by type one.org. Go up to the top of the page where it says programs there you're going to see all of the terrific things that touch by type one is doing and I mean it's a lot type one it's school, the D box program golfing for diabetes dancing for diabetes, which is a terrific program, you just click on that to check that out. Both are caused their awareness campaigns and the annual conference that I've spoken at a number of years in a row. It's just amazing, just like touch by type one touched by type one.org or find them on Facebook and Instagram. links in the show notes links at juicebox podcast.com To touch by type one and the other great sponsors that are supporting the remastering of the diabetes protip series touched by type one.org. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. G voc hypo pen is a ready to use glucagon option that can treat very low blood sugar in adults and kids with diabetes ages two and above. Find out more go to G voc glucagon.com forward slash juicebox G voc shouldn't be used in patients with pheochromocytoma or insulinoma visit G voc glucagon.com/risk. One second, I gotta tell you something

Jennifer Smith, CDE 27:43
else you follow fallen asleep in class because she's so tired from studying so late last night.

Scott Benner 27:48
She's actually on her way to lunch. She's been at school for 25 minutes and she's going to watch now which is great. No,

Jennifer Smith, CDE 27:52
we always we always talk at the time that she's into lunch. Yes. And you're always texting her do this or did you do this or today?

Scott Benner 28:00
Tell me to pull the curtain back a little bit. People like hearing about that. So there's a reason why I'm always recording while Arden's at lunch and not another time. I'm much more well thought out than I give myself credit for or the way that I let you believe I am. Okay, and then she asks the end is it ever okay to shut off insulin so Misty, I'll tell you that I was rockin Arden's blood sugar for hours in the emergency room and there was no food going into her like we had some juices once in a while we were sipping juices always let the nurse know juices happening. Because the nurse was always like, Look, if you can't manage this, we'll use I don't know what it is dextrose or glucose or something like that. I entered it trip. And I was like, okay, you know, but I was trying really hard for that to happen because just like the nurse who called the endo on Misty, I didn't have any perspective for that. I did not know what was gonna happen next. And I use texting Jenny, I was like, what's gonna happen if they give her this? Like, what trying to be ready because I've taken insulin away, like, I don't know what to do. Right. And we kept it going for a long time. But finally I just couldn't, I couldn't keep it up anymore. Right? And so they gave it to her. And the woman's like, let it go for a minute to see what happens. She was right, like it's shot up. But it came back down pretty quickly again, like had I given her insulin for that that would have been a major like prostate, right? Yeah. And then once we got that drip regulated, and then got her Basal rate to where, like I just adjusted her Basal to manage the dextrose instead of what it was usually a manager, she was getting a very tiny bit of insulin, but a little bit, and that was it. And it's making me realize as we're talking the tools really do work anywhere. Like they work in that situation too. So I guess confidence and honest actual confidence that comes from it comes from experience that you know is gone over and over again the right way is really helpful.

Jennifer Smith, CDE 29:51
And I think that you know, as far as what you were doing because you know how to manage and you know how to adjust you know how to turn things down or turn them up or micro Adjust with little bits of juice, if you know the person can take a little bit by mouth, and it's okay according to what, you know, their protocol is in the emergency room, or again, like a dextrose drip, if that's an option, and you can adjust accordingly with your Basal insulin drip. Great. But it's and I hesitate to say, is it a yes or no? Is it ever okay to shut off insulin? Technically no, for somebody with type one? I mean, really, it's not. I mean, we know what happens if there's 100% deficit of Basal insulin, you're not going to see the impact right now. But you are gonna see the impact in the next several hours based on that deficit of basil that was supposed to be there, even if they needed less Basal insulin, they will always need Basal insulin,

Scott Benner 30:51
and you and if you get to that spot where your it all is out of control, they're going to take it over, then they are going to take it over the minute your life feels a danger, and they don't think that what you're trying helps him or you're going to lose control the situation. Right, right. And that's, that's obvious. I want to fill in here that misty said that eventually, it seemed like the ER doc was probably confused about pump therapy in general, and didn't realize that her child wasn't also getting a long acting previously injected insulin. So that doctor did not understand what the pump does.

Jennifer Smith, CDE 31:28
And that's not a common misunderstanding, quite honestly, like I said, initially. The docs and the nurses and the staff that work in the emergence in the emergent setting of an emergency department, they know a lot, they really do. But they're they're not schooled in, in this setting. What was the difference? Again, between type one and type two, they're just, I mean, they know if they sat down at a desk and talk to somebody, they could tell you the difference, right? But I think because they don't work it all the time. There really is this disconnect in understanding someone with type one diabetes, and I hope lots of health care professionals. Listen, maybe. But that there is a Deaf that you don't have insulin production, you have got to have at least the background drip drip, drip, drip drip of insulin. And if you're somebody on MDI, which Missy also asked, you know, what about people who are using multiple daily injections, what about them, if and that kind of goes along with the emergency preparedness bag, if you can grab your supplies and take them along to the hospital with you, and you're on multiple daily injections, I guarantee you need to grab your Basal insulin, whether it's you know, whatever brand you're using, bring it along, because while the hospital will have within their formulary, a Basal insulin to use. They may want not know how much you're using, and they'll base it on a formula to calculate how much to give you. But if you don't tell them when you've taken your last dose, or when you usually take your doses of Basal insulin, in the hectic nature of what they're trying to do for you. Maybe you take it at 5pm Every night, and you end up going to the emergency room at 3pm in the afternoon, and you're there for seven hours. Well, you know what 5pm comes and you don't get your Basal insulin, you're going to be at a deficit, but they don't know

Scott Benner 33:24
that. And they're going to be not inclined to give you medications they don't understand. So here's she says, How should you advocate for yourself for your child? If things aren't happening, right? Like, she's like, What if like asking nicely, just doesn't work? I think then it's okay to ask to speak to someone else. Correct. You know, like, at some point, you have to just say, Listen, I really do see that you're trying to help. And I don't I always put it back on myself. So there's a little trick I use sometimes in personal communication, where if things aren't going the way I want them to, and I believe it's because the other person's not understanding me. I put that misunderstanding on me. Maybe, you know,

Jennifer Smith, CDE 34:08
I think I can explain it right. Yeah, I

Scott Benner 34:10
know, I'm not explaining this correctly. But it's obvious that we're not on the same wavelength here. Could I just talk to someone else and maybe re explain, maybe they'll hear me differently, you know, maybe how I'm saying it will hit them differently, whatever, but just know that I've been at this a long time. And I know this isn't right. And so this can't, this can't be the end result where we're at right now.

Jennifer Smith, CDE 34:33
And that's where I think advocating sooner than later. If you are getting any pushback even in the first you know, minutes of being there. Ask for a consult with an endo ask for somebody to come in who can from an understanding place. Advocate with you and or for you based on what you then tell them and I think another piece that I've obviously goes into It is, what is your typical plan of care for a day? Right? How much insulin, how sensitive Are you all those dosing, you know, strategies that you use all those doses and everything that you use from a ratio standpoint, sometimes having it just written down rather than trying to explain it visually to somebody who is medically trying to help you at that point. They could read it, and it may just click

Scott Benner 35:27
yet because they're not used to looking at your pump settings or talking about it, maybe even the way you talk about it. And I listen, I speak to a ton of people as you do. There are a million different ways that people explain the same things all the time, right? Like you hear somebody say it one way, then someone else says it another way. And then a third person found a fun way to say it. And like, you know, the emergency situation, you don't want to be using the fun way around the house to explain it to the doctor, because they don't know what the heck you're talking about. No. So So Arden's emergency room visit was eventually it turns out because she had a cyst next to her fallopian tube, and it would cause her like incredible, like stomach pain. So eventually, after a lot of testing for other things, we figure that out. And we found ourselves getting surgery for art and to have the cyst removed. So we must have met with the surgeon, four times prior to the surgery. And every time at the end, I would just say, Hey, just wanted to remind you that Arden has an insulin pump, and a glucose monitor, right? And that we want to keep them on her during what is really only a 45 minute procedure. And the doctor was Oh my god. Yeah, that's great. Yeah, you guys are doing great. Just do it. She just boom, yeah, sure. Then we get to the hospital that day, and we're doing intake. And I realized the first nurse is just getting her set. She's not going to be part of the procedure. But then eventually another nurse comes in, who's obviously going to be in the room, I say, Hi, I don't know if the doctor told you. But my daughter has type one diabetes, and she picks the chart up. And look, she goes now I didn't know that. And I was like, I was like, okay, and I said, Well, she she does. And she's wearing an insulin pump, a continuous glucose monitor and look at her blood sugar right now, look that I've kept my daughter's blood sugar between 100 and 130 for the last 12 hours, because you made her fat for this. Okay, right. And so keep in mind that that's incredibly difficult to do. And I don't want you to take this the wrong way. I've done it. Okay. So and if you need it for another 45 minutes, I can do that too. Okay. She goes, Well, protocol is and I went oh, okay, so now my brain starts going argue with the doctor said it was okay. No, don't do that. Ask for the doctor, maybe. Then another nurse works, walks in the room, I swear to you, I turned away from the woman I was talking to looked at the next and I went Hi. I don't know if you know this or not like the first nurse wasn't even standing there anymore. But my daughter has type one that and I went all through it. And luck habit she goes, my best friend has type one diabetes. While you're doing great. Let me see your graph. I think my daughter, I think my friend has a Dexcom too. We talked about this sometimes. You're doing great. He had do whatever you want. Yeah. And that was it. And I said, Okay, great. I said, if she does get low, you feel free to give her glucose to bring your blood sugar up? Would you like to take her phone into the operating room? And they were like, yeah, absolutely. And they put it in a surgical bag, they stuck it on the operating table so that it could stay connected to everybody. Once I found somebody who got it, she was thrilled to not be involved in it. Right? Much like your school nurses, and your and your administrations at school once they realize you can take care of this and you're like, we don't want to go to the nurse anymore. That's their dream not to take care of your kid, you know. So I found that very same situation kept his blood sugar nice and stable during the procedure. And then as soon as she was out, and her blood sugar tried to go up, I stopped that I was much less aggressive than normal. But I had a goal like I'm going to try to keep her under 170 You know, without getting her low? Because she was she was loopy.

Jennifer Smith, CDE 39:03
Yeah. Not fun,

Scott Benner 39:06
right? And, and it worked. But it didn't work. Because I had the conversations with a doctor. It didn't even work because I had it worked because I kept having the conversation. And so don't get into a position where you feel like I've said this once because you said it wants to somebody doesn't understand.

Jennifer Smith, CDE 39:24
And it's also hard in that scenario when you've explained it. And now you come in and said you have to explain it yet again. And then they come in with more people and you have to explain it yet again. It's hard not to start to get like this escalation of, oh my god, if I seriously have to explain this to one more person. I'm gonna like my head's going to explode. We I mean, you really have to take that level down so that you can advocate well for yourself and you don't start to look like the crazy person,

Scott Benner 39:52
right? Think about the suspension of I don't know what it is expectation or ego or some thing like that you're just, you're just and I always explained, I never explained it from a asking point of view, I was always being matter of fact about it. Like you don't I mean, like there's, there's a, there's an idea behind having, you know, whether you're buying a car or any kind of like a situation like that someone's in charge, right? Like someone's in charge. And when you start at the hospital, by default, the hospital people are in charge, if you become subservient in the conversation, you are immediately under them, and you'll never go anywhere else. Right, right. And it's just, it's all human interaction. So you start with high, you know, I don't want to sound crazy or fool of myself, we're really good at this, let me show you how good we are at it, I promise, I'm gonna, you know, this is the truth. And here's what I'd like to do, here's what I think I can accomplish with that work for you, then you kind of loop them back into the process, again, showing them they're important. It's manipulation, really, but other people call it communication. But you know, what you gotta do

Jennifer Smith, CDE 41:02
is you and sometimes it's sometimes even the team might have, you know, in a scenario of going to the hospital, even for like a planned procedure, like the case of art in surgery, right? I mean, in in August, I had surgery for kidney stone. And it was entirely different than the surgery I had just a couple of months before that in May. In August for my kidney stone. I had to, like my mom came to the procedure with me after it when she was bringing me home. She's like, I can't believe how many times you had to explain to different people, the same exact thing. And I was like, Yeah, I know, I've done this many times now. And she's like, I know, but she's just like, you know, really proud that you didn't get so flustered. And like she's like, I would have like hit somebody over the head with a charge. She's like, I wouldn't have done that, like, well, you would have but you know, it was actually the anesthesiologist who was the most besides the admitting nurse, who was the anesthesiologist, for me, who was really phenomenal. He, he was really interested in my CGM graph he was really interested in in fact, he kept my phone in his pocket. The whole entire procedure, you know, and he, he was awesome. It was actually the surgeon who kept asking me like, how much did you turn your Basal insulin down? And like, I didn't turn it down? Because I know what my Basal insulin does. Totally fine. Are you sure you don't want to turn on like, Look, buddy? I know what I do. I

Scott Benner 42:35
do your part. I'll do mine. How's that? So

Jennifer Smith, CDE 42:37
yeah, it was but yeah, you'll encounter different people. And just continuing to kind of continuing to know that you have rights, you have rights, you as long as you do know what you're doing. Your rights include advocating for yourself, and also asking for other care team members to come in, that may be able to help you better, right,

Scott Benner 43:02
right. It's like being on the phone with customer service, and you realize the person you're talking to is does not have the power to do what you need them to do. And you gotta get to somebody else, you just gonna have an argument. All right, Missy says, you know, what rights do patients have once they're in the hospital setting? And what she means specifically by that is, can you demand things be done in a certain way? But then it's interesting in her in her question, she doubts herself, she says, and how do I verify that what I'm asking for is actually the best for treatment? So how do you like how do you make the leap in your head that this is what we do at home? But maybe this doesn't work here? Right? Yeah, maybe they know more than I do.

Jennifer Smith, CDE 43:39
Some of it's also in terms of, you're going to the hospital with a condition that you know how to manage, but you're going to the hospital, let's say it has nothing to do with that condition. You're going to the hospital because you got severe abdominal pain. Clearly, Scott, you don't have any idea why Arden had abdominal pain, you can't like see into her belly and see what was going on. I mean, some of those things, you have to say, You know what, I came here for this year, the team, you're the experts, I expect you to figure out what the pain is, but I've got this part of it. I've got the diabetes management part of it because I do this 24/7 And you don't. So some of those things, you have to you know what you're requesting. I mean, if you're requesting something like jelly beans that your kid needs to eat, but he's throwing up, quite honestly, they're probably going to look at you like you're crazy and say you know what jelly beans might be what works really well, but he's not going to keep them down. So let's do a Dextral strap. Yeah.

Scott Benner 44:42
Again, I'm a big fan of keeping people involved. So we were not the last thing we did before Arden surgery was I said to the doctor, here are all the places I can put Arden's insulin pump for the day of surgery. Which of them would you like it on? Now? Let me tell you a secret Jenny, it wouldn't matter which one it was on. I was actually giving her something like, Do you know what I mean? Like, I do the same thing in 504. It's like I find something in a fiber for that. I'm like, Oh, we don't need that anymore. And when I go into the meeting the next year, I give it back like It's a present. I'm like, oh, you know what, we don't need this line anymore. Take that out. I'd like to make this as easy for you as possible. Yeah, like, Oh, look how nice he is. Right? So in this case, it's a little ego stroke for the doctor. You tell me what's best here. That was arm or it was thigh. Mater. Like neither of those were going to be in their way. And I let the doctor pick. Yeah. And that was it. Right. And by the way, double down on my maniacal thinking. I was trying to get Arden to use her arm again. And I thought he'll probably say, she'll probably say arm over thigh. So I'm just going to give her arm or thigh. She'll pick arm. I'll make her feel better. And I'll get Arden's pumped back on her arm again. Haha. Yeah, I was like an evil genius in that moment. What is okay to let slide and she's like, What hills? Should you die on? I think we're answering that question along the way, right? Like you just you what's important to the management of the diabetes? What keeps insulin going as best as you can? So what do I do about pump settings that I don't, I don't even follow myself all the time becoming and so so she's a fluid person, like she listens to the podcast, right? And so what happens when your management is fluid, and then all of a sudden someone wants to make it static for the situation? Right? To me, I would tell them that, I'd say look, let's start here. If this doesn't hold it down, we might have to amp it up a little bit. And if it's too much, we might have to take it away. But I don't know, because this is a different scenario than we usually manage. And these numbers are not set in stone like Jesus. That's the that's the core of the podcast, right. And I

Jennifer Smith, CDE 46:59
think a better part of it too, is to explain in a more simple way, maybe to them. This is the baseline that we work off of based on what's happening with glucose, because we've got a trend on our fancy CGM. I can because the pump settings, the smart features of my pump, allow me to do this, if, if his blood sugar is starting to go up, I'm going to do something that temporarily allows me to just up, I'm also going to temporarily adjust down in this scenario. So explaining that in the simplest way that you can help them to see that what's there as settings, is it's meant to be fluid. You know, it's these are what we start with, and, you know, in the in the case of something like the carb ratios, you know, she's like, well, then carb ratios are a little bit more of a suggestion. They're really not something that we 100% hard number go off of, you know, what, if in the emergency room, you get to the point that they're bringing you food, and you're bolusing you know what, you give them the ratios that are in your pump, and you do what you know, works. What they will usually ask for is what dose did you give, because they need to put that in the medical record, right? They don't know that it's been adjusted or just a down based on you know, whatever you say, This is what my pump suggested I take this is what I'm taking adjustment up or down that that's a piece that quite honestly, they're not really going to care nor know about. I mean, when I was in the hospital for both post deliveries of my boys, the nurses every shift, they would ask what is your Basal running at? Have you made any adjustments? Where's your blood sugar? Have you taken any boluses? Have you eaten? All they needed to do was really document what was going on? That's it. There's a lot of but covering going on? It is a lot of exactly. 100% Yeah.

Scott Benner 49:02
And so even if you're MDI, that's really the same advice. Like it is no, if she does make the point that they like to give like a set dose? They do. Right. And so, you know, but and that kind of leads into one of our other questions. Is it ever a good idea to just do things on your own and not tell the staff? And I would have to say, I mean, no, but but probably

Jennifer Smith, CDE 49:28
in some of it is a little bit of like coding an answer, right. Like I said about the Bolus thing, right? It's Is it ever a good idea to do things and not tell the staff not not know, but if you're bolusing for a meal, and they ask you did you Bolus or to have you taken any corrections or whatnot? I mean, the simplest answer yes. And this is what the dose is. That's kind of the level that they need. They don't need to know that you factored in. Well, it looks like his blood sugar is dipping. So I adjusted backed by this, but they don't, again, too much story, right? They don't need to know,

Scott Benner 50:04
their loss because they don't have diabetes, right? And then they start

Jennifer Smith, CDE 50:08
thinking I've got a crazy person who's like just giving willy nilly doses of insulin. I don't I don't agree with it. Let's shut the pump off. Yeah,

Scott Benner 50:16
it might seem disconnected. But you know, when you hear a late night talk show host make a joke about diabetes. And you think, how could they possibly do that? When I know all of this stuff about life would die? They don't know. That's the answer. The answer is they don't know any of that stuff. And so these people you're talking to very well may not know most of what you're saying. So listen to what Jenny's saying. I've said it one way, she's saying it another way, get them to do what you need them to do, if they say five units, because that's what we do. But you know, it's six, and maybe it's okay to do six. If if they want to do five, and you think it's 15, that you're probably gonna have to say to them, right, because you're protecting your own safety. That's what you're really doing, right? You're trying to protect your safety against your blood sugars. And going high is how it feels most of the time. But the truth is, too, you would need to protect it from going low, you would not want to give yourself way more insulin than your doctor knew about because if you did get low, that would be unfair. needed. Yeah,

Jennifer Smith, CDE 51:15
exactly. And, you know, for some of the MDI users that I've worked with, and a very good friend of mine, some don't even really have a true set ratio as a dose to use. And I think you had done this for a while, too. It's like, you can look at a meal. And you can say, like, my good friend, ginger, she can look at she knows her apple and her peanut butter is this many units of insulin. This is what she takes for it all the time, unless her blood sugar's higher, or lower or whatever. But this is always what she takes for it. That's not really a ratio, could she figure out a ratio to tell them? Sure, right? She could. But technically, there's no ratio there, because you've just figured it out. Because they're standard foods that you eat. And you know, that five units or two units or 12 units always works for it.

Scott Benner 52:02
And so when you're not ginger, or you or me, or maybe a lot of the people in his pockets, what does those people do, people really don't understand this yet about their diabetes, are you just in the hands of that,

Jennifer Smith, CDE 52:15
and that's where these protocols are put into place, with the expectation that the medical staff knows best, and that the people coming in, aren't taking that type of level of care for themselves. So they have protocols, they've got these, if this, then do this, if this is where it is adjust by this much change to this, add this, plug this in whatever. And those are safety protocols they are. But I think from the staff position, or the medical, you know, person position, you do have to look at the individual, you have to look at the person who like you comes in with ordinance as I got this, I'm following it, we do this, we do it this way. I know where things are, she's beautiful, she's level, I can manage it, versus the person who comes in and can't even tell you the last time that they took their insulin, or what their rates are running at in their pump, okay, that person may be the time that one, the staff should then get an endo consult in and to the staff needs to follow their protocol, because they can definitely say this person has no idea what they're doing.

Scott Benner 53:30
Maybe that would be a wonderful opportunity for somebody on staff to help that person, you know, because at the end of Arden's initial emergency room visit that I mentioned, as we were packing up and leaving and getting ready to go home and everything the nurse did come in and say, I really appreciate all the help. I hope I was good. You taught me a lot today. You should understand, though, the way you and I started today, because it was a little contentious at the beginning, I just tried to stay away from it, because 99% of the people I see in here don't understand their diabetes in any way.

Jennifer Smith, CDE 54:03
Right. And the majority of people she sees that come in are likely type two, who had much less education, even if they are on insulin, have had much less education than somebody with type one.

Scott Benner 54:19
No, of course. I mean, so it's just to kind of go on the side of the doctor for a second and talk about it from their perspective. You and I talked to a lot of people in our private lives who are constantly raising and crashing their blood sugar's like all day long, but by what they're doing, they don't realize that they think it's happening to them, but they're doing it, you know, and they don't know what they're doing. And what if I get you into a situation where you have multiple units of insulin going and your blood sugar's crashing. You want to have a seizure here at the hospital and in front of the nurse who doesn't particularly understand it to begin with, like, you know, But then, you know you have, you just have to understand their perspective and not just understand it for like, you know, nicey understand it so that you can tell them what they need to hear. Like, right? Like you just, I don't know a better way to say it when you're, you know, when you're arguing with your spouse, right? And you in your heart, you're like, why are they not hearing what I'm saying? It's because they think differently than you think. But if you understood how he thought, or vice versa, you could say to him the thing that would put him at ease, and help him understand you. And that's what you're trying to do here, you're trying to communicate on a better level than we all communicate on most days. Right? That's all right, right. And,

Jennifer Smith, CDE 55:47
you know, when I worked clinically with an endocrine group, in DC, at our hospital, we actually worked with the emergency room staff to develop a protocol for both type one and type two diabetes for when somebody was admitted to the emergency department. And we also had a protocol within the type one. If somebody came in on an insulin pump, it was an automatic endo call. They got somebody there. And if the endo couldn't make it, which was most often because they were busy, one of us, the CD EES got called to the emergency room to help the ER Doc's manage, right. So you know, not all hospitals obviously have that. But we did it mainly because we saw the need, we were getting called so frequently to the emergency department to manage that they were like, well, let's just get something in place. So we better know what we're doing, and when to actually bring you guys here,

Scott Benner 56:44
right? That's a it's not an easy fix. But these are just ideas that hopefully some of them will make something better for you or the conversation or your health. It's, there's no, there's no like, do this, this and this, and you're going to be okay. After this all got posted online, they actually sent me a follow up question. And it was from another person. And the idea basically was, what if you're an adult friend of a person who has diabetes and is not capable of talking? Right, can't speak for themselves in the moment? Like, is there a way to advocate for them? I mean, as I read that, I thought, That's a wonderful idea. I just mean, if you're not a blood relative, first of all, you can't, they're not going to listen to you to begin with. I mean, they might listen a little bit, but what are you even going to say you don't understand their diabetes, probably any better than? Right? You know,

Jennifer Smith, CDE 57:37
I think the easiest, the easiest way to advocate then would really be to ask the emergency room staff, if they could get an endo consult, quite honestly. Because you know, you can, if you know your friend well enough, and hopefully you do, if you're taking them to the emergency room, you haven't just met them on the street corner, and, you know, took them in or whatever was in a

Scott Benner 58:01
bar, and this guy passed out and

Jennifer Smith, CDE 58:04
decided to help. Like, he's wearing this pager with a tube, and I'm not quite sure what that is. But, you know, if you're enough of a friend, bringing another friend to the hospital, you would, you would typically know that they've got a pump, or that they use injections, you may not know how they use it, but you could at least say hey, you know, he or she has the pump on here. He or she wears and uses this thing that tells them what their blood sugar is, you know, those kinds of things would be easy enough to be able to share with the staff at least Yeah, I think

Scott Benner 58:38
instead of trying to find a way to talk to the friend, we have to be talking to you listening who has diabetes, you you have to as crazy as it sounds, you probably have to try to break down your diabetes into six bullet points. And explain that to your friend so that they have that information to ask somebody, listen, you've all been diagnosed, right? And someone downloaded an hour's worth of talking into your head and you got home and went. So you know, like your friend over you know, dinner once in a while when you mentioned your blood sugar. That's not how they're gonna do. But if you had a bullet pointed, like five pointless, like, make sure they know, this is what my Basal rate is, make sure they know you know that I'm MDI and that means I inject my slow acting insulin and my fat. They're two different insoles like that kind of like simple stuff, like break it down into t shirt slogans for it. Right, exactly,

Jennifer Smith, CDE 59:30
then even even when you change therapy, then it's important to share with them, hey, I'm not using injections anymore. I'm using an insulin pump. Even that as a simple statement can be very helpful within those simple bullet points of do this, or do this is behaving this way, you know, help me this way, whatever. That just the other day I brought up with my husband in the, you know, couple of years that I've changed over the type of pump Same strategy that I use. I, my husband was very good with my other pump. He knew how to push the buttons and how to do everything. And since I've changed over, while he knows what I'm doing the button pushing and stuff. I've never gone over with him again. And just the other day I was thinking, I really need to like reteach him. Yeah, all of this in case of me.

Scott Benner 1:00:26
I really do. Yeah, 100%. Jenny, we've done it again, I really believe that this is a good episode.

Jennifer Smith, CDE 1:00:32
It's a good episode, a really great awesome that you're, Miss Misty, decided that it was a really good topic, because

Scott Benner 1:00:41
it was really thoughtful of her to do. Really, super, actually. That's what I like about Listen, all of you listening are terrific. You know whether I've ever met you or I'll never meet you, or you'll never say a word to each other. But I've gotten to meet some of the people online a little closer. And it's really wonderful like that Facebook group is little more than a couple 1000 people who really understand what's being spoken about on the podcast. And when new people come in, they're really helpful. And I just put a post up the other day where I very proudly said, No one's ever been banned or deleted from this place. And even when they when they don't disagree as much as they, they they have conversations. It's really lovely. Actually, that's nice. Yeah, it's wonderful. You can actually talk to people you don't know who disagree with you and not yell at them. And it's still okay. Yes. So do that while you're at the hospital. Let me say this right, before I let you go. Yeah, I don't know that most of what we just said here today does not apply also to when you're in your general practitioners office. Right, like the idea that they probably don't understand as much about your diabetes as you hope they do. Correct. Right. So don't make that assumption. I think I think that's really it. Like, don't assume anyone understands. And you don't if you're an adult with type one, and you're worried you're going to be in the hospital by yourself, make that bullet point list for yourself and keep it keep it on you. You know,

Jennifer Smith, CDE 1:02:08
absolutely even you mentioned that, like the iPhone with the notes or the you know, the phone with the notes and whatever. I know some people even use, I know iPhone has the swipe screen that you can actually have your medical ID right up there with all of your information within that medical ID. You can put it right there. Right in the health app.

Scott Benner 1:02:29
Yep. Yeah. And again, for all and please don't take this the wrong way. But for you type a lunatics be brief, okay. Yes. Doesn't need to be a dissertation. Right. Then one time when she was six, okay. The doctor stopped reading when they got to that

Jennifer Smith, CDE 1:02:45
planters war that I treated this way 40 years ago. Now my

Scott Benner 1:02:49
blood sugar was a little higher during that week and I really think that plainer word in medicine is what? So please keep that in mind. I don't have one now. But I mean, say I'm unconscious for four or five months here at the hospital night developer planners Weren't you decide to take it off for me? I really want you to keep in mind what happened before? Yeah, just keep it simple. What did they say? Kiss keep it simple, stupid, right? Like, I don't think they're calling the person stupid. They're saying super simple. And there is a way if you think about it. And if you listen to this podcast, really, you probably have it now. There's a couple of simple ideas that will keep you within a reasonable range and safe. So tell the doctor that stuff. All right, or just don't get sick. I say is my nose is stuffy this

Jennifer Smith, CDE 1:03:32
year. So it's harder to do that than other years really?

Scott Benner 1:03:36
100% right. There's a lot going on. There's a lot

Jennifer Smith, CDE 1:03:38
of illness going on.

Scott Benner 1:03:40
So I'm gonna tell Jenny, a really gossipy story that you guys don't get to hear so goodbye. Bye bye. I want to thank assenza diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free contour next gen starter kit at contour next one.com forward slash juicebox free meter while supplies last US residents only. If you're enjoying the remastered episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org. A huge thank you to one of today's sponsors G voc glucagon, find out more about Chivo Capo pen at GE Vogue glucagon.com Ford slash juicebox you spell that GVOKEGLUC AG o n.com Ford slash juice box. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low Beegees. In Episode 1015, Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two, in Episode 1008 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022, weight loss 1023 Honeymoon 1020 for female hormones, and in Episode 1025, we talk about transitioning from MDI to pumping. Before I go, I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active took me already from a decent 6.5 A one C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link.

#1014 Diabetes Pro Tip: Glucagon and Low BGs

Everyone needs to understand the role of rescue glucagon when they live with type 1 diabetes.

You can listen online to the entire series at DiabetesProTip.com or in your fav audio app.

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:03
Hello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right, you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CD and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisit double. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. While you're listening please remember that nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have an amazing offer for you right now at my link only contour next one.com forward slash juicebox free meter you can get an absolutely free contour next gen starter kit that's contour next.com forward slash juice box free meter while supplies last US residents only. This show is sponsored today by the glucagon that my daughter carries G voc hypo pen. Find out more at G voc glucagon.com forward slash juice box. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. Hello, everybody. Welcome to Episode 301 of the Juicebox Podcast. Today in a pro tip episode Jenny and I will talk about glucagon emergency Lowe's, just you know how they manage that kind of a scenario? And what happens if you need glucagon? And how do you use it? That kind of stuff? It's not a bummer. Don't worry, Jenny and I laughed more during this one than most of them. So we're gonna go over how to use the glucagon. What glucagon is, what is it do the three different kinds that we could think of there on the market? Pretty much. It's a nuts the bolts glucagon extravaganza talking about low blood sugar somewhere else you're going to talk about people having seizures, and hearing them laugh at the same time. I mean, who else is putting out diabetes content laughing about a seizure? It's not funny, by the way, it's just the situation was fine. You'll see when you get to it, don't get upset. I liked your idea, a lot of doing a pro tips for glucagon. And I was wondering if we couldn't meld it together with like emergency situation ideas as well. You know what I mean? So I just I realized, well, we'll talk about what we're talking about it. I don't know how to start this. Honestly. I can tell you that. We buy glucagon religiously. I always have some when it expires, we always get more. We've never used it. We've had opportunity to use it twice when Arden was little and both times opted to try glucose gel instead. Which worked. Here's the best place to tell the story, I guess. And I'm sure I've said it here before, so I'll encapsulate a little bit. But, you know, when Arden was really newly diagnosed, she was probably like two and a half years old. And thinking back now knowing everything that I know, she's probably honeymooning still, right. And I had no one ever spoke those words to me ever. I didn't know that was a thing back then. And we got kind of ahead of ourselves one day and Kelly was getting ready to leave on a business trip. She was gonna go overseas. And it was like, six or seven hours before her car was going to come to take her to the airport and she's like, Hey, I need another piece of luggage. Like let's go to the mall and you know, a little piece of luggage looks like alright, so we get over to the mall and it's a Sunday. And we're hungry while we're there. So we grabbed you know, the worst thing in the world like mall food, Chinese food, just not just more food, more Chinese food. And I was just like, boom, I counted my carbs. And I was like, pull up my insulin and the needle, bang, go ahead and eat. I figured this out. And she ate the food we ate, we bought the bag, we went home. It was super little. So she fell asleep in the ride home during the ride home only like 15 minute ride. And I carried her into the house and put her in her crib. My wife's packing and my son's watching the football game and everyone's living their life. And all of a sudden, it sounded like there was a wild animal trapped in the house. Right there was like this grunting and grunting and grunting. And you know, it's like anytime, like, I'm just like, what is that, and I start moving through the house towards the sound that's coming from Arden's room, and I get into her room and look in the crib, and she is having a seizure, you know, and I was just like, I did not 100% know what to do. So I picked her up, and I went through the house to where Kelly was. And we had just this kind of little area rug. And I said, I'm like Arden's having a seizure. And so I put her on the floor, and I got out the glucagon. So the red box, you know, that

Unknown Speaker 6:13
has changed

Scott Benner 6:16
forever and ever. And this is the one Lilly sells, right. And so the red box, I pop it open, and there's a needle in there, the needle needs to be put together, the needle has liquid in it, I know the liquid needs to be shot into the powder, that it has to be reconstituted and drawn back out. And I'm going to be 100% honest with you, I was so freaked out that I fumbled with that thing. And I was nowhere near getting it put together before Kelly was rubbing glucose gel into her cheek. And I'm not embarrassed because I look back on that time. And I remember when they gave it to us, the nurse made such a big deal of saying, This is life saving glucagon. But but don't worry, you'll never need it. And so when she said that, I was like, well, I'll never need it. Whatever

Jennifer Smith, CDE 7:09
was in the house, at least it wasn't like, you know, in the bottom of the dog's bed or something. Right? You knew where credit

Scott Benner 7:17
for knowing where it was. Fair enough. So So literally, during you know, the Kelly put the glucose in her cheek, she started to come out of it. I will tell you 100% of the the experience of watching art and have a seizure will never leave me i have never forgotten any of the details of it. She was blind, like she couldn't see anybody. She couldn't talk. But I don't think that meant that she wasn't aware of what was happening. Because there's a I've shared it on the podcast recently. But there's, you know, there's a video of her from a year or so later explaining how it felt to have a seizure. And so you even when you touched her, it scared the crap out of her when you touched her, you know. And so I just never even figured out how to put it together. I had shown it to nurses, I had shown it to people like everything, but when the time came, I was like, not very high. Anyway, the glucose gel did work. And then we went to the hospital, we call 911. And we went to the hospital. And then you get to the hospital and then the hospital kind of treats you like, you don't really need to be here. Like there's that kind of feeling. And then you realize like, Oh, it's over. Okay. Yeah, it's okay. So, later, while we're talking, I'll tell you about the second time I've had a seizure, people are gonna be like, Why am I listening? This podcast only happened twice, relax. It was in the beginning. So I guess, let's really start at the very beginning, right, like, what is glucagon? And what does it do when you inject it?

Jennifer Smith, CDE 8:59
It's made by the body to begin with glucagon, right. And so in the human body, it's a piece of the glucose management system that your body has in place without diabetes in the picture, right? So you've got this management system of your body releases insulin, your body also releases glucagon, which enables the body to break down glycogen, which is stored form of glucose, right? And so you get this drip, drip, drip, drip, drip, drip drip of both, and that helps to keep things stable through the course of your life. So you know, in a person without diabetes, you've got blood sugars that might start dipping down your body releases a little bit of the glucagon, which enables the body to break down the glycogen into glucose and it starts to navigate things back up, but it's a seamless system, right? I mean, nobody walking around on the street right now. Right now, even the most highly educated biochemist, whatever is probably thinking, Oh, I wonder what my body's doing. thing right now

Scott Benner 10:03
is just one of those things

Jennifer Smith, CDE 10:04
like breathing, you don't think about it, it happens. But in diabetes, we, we kind of have like a faulty system, obviously, right, our body isn't making insulin anymore. But we still do have this like drip drip of glucose into our system, or we wouldn't need Basal insulin. Right? Glucagon, however, is, as you explained, well, it's an emergency, we know it as an emergency, we have to use this if this situation is here, right? A low blood sugar, treat a, you know, a friend, a child, a spouse, whoever it might be. So when we inject glucagon, it stimulates a very large amount of breakdown of the glycogen, the stored form of glucose, so that the glucose can get into the system, thus bringing the blood sugar

Scott Benner 10:58
up. It's stored in your liver, right?

Jennifer Smith, CDE 11:01
Glycogen is stored in both liver and muscle cells.

Scott Benner 11:05
And muscle cells. Okay? So, in an in a functioning person who doesn't have type one diabetes, your body really is bumping in nudging. It's giving you it's giving you insulin, and then it's saying, oh, this person needs a little more glucose. And so I I'll release a little here, I'll release that. And that's happening constantly back and forth, back and forth all the time. So so when we're diagnosed with type one diabetes, when someone's diagnosed, we always I mean, for me at least, like, in my mind, what happened is Arden's pancreas stopped making insulin, but more happened in that right but we just don't talk about the rest of it usually, like, you know what I mean, like, in because you hear people say like, my pancreas is dead, but it's not that does other it does way more things than absolutely,

Jennifer Smith, CDE 11:54
absolutely it doesn't mean you got more things in your pancreas than just the beta cells 100% In fact, the the glucagon actually is made in the alpha cells of the pancreas. So a completely like different little cell hanging out, you know, Lottie, da here I am to do this thing, right. So overall, our pancreas isn't dead. It's just a piece of it. That's, it's purposeful,

Scott Benner 12:20
as well as you want. Yeah. And, okay, so what what's interesting, right, like, So how often do you think how often you speak to someone who's needed to use glucagon in an emergency situation?

Jennifer Smith, CDE 12:35
In if I had been doing this 20 years ago, likely more mainly, because I think that with the influx of the technology that we have, now, we've got alerts to actually tell us when things are dipping, before we would even get to the place of needing glucagon. Now, I mean, that doesn't mean that it isn't potentially, you know, necessary, we've got the standpoint of prolonged exercise, you know, or you've had, like, people who do like a whole entire Ironman Triathlon, in that's a huge depletion in your body's glycogen stores, even if you've been fueling along the way as you should be. That's a huge depletion, your body has tapped into your stored glucose to fuel that long duration movement. So, I mean, if you have exercise like that, potentially, you're going to need something to boost glycogen out of the system to bring a low blood sugar up and or you've got too much insulin there to begin with, for whatever reason the dose was wrong or the dose was wrong along with a long act, active day or whatever this scenario, glucagon will potentially at some point be necessary. I knock on wood, I'm not really superstitious, but that's like, my grandmother's thing to do is like, knock on wood. Whatever works, right, but I mean, in 31, in plus years with diabetes, I've never had to be given glucagon. I haven't. I mean, my husband knows how to use it. My parents knew how to use it. My teachers at school, my Girl Scout leaders, that I mean, everybody that I interacted they all knew how to use glucagon and went to sleep overs with the glucagon in my bag. I did never had to use it. Thankfully, in the amount of people that I now work with, I would say it's not it's not common to have had to use it, at least not. I mean, we may talk about this a little bit later, like different kinds of emergencies settings of use, but mean there is the benefit of also many dosing, and some adults especially The adults that I work with are much more proactive in in trying to offset something they know is not working right, you know. And so, ability to micro dose a glucagon injection and offset a low that you don't pass out from and nobody needs to help you. You can help yourself, right? It's,

Scott Benner 15:21
it's funny the way you put it because I'm thinking back now, you know Arden's very infrequently low, but she has like a crazy low once a year that just comes, it appears to come out of nowhere, right? And when you think back on one of those, you realize that without the sensing technology, like if she didn't have a Dexcom those she would have seizures, yes. Moments, right? Because it's, it's unexpected. First of all, it's not like I've done anything different that day than another day. I'm not standing around all day going, Whoo, this is going to be the day it never happens. It never happens on a day when you're like something's gonna get squirrely today. Right? It's never that day, right. And so you know, you're it's one two o'clock in the morning, and you get the alarm, and you realize she's falling way faster than you would have any expectation for. So there's something, whatever it is pushing down on her blood sugar, and nothing to resist it in the other direction. And it's just falling and falling and falling. So we get, you know, we get an alarm to go in, you give her I mean, for me, I give her juice first, because I find that works very quickly. Like it's the way I think of it is like let's get something in there working. While we do the rest. Right? Then I look for things like that are like palatable quick. I always look for like a banana in that situation. Because it's not hard to eat a banana. It's sugary, right. And then you know, I'll roll back to another juice if I have to. But you'll see those, those crazy lows go like 70 6050. And they fall really quickly. And before you know it, you're treating at 50. And you would have treated sooner you just there was no time and you're treating it 50 You're into the 30s. Now you're testing now you're doing the like, are you feeling? Oh my mind? Yeah, let me double check this right. So you're 50 You finally have a second there's some food in. So now you hit a finger stick, and it says something like 30 or 26 or something ridiculous. And you're just like, Okay, now I'm here waiting for her to either have a seizure or not. Like that is really what it feels like, like I've put the food in, it's in there, it's going to do something. And you know, and you're just the I don't know about everybody else, but I test and then I wait like, not long, you know, it's like four or five minutes later, and you test again, and you're looking for just any sign of stability? Did the 38 stay at 3840? Good? Did it go to 40? Because if it went to 40, I don't think she's gonna have a seizure. Right, like, and so I think everyone needs to know how to handle a moment like that. Absolutely. You know what I mean? But I'm now now, you know, having seen that moment, a few times in my life. I see, as you're talking that without the sensing technology, she would have went from 50 to 30. And the, the alarm I would have gotten would have been the grunting and the disabled and the seizure. And without and then I would have been and without

Jennifer Smith, CDE 18:09
this technology. I mean, I I think fully even to this point, I I still have symptoms for Lowe's. I do even with the technology that I have that alerts me and whatnot. I still know when I know usually even before my system is going to tell me I can tell where I am. What's your number

Scott Benner 18:28
when you know you're low? My number is usually in the 60s. Arden's it's yeah, she knows it's six. But you

Jennifer Smith, CDE 18:35
know, years ago when I was first diagnosed, in fact, a good a good case where my parents probably could have used glucagon, but didn't. It was the summer like several months after I was diagnosed, we were camping, had been out playing, you know, rafting in the pool at the beach, doing everything that you would normally do when you're on vacation, you know, and it was the evening and my dad was making popcorn at the fire. And we were all going to sit around and whatever you do at play games, and it was time for me to check my blood sugar because it was like nighttime, right? It was bedtime almost. So I sit down to check my blood sugar. And my mom was like, that number is not right. And I looked at the number. And I mean, I was the age that I knew numbers and I knew where my numbers should technically be. And it was 26 on my meter.

Unknown Speaker 19:21
Like you were fine, right?

Jennifer Smith, CDE 19:22
Like old meters that took like four minutes to test you had to swipe the blood off, stick it back in the machine, push another button, wait for it to actually give you a value but yeah, 26 My mom's like, that's not right. She's like, Did you wash your you know, all the things I washed my hands again. And like, I tested again, my hands like how are you feeling? I'm like, I feel like I did like 30 minutes ago. I'm like, totally fine mom, you know, she tested again. It was like 25 It was like literally it hadn't moved and my mom was like, like my mom is the kind of person who's just like, oh my god, like seriously, you know, and my dad was right there and he's like, Oh, just give her some juice. And my mom was like This number isn't juice. This is like we got to do. He's like, give her the juice. She's talking. She's fine. She's answering questions. You know, I mean, I can remember this very vividly. Give her the juice, I drink the juice. You know, my mom's like, let's check again. You know, like, all the thing is certainly, it started coming up. It was slow. And it's a painful Wait, it really is. But maybe my mom was like, there. She was like that glucagon is going to be here in 15 minutes if this juice that your dad wanted to give you is not working. I mean, and who knows? What was the accuracy of a machine like 30 years ago? You know, I mean, my blood sugar could have been 50. Who knows? But yeah, again, I think you also have to judge those scenarios, like, okay, she can take something in to eat, she's talking, he's talking the person's, you know, with me? Can we actually like do the glucose gel? Can you do glucose tablets? Can Is it safe to do something to chew? Or should we just do some juice? I mean, but glucagon is always there, if you don't know. And you can't tell us the glucagon. It's, it's going to work for you.

Scott Benner 21:08
But it's the only thing you have at that point. So it's because, you know, just as I'm describing Arden, having a you know, a bad Lo, she could still eat and reason and talk and all that stuff. And so that's fine. But when she was seizing, you couldn't have, she couldn't have drank anything or eaten anything that wasn't happening, she was gone. You know what I mean? So she needed she, you know, in perfect world situation, we would have used the glucagon in that scenario for certain, you know, it's just it's in it's, listen, I have to say this, too. It's frightening. But if you think you're going to live a whole life with type one diabetes, and not get into a situation where you test and see a 26. And I think you're wrong. I think it's going to happen. At some point, I used to tell. It's funny, because you described how everyone in your life knew how to use glucagon. And then I've done the same thing, right? You've explained to a million people that it never comes up. And I think that sort of builds a false narrative in those people's heads like, oh, this diabetes isn't as bad as these people say, right? Because they showed us this emergency thing. We've never used it. It's this. That's not a real concern, because it never happens. I do think that's one thing that happens, but but the other thing is that is that you have this kind of feeling of I don't know, like, like, it's it's never going to happen. But it could, it just really could happen. And and if it does, you can't be freaking out in that moment. Because trust me, I freaked out once. And if Kelly wasn't there, I don't know what would have happened. Because I was like, not processing. Well. And then since then, you know, you learn the second. Yeah, you know, storytime, the second time our had a seizure. We were Disney. And we had spent the entire time day at a party. And we were coming coming back later at night. It was hot. We were walking, she was eating we were giving her insulin, you know, the way we thought we should we were testing she didn't have glucose meters long time ago. And we're we're within like visual sight of our hotel walking back through the park. And this popsicle salesman's walking at us. It's like 1030 at night. And I remember looking up and seeing this guy holding these giant popsicles thinking like, what devil sent you in my path? You know what I mean? You know? And so the kids are like, can we get those? And we're like, yeah, of course, and we gave her some insulin for it and gave it to her right? Looking back now, I never would have given her insulin for a popsicle and that sort of scenario, knowing your blood sugar or not knowing your blood sugar. And so we you know, she eats the popsicle, we walk back to the hotel kids are again, exhausted, she goes to sleep. The About an hour later, the grunting sound happens. And I'm like, this time I'm like, oh, there's no raccoon in the house. Arden's having a seizure. I know what this is. And so it was both comforting and hilarious and scary. All three, excuse me, not both, but all three. I went into the other room got her. Sure enough, she was having a seizure. We went right for the glucose gel because you're like, Well, we know this works. And take the cap off the glucose gel and go to squeeze some out. It won't come out. And in the panic, I just thought, I don't know what I thought. But just the little silver paper was still over the thing, the freshness seal. They squeezed it way too hard. The freshness seal did not come off. But it sprung a pinhole in the back corner of like the sealed part of the tube. So imagine icing tubing and M squeezing it and I am writing in calligraphy all over the ceiling of the hotel room in this laser thin beam. You know, and we all look up everyone laughs we spin the thing around and shoot the glucose challenge Her mouth out of the pinhole and out of the thing rubbing her cheeks, she wakes back up again. She's fine, she's kind of looking at you like yo, what's up, and we get, we get her stable, make sure she's not fallen, and we put her back to bed, the whole thing took like 15, right? And then that was sort of the end of it. And she's never had one since that, you know, but we learned a lot in that in that time. So if you don't think that's going to ever happen, I hope it doesn't happen to you. But to live like it can't happen. That's a mistake. And so back to my original point, when when I used to spend time before when I was younger going into school, and saying, look, here's what you really need to understand about diabetes, and I would go over the stuff. But I would always end with I know, you feel like we're sitting here today, getting ready for when it happens, because it's something we can prepare for I'm like, but the secret about the diabetes and an emergency is, you sort of can't prepare for it. Like, if you knew it was coming, you'd stop it. And that's always the weird part about this stuff is it always happens just when you would never expect that to happen, like because otherwise you'd be sitting around going, oh, you know what's going on this afternoon. It's totally a seizure situation. Like no one thinks that way. And so I don't know, I just, I think it's incredibly important to be prepared as

Jennifer Smith, CDE 26:17
well. And one additional to that, like preparation. Let's say you are prepared, you've done all of your homework, you know, you've got the glucagon, you know how, you know to use it, your friends know how to use it or whatever. And I, I bring this in, because it's something that I do discuss, especially with like older teens, and like college students, and anybody who does a lot of socializing within their job. I think it's, it's really important to know that there may be a point at which glucagon may not work.

Scott Benner 26:50
And that is mess around drinking, right?

Jennifer Smith, CDE 26:53
And I mean, there really is, there's a real reason it's not like the glucagon is like, Oh, I'm just not gonna work today.

Scott Benner 26:59
That's not upset with you for being a drunkard. It's like, you know what? Jenny drinks too much. She doesn't deserve for me to work. It's not like, you're not being judged by the

Jennifer Smith, CDE 27:09
beer. And I would rather she had, like, you know, a Mai Tai or something? No, not at all. It's just, you know, it's the there are biological reasons, right? I mean, your liver again, your liver is like this phenomenal organ in your body. It really is. It's, it's fantastic. And it does a tremendous amount of stuff for you. One of them is, and we kind of call it your body's detoxifier. Right? I mean, that's a really like nutshell term for the things it does. But the livers task of ridding the alcohol out of the system, which it sees as a toxin, it's going to do that first. Before it does its job, it's going to see a toxin is gonna be like, this body doesn't need this, let's get rid of it. And it takes a while for your body to process that alcohol. So I think it's like one drink takes about an hour and a half to process out of the body. Okay. So in that time period, your liver isn't going to as efficiently as effectively check into what's happening with your blood sugar. Right?

Scott Benner 28:15
Yeah. It's not a multitasker.

Jennifer Smith, CDE 28:18
If you give glucagon in that scenario, and now you're asking the liver to do another task, it's not a multitasker. Juggle. I'm

Scott Benner 28:30
busy already. So are you. I feel like Jenny's saying that a liver is more like a guy. Like you give it a thing to do. And it does that thing until that thing's over. And then it moves on to something else. I know, this is a generalization. It's sexist. But, you know, I don't know that. It's, I don't know that it's that wrong?

Jennifer Smith, CDE 28:49
Yeah. And drinking in and of itself can also, you know, do some crazy things just to blood sugar levels in general, right? So if it's got carbs, and if it doesn't have carbs, if it's pure alcohol, etc, you may not have been eating with the alcohol. So I mean, there are a host of other things that could go into a low blood sugar in terms of alcohol consumption. But one of the things of course, is that the livers not doing that drip drip of glucose, right, or glycogen to turn into glucose, etc. So your Basal then that's dripping in the time period that it was beautifully tested. It should be working great. Your Basal is managing without the normal glucose drip.

Scott Benner 29:35
Right? I feel like that's a very important point.

Jennifer Smith, CDE 29:37
So yeah, if it's not doing that, then what happens you get a low blood sugar. Now when you take the glucagon, you're now telling your liver like I said before, to do something to release this glycogen and to give you some extra glucose to bring the blood sugar up. And there's either a major delay or it doesn't, it doesn't do it. So really injury thinking some emergency you know, if you're with it enough to know that your blood sugar is dropping, obviously simple carb, you can do the juice, you can do that as if you're with friends, college friends, a spouse, a significant other whatever, they should know where the glucose gel is something safe. If it's not glucose gel, they should know where the honey is, if they don't know where the honey is, make sure it's cake frosting, something that can be squirted into the cheek can be rubbed in massaged in, it starts to absorb and it can bring the blood sugar up. So

Scott Benner 30:30
we don't want it we don't want to have to swallow it to make this process happen. We want it to absorb through the lining in your mouth.

Jennifer Smith, CDE 30:36
Correct. Exactly. So that's one I think one in that like emergency time of potential Oh, get the glucagon out.

Scott Benner 30:47
Try some other stuff first.

Jennifer Smith, CDE 30:49
Obviously even calling you know, emergency services. Obviously, if you're with somebody you really don't know what to do. Call 911.

Scott Benner 30:57
Yeah, so Well, it's so interesting, because what you just said about when the liver stops making, you know, it stops dripping out this glucagon, this glucose, we always talk about, you know, you need your Basal insulin set up, I'm always saying, right, it's like timing and amount of the right amount of insulin at the right time against carbs or body function. And you know, then we talked about body function being like stress or anxiety or pain, or, you know, all that or your liver and what your liver is doing, that's a body function that's causing your blood sugar to try to go up. And if all of a sudden it's not trying to do that anymore. Now your Basal match, right? It's actually on top of everything else,

Jennifer Smith, CDE 31:35
right. And it's actually the reason that with alcohol, our standard of of education that we see to do is for every alcoholic beverage to take your Basal rate, if you're using a pump, that is take your Basal insulin down by 40% and set it to last duration, at least two hours for every drink consumed. So if at the end of the night, you've had, you know, four drinks, that's eight hours worth of a decreased Basal. So,

Scott Benner 32:06
okay. All right. So let me so now I have this question as we're having this conversation, and maybe I'm wrong. But this thing that we call glucagon that we inject inject in emergency situations, is it actually glucagon or is it something that makes your body produce glucagon? When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. G Bo Capo pen is a ready to use glucagon option that can treat very low blood sugar in adults and kids with diabetes ages two and above. Find out more go to G voc glucagon.com forward slash juicebox G voc shouldn't be used in patients with pheochromocytoma or insulinoma visit G voc glucagon.com/risk. The remastered diabetes Pro Tip series is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have a unique offer just for listeners of the Juicebox Podcast. If you're new to contour you can get a free contour next gen starter kit by visiting this special link contour next.com forward slash juice box free meter. When you use my link you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juice box free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen it fits well on your hand and features Second Chance sampling which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash juice box free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips you can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now through your insurance. Contour next one.com forward slash juicebox free meter go get yourself a free starter kit. while supplies last US residents only touched by type one has a wide array of resources and programs for people living with type one diabetes. When you visit touched by type one.org Go up to the top of the page where it says per grams. There, you're gonna see all of the terrific things that touched by type one is doing. And I mean, it's a lot type one, it's school, the D box program, golfing for diabetes dancing for diabetes, which is a terrific program, you just click on that to check that up ball for a cause their awareness campaigns and the annual conference that I've spoken at a number of years in a row. It's just amazing, just like touch by type one touched by type one.org, or find them on Facebook and Instagram, links in the show notes, links at juicebox podcast.com. To touch by type one, and the other great sponsors that are supporting the remastering of the diabetes Pro Tip series touched by type one.org.

Jennifer Smith, CDE 35:43
No, it I, I understand that it's glucagon.

Scott Benner 35:47
So glucagon makes your body make more glucagon,

Jennifer Smith, CDE 35:49
glucagon injected makes your liver release glycogen and transition it into glucose.

Scott Benner 35:57
Okay, so is this stuff that we're injecting helping bring up our blood sugar? Or is it just making that function

Jennifer Smith, CDE 36:04
that's making that function, right? It's the glucagon that you inject is telling your body to release the stored glucose and send it into the system. That's what raises the blood sugar.

Scott Benner 36:15
Gotcha. It seems like such a simple thing. But as we were talking, we're a half an hour into this. And I'm like, maybe I don't understand what's in the vial.

Jennifer Smith, CDE 36:22
It's unless somebody else knows something else. I all the years, it is glucagon in the it's in that little vial. And it's not as very stable compound at all. I mean, that's why it's in that like, it's why it should shift the way it is. That's why it expires so frequently. That's why you have to mix it and use it. You know, I mentioned briefly before even using mini glucagon, a small portion of what you mix up, if you are you know, alone and you can use it yourself that vial that you mix up then it's only good for 24 hours kept in the refrigerator. So so

Scott Benner 37:00
and so you're talking right now about the one that comes in the red box, the one that's made by Willie so I guess let's break them down a little bit because now they're suddenly on the market more glucagon it for ever and ever. It was the you got the red box, right? And so inside of that red box familly is a vial like a glass vial. And it's got powder inside of it. And then there's a, a needle with and it's an inter muscular needle. It's not an under this. It's not an under the skin like little insulin needle. It's like a

Jennifer Smith, CDE 37:30
all the way and it's a good size. No, yeah, it's

Scott Benner 37:33
a hunk of a needle is what it is. And so you pull out the vial with a powder in it. You take the needle, and you inject the liquids, it's in the needle into the vial, then you kind of spin it together, you know, between your two hands. I know you can't see what I'm doing. But you write that and then it, it constitutes it, it mixes the powder with the liquid, then you have to draw it back into the syringe. And then you're supposed to stick that syringe like into the muscle in your butt, right? Or something like that

Jennifer Smith, CDE 38:00
right into the bot. Yep. I mean, yes, that's the easiest place.

Scott Benner 38:04
You're injecting that glucagon into the muscle. All right. Now that's one glucagon. But since that's happened, another company made a nasal glucagon who made that you remember?

Jennifer Smith, CDE 38:15
Gosh, I don't remember the name of the company. It's back shimmy is the name though? Of the

Scott Benner 38:23
so now that's sort of like, you know, everyone, I think assumed it was like an aerosol, but it's more powdery, right? Have you talked to anybody who's used it? I've

Jennifer Smith, CDE 38:32
not talked to anybody who used it. I have it myself. I did get a prescription for it. And part of the reason quite honestly, that I got a prescription for it is well, twofold. It's it's certainly much easier to use from all of the research and all the studies. The there's a significant decrease in accuracy of use, or a significant increase in the accuracy of use with the back shimmy compared to the mixed injectable.

Scott Benner 39:03
Okay, um, let me do me take it first. And I'm looking at it so it's actually also made by people and and it's so it looks like it comes in a thing that looks like you know, sailing, you'd say the tube looks like a sailing thing you'd sprained your nose, but I'm reading it here it is a powder, dry powder spray in a portable single use ready to use device now. I have only heard from a couple of people who have tried it. And so far the people who have tried it have said to me they burned their nose interesting, like so the inside of their nose. I don't they didn't say about how well or not well at work, but Jenny's hearing that it works more that it works better than the

Jennifer Smith, CDE 39:42
in terms of accuracy. It was from what I know it works the same as dosing, but the accuracy if somebody else has to give it to you, it's more accurately delivered.

Scott Benner 39:53
Okay, so in a panic situation, your friend is a little more able to stick somebody Your nose in squeezing than it is to do everything I just described, and then tricking your body.

Jennifer Smith, CDE 40:04
I mean, I guarantee that Arden was two and a half, if you had had something like this, taking it out of the bottle, sticking your nose and pushing it in, you would have had no trouble doing that, you would have been able to figure it out. And I, you know, a big part of having it in the house is because with little kids, you know, I, my seven year old is a smart kid. And while he would know to call 911, he would know to go to the neighbors if I was a whole loan with them, and I wasn't right. Yeah, this is something that I easily showed him in two minutes. And I was like, this is all you got to do and then run to the neighbors. That's that's all you got to do.

Scott Benner 40:47
You know, you're gonna sleep soundly one day and wake up burning up burning in your nose and your front door Why No, kids gonna be like mommy's down, and you'll be like, I was just sleeping. So now there's a third one on the market. And I just left Arden's appointment the other day, and I got our glucagon change to G voc. Okay, so, so g voc comes in a syringe still, but it is the I think the kind of the genius of what this company figured out is, is that it's, it's pre constituted, you don't have to mix. It's not a powder in a liquid. And it's incredibly stable. So my assumption, I'm making an assumption that you might, you know, maybe people who used to think, oh, one day, we're going to make a closed loop system with glucagon and it but we couldn't, because they couldn't figure out how to keep that glucagon stable long enough. I'm starting to think maybe that that might be the next step after these algorithms. You know what I mean? Maybe it will be a dual chamber pump with an algorithm. And this, but I went with this one, and I will be 100% Honest, why? There's two things. The nasal thing to me, seemed everything what Jenny just said, like, seems super easy to do. And all that stuff. As soon as I started hearing about the burning, I thought, okay, like, that makes sense. And I still was gonna go with it. Until and again, this is me being very honest, the makers of jokes said, we'd like to come on the podcast and talk about the glucagon. And so sometime in the future, you're gonna hear an interview with the CEO, and he's gonna tell you why the company started and all this stuff. And it was super hunched, hitting an incredibly interesting life. i It's possible that when you listen to it, I mean, if you listen to this podcast enough, you might not be surprised by this, but I don't know exactly how much we're gonna talk about the glucagon how much I'm just gonna be like, so what did you do after college? That's weird. And, you know, but that, so I went with it, for two reasons. One, because it's stable. And you know, I don't have it doesn't have to be mixed. The injection isn't intermuscular it's just normal. It's just a normal like, little needle. And I thought, maybe I can use it for bumping, like doing glucagon, like little bumps to and that wouldn't be possible with.

Jennifer Smith, CDE 43:10
And there is, I mean, there is a guide, certainly for using you're talking about like that mini dosing kind of of glucagon. And there is a guide for it. In fact, it's, it's actually a guide that starts with, you know, a tiny, tiny amount for little people.

Scott Benner 43:26
And you and I talked about it on the prototyping so yeah, about Elvis, we talked about that, right. So people can check that out if they want to hear that but and so incredibly, ironically, I guess, not long after you and I recorded the the illness Pro Tips episode, Arvind, got sick for a number of days. And unlike most people who are like, Oh, I got sick, and my blood sugar went up, Arden gets sick, and our blood sugar goes down. So there was this one time her blood sugar was, you know, was at 70. And I'm like, it's gonna hold it's gonna hold eat something. And then the food didn't do anything to her. And it kept drifting down. And I gave her more and more. And then there was this moment, you know, we're like, 45 minutes into this, and she's now 55. And I'm like, Jesus, none of this food is touching her. And I so I'm thinking to myself, what's next? Like, I have to do something right now. I walked up to her with a juice box. She goes like this. Put your hand up and she goes, if it's my time, it's my time. But I'm not drinking another juice. Like girls super serious and trying to be funny at the same time. I said, right on, okay, I hear what you're saying. She's like, seriously, if I drink another juice, I'm gonna throw up and I was like, gotcha. So I went downstairs. This is probably look first of all, this is completely off label. But it's also why at the beginning of the episode, I tell you, this isn't I'm just telling you what I did. It's not medical advice. And I took my old you know, read kit from Lily and I mixed it up. I went back and listen to what you and I said to each other. This is maybe like, I'm like, I wonder what I'll do. You know, like, there's a podcast episode about this hold on. Then but and I remembered and I drew up like I kind of spit balled it a little bit. It was off based off of weight, I remember that I drew up seven units. And I gave it to her. And it took a little while. But no, why her blood sugar went back up, not too far. And it leveled out. It stayed there. And I was like, right on, I am definitely getting the G voc instead of the nasal stuff, because this might happen again. And that that was my reasoning for going that

Jennifer Smith, CDE 45:30
big question about the G voc would really be the pen itself? How How, how much is in the pen? Like how many? You know, what's the dosing because when you look at how much to give, it's, I think it's if you're over 50, in the doses, 15 units of mixed up glucagon. And that would be given kind of like we talked about before, and the other, the other episode, a certain amount of time. And then if it doesn't bring the blood sugar above 80, then you reduce with the double the amount. So just with the G voc, my question would really be how, how much do you know that you're giving as a mini dose? Right?

Scott Benner 46:12
And I'm gonna find out because you're 100%? Right. And so I'm gonna try it. I'm gonna find out. And if it's not right, I'll switch to something else. Yeah, no, but I think is this gonna work enough to

Jennifer Smith, CDE 46:22
do any of that extra stuff? That's really awesome. Yeah.

Scott Benner 46:26
I think that as a replacement for the lily one, this one's a no brainer, right? Because you don't have to mix it up. And it's not this giant needle. But I think and this is not something the company said to me. My but my assumption is, the real excitement here is about the possibilities for dual chamber pumping, right? Because it's stable. And not only that, I think the bigger excitement and I think the CEO alludes to this, if I'm not mistaken, I'd have to go back to listen. But my assumption is, they figured out the science of making something liquid stable, which now means that science could get applied to other things. I'm guessing, I'm guessing, I'm guessing this is the very infancy of this company is what I'm is what I'm thinking and run by nice people. So that's cool. Okay, so we went over the three different kinds of glucagon. What and the when? Right, you're going to use glucagon when somebody can't physically take something in their mouth? Right, right. When Arden had a seizure, we only use the gel and rubbed it into her cheeks. We weren't trying to get her to swallow it. If you try to get somebody having a seizure to swallow something, you're gonna get them to aspirate. It's bad. Right? Right. Don't do that. Right.

Jennifer Smith, CDE 47:40
Maybe even a you know something for, as we know, symptoms of low blood sugar, even if you're not passed out or having a seizure, you could be not together with it, right? I mean, many people complain about their spouse, significant other child child getting very violent, or very abusive, or whatnot. I mean, getting them to eat something is maybe impossible. So using glucagon, in a scenario like that may be your only option.

Scott Benner 48:11
Yeah, you might be maybe

Jennifer Smith, CDE 48:13
tackling them and holding them out. Exactly. But you hold

Scott Benner 48:16
the needle, I'll tackle them that hand me the needle, it's gonna be a lot of fun. Yeah, well, well, that really is, you know, I've heard the stories too. And there's been people who've come on here and told them, but I've heard them privately two of the worst scenario ends up being when you're two adults, and one of us physically smaller than the other one. And the larger person, you know, becomes combative or angry. And I've heard about, I've heard about people throwing furniture and, you know, say saying terrible things. And you know, and everything.

Jennifer Smith, CDE 48:49
From a safety standpoint, you know, if the person is up and moving and in, let's call it like a violent sort of behavior, and you're not safe. Just call 911. Call 911. That's really, I mean, don't try to get close to them with a needle and try to stab them is not a good idea.

Scott Benner 49:09
It's such a, it's such a bad television show. You just see two people standing across from each other and one guy's ranting and raving and holding a lamp and you've got a needle in your hands. Really, it's like every bad movie I've ever seen in my life. I think the goal would be not to get that low. You absolutely can. But like we said, these are emergencies, they don't happen on purpose. I think it's just very important to remember, like, you can't plan for an emergency. I mean, you can plan for what to do when it gets here, but you can't plan for when it's going to happen. Right. So let's talk about since we're in this vein right now, and we're using up our time and we have a couple more minutes. Let's talk first about low symptoms. Some of the things you've heard people saying I will start with the one that aren't in tells me what is happening. Why or why am I being treated poorly here? Oh, you know what, actually, this is funny. It's Express Scripts I have to say okay to prescription to the to the glucagon prescription. I'll call them back off the call them back in a little bit. But I know that's what that is. Now my wife has picked it up downstairs and she's busy listening to a recording. And she's trying to figure out why she's listening to it probably. So are we the other day? She she got a little low, right? We were going right into a restaurant. So she went like quickly from like, 75 to 60. And I was like, Hey, you're dropping? And she's like, Yeah, I know. And I was like, how do you know? And she said, My lips are numb. And I was like, really? She goes, Yes, she's like, that's the one that I like. That's my physical tell. She's like, my, my lips get numb. And she goes, and if you don't take care of it. She's like, I didn't realize before. So she told me a story. She said one time she was out with my wife. And this happened. And my wife gave her a drink to have. And she drank it in orange, like, oh, this tastes terrible. And my wife said, really? And my wife tried it and said, Kelly's like no, it seems fine. And Arden kept drinking a little while later, I think we were at a baseball game for my son's and I was on the other side of the field. So I came back over eventually. And my wife said, Hey, Arden was low earlier, but we took care of it. She drank this. She said it tasted weird. And so I tasted it. I was like, I'm zone tastes fine, you know. And so it took Arden She said, It took her years to figure out that when that numbness comes, it's it's affecting like her tongue in her mouth to she feels it on her lips. It says everything. Everything tastes weird. At that moment, I was like, Oh, no kidding. So I was wondering if that happened, anybody? But what are some of the, like, what happens to you?

Jennifer Smith, CDE 51:42
So and I think that's, it's good to acknowledge symptoms and understand that there are many symptoms, because they can also change over the years. Like I, you know, when I was younger, my symptoms were the classic like, I would get, like, visibly shaky, I could hold my hand out and I was like, visibly shaky, beyond just the internal symptom. It was there was a visible cue there, too. In college, I also had something very similar to what Arden is describing. But it was more it was more like an internal mouth numbness. It wasn't really my my lips, it was more like an internal mouth like it almost like you know what it feels like to be numbed at the dentist that like you feel like your whole mouth is thick, and like, puffy. That's what it felt like to me. Now,

Scott Benner 52:36
how long did it last after you ate like after you brought your blood sugar back did it last?

Jennifer Smith, CDE 52:41
Ah, for gosh, I mean, I would say it probably lasted a bit of time after my blood sugar was actually normal. Because they specifically remember it. Like in college, I was still on injections. And so I would often have that as I came into lunch, because they had pretty full mornings of like zooming around on campus and getting back and forth to classes and whatnot. And so I would often have that at lunchtime. And I can say that, before I headed out into my next course of classes in the afternoon, I still had that feeling even though my blood sugar was already back up from having eaten. So I guess for a bit of time, it seemed to last. Whereas my symptoms now don't last after I've treated, they don't last long unless it is, unless it's been a significant drop. That's happened very, very quickly. And it takes a while for the carbs to kind of start to make me feel better. My symptoms now are much more like this, like feeling of everything rapidly moving. Like I feel like the world is spinning and moving. And my thoughts are fast. But I I feel like I'm walking through mud. I feel like I just I can't keep up with the way that my brain is thinking about things. So

Scott Benner 54:16
I wonder if we'll never know, obviously. But I wonder if your thoughts are at regular speed and your body is slowed down? Or if your thoughts are sped up and your bodies that regulate. I'm so interested in that. There's no way to know, because it's one or the other, right like your one part of you is being fooled about something. Yeah, yeah. And everything feels like it's like, you feel like that might be what it is. Maybe it's like that. Maybe you feel like you're in slow motion. I don't know. Isn't it weird? It feels like it makes me feel like you're in a country. And you're like kind of screaming like you know what's going on but you can't affect anything. Is it that kind of a feeling or no? Am I wrong?

Jennifer Smith, CDE 54:58
It's somewhat Yeah. The other one is kind of feeling like drunk. Like I get kind of tipsy. And I'm like, I've I've literally been like drunk maybe three times in my whole entire life. Right, but that's what it feels like. But that's not every time but some of my lows feel. And I'm a I'm a very happy like drunk person, like everything is fine and happy. I'm not an angry drunk. So, I get kind of tipsy with a low blood sugar sort of like, Ha ha ha, that's funny when it really isn't funny at all.

Scott Benner 55:39
It's and it's like I'm describing with Arden to like, cuz she's done that a couple of times, like, you know, I'll be like, aren't getting up, you have to do something, your blood sugar's low, and she'd be like, I'm just gonna die over here, like, but that's very jovial when she says it, like she's very like jokey about it, like, I guess. Yeah, it'll just be fine. But you know. Yeah, I think it's interesting. So when people have you heard from other people like some of the stuff because they are, before we go into that, let me ask you this one. When you wake up after you've been low for a while, and you didn't know, why are you so sweaty? Do you know, it will sweat when their blood sugar is

Jennifer Smith, CDE 56:14
low? It's a body response to the low blood sugar. All of the physiologic like mechanisms that make it happen, I, I can't really speak to, but I do know, it's very, very common to wake up in a sweat.

Scott Benner 56:30
Yeah, like bad, like change your clothes after you treat your blood sugar. Like, take the sheets and wave them around for a while. You're just like,

Jennifer Smith, CDE 56:39
right, I even kids. You know, I've heard some parents comment too, that, you know, an older child will obviously wouldn't be wetting the bed anymore. With a low blood sugar may have mainly because they've not got the conscious, I guess, ability during that time period for their brain to wake them up to actually get up and go to the bathroom. Because they're low, you know, so but I mean, outright symptoms, you know, even blurred vision can be one of those sort of like a tipsy feeling on your feet. The shakiness in the hands, people talking kind of like, kind of like off the rocker sort of like you ask them a question. They don't make sense. Yeah.

Scott Benner 57:21
Confused, confused. Right. And I guess it's funny to like I, I've read, you know, back in the day, like all kinds of blog posts from people where they talk about being low, and everyone describes it like slightly differently, but I think it's situational, too. It's really interesting. There's somebody I keep thinking of having on just to describe a low one time because this person's low was like an amazing story. And I'll have to see if I can figure that out someday. Okay, treating things. Like let's so let's talk about it for like to finish up real quick. My blood sugar's falling, but I don't want to get high again. I'm ahead of it now. Like, you know, I know people know Arden's a juice box person, if you know if, if she's looking for a quick hit, if she's not hungry, juice boxes work for her, we use this very specific juice box. I think it's important to remember that you're not looking to drink. So I found the smallest box I can with the most carbs, so that she's not having to us like I started helping Arden's friend the other day. And you're gonna and she's doing great boy. Yeah, and but you know, at the first time was like, hey, I need you to drink some juice. She pulled out this juice box, and it was huge. And I'm like, Yeah, you that's fine. here and I sent her a link. I was like, get these like, you're killing yourself. You drink eight ounces of juice to get 15 carbs. I only want you to know, the juice is medicine. It's not for fun, like you know what I mean? So juice boxes work. I've talked to people who use jelly beans, Skittles glucose glucose tablets Skittles like so you're you're looking for something that's a real simple sugar that's getting absorbed in your mouth and then hitting your body quickly when you swallow it like that's it so what sometimes people say milk but I don't think milks is fast right that's

Jennifer Smith, CDE 59:08
yeah, I mean ages ago that was one of the treatment things even on my list when I was little for low blood sugars it was milk. Well when you consider like whole milk when there's fat there, there's protein there. And the body actually has to has to break down the milk sugar in order to get the glucose part out of it, which is what actually brings your blood sugar up so I don't ever recommend milk. I really don't think it's I don't think it's a good low I mean obviously if you don't have anything else around, have at it, drink your milk, but there are much better simple sugar things to carry along with you even dried fruit. And you know when I was little, my mom actually used to give me the little mini mini boxes of raisins. And then I at the end of the school year had these like dead raisins sitting all over the bottom of My backpack that had to be like, they were disgusting. They were like, you know, full of dirt. And they were gross. But that was what worked. I mean, raisins were easy. They they worked well. They got the glucose tablets when I was little were horrid. They were horrid. I mean, if you think they're bad, or no, they were bad years ago, I mean, now, the only ones and I don't even I don't I don't know if they're on backorder still, but the gluco lift brand is the only one that I love. They taste good. They don't come from a GMO glucose source. All the colors and the flavors come from natural fruit and fruit extract. So they're not artificial. You know, no Lake number 70, or whatever it is. So but something simple. I like your juice box, though, I actually have kind of the opposite. I look for the smallest juice box that has the least amount of carbon it because I want to drink either I'm like half awake, if I ever do have to treat a low overnight, which thankfully, I haven't had to do in a really long time. But I don't want at two o'clock in the morning to have to be completely fully conscious like

Scott Benner 1:01:14
to say to yourself, I really just need half of this juice box.

Jennifer Smith, CDE 1:01:18
boxes I get are actually they're they're four ounces. And they're only eight grams of carb apiece. That's Oh, cool. So you know, they work Nice.

Scott Benner 1:01:27
Nice. I know. Arden also carries those little pouches of fruit snacks, whether and they always have like eight or nine fruit snacks in them. And it will sometimes eat for fruit snacks to eat to for snacks. So the other morning, we were heading to school and she goes here, throw this out for me. And she gives me a package of open fruit snacks. I still have four in them, but their heart is a rock, you know. And she's like, they're hard. And I was like, Okay, I'll get rid of them for you. And but yeah, she always has one of those. So in her bag, she has a juice, a small juice box and a small pack of fruit snacks. And she always has that whether and then and then there's juice boxes sort of spread around the school. So Arden's in high school, so she changes, obviously, you know, classes. So there's, you know, in a closet somewhere, there's a couple of juices in each class. And then wherever she is and she has to take one out and drink it from her purse, if she does, she just hits the closet and replenish his or hers. You know, I have to say that we don't you know, the beginning of the school year, it's not as it's not as intense. When you're older. And you've done it for a while, we just take two bricks of juice boxes and spread them around, like, you know, like rose petals that are at a wedding, we're just like, there are some here and there, then you're done. And then maybe once a year, Arden will be like, hey, I need more juice boxes. So she might go through. I don't know, she might go through 1020 of them a year at school. But that's

Jennifer Smith, CDE 1:02:49
pretty minimal. That's actually pretty good. You know, when you when you get to be an adult with diabetes and have kids in your house, you actually have to be kind of good at hiding things. before disappearing, appears like literally I mean even I mean, even my husband will drink them or eat them. And he I mean, you know, he'll tell me if they're obviously not there anymore. But me my kids, if I have my glucose tablets out, they'd love them. So I hide them. And so it's like it becomes really important like purses, by purses. I have like these internal like hidden pucks pockets in many of my purses. Because when they see an open purse on the table or the floor, they're like, Oh, does mommy have any of her stuff in here? Like, mommy stuff is for a really important reason.

Scott Benner 1:03:37
You actually reminded me that during during a family vacation once there was an argument. Because we were we were in a moment where it was summertime. And we now by the way, we now because of Disney knew how like magical popsicles were right. They give you a little bumper that didn't make you go too high or anything like that. And for our net lease, and so we bought these box of popsicles, like you know, you get to a shore house, you go out and go shopping. And someone said, Oh, I'm gonna have a popsicle. And I was like, hey, you know, I just need you to not touch those where you've got them in case Arden gets low, which prior to all the technology was going to happen like you were going to use those popsicles. And one of the parents said, that's not fair to the other kids. And I remember Kelly going will tell them to get diabetes and then they can have all the popsicles they want out of the box, you know, but like for right now, just don't touch the popsicles. But it actually caused it was like, ah, like, you know, that's that's not fair. Are Kelly's like, are we talking about fair because my kids

Jennifer Smith, CDE 1:04:34
got diabetes got.

Scott Benner 1:04:38
If we're measuring fair, I think I win, you know, like, so anyway. Do you feel like we did a good job here? I do too. All right. Cool. So I will so let me say goodbye let you get back to your business. I want to thank assenza diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free Contour. Next One. starter kit at contour next one.com forward slash juice box free meter, while supplies last US residents only. If you're enjoying the remastered episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org. A huge thank you to one of today's sponsors G voc glucagon, find out more about Chivo Capo pen at G Vogue glucagon.com forward slash juicebox you spell that GVOKEGLUC A G o n.com. Forward slash juice box. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years, and she works at integrated diabetes.com If you're interested in hiring Jenny, you can learn more about her at that link. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed or starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bumping nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low Beegees in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two in Episode 1008 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and an episode 1025 We talk about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with this and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active. Took me already from a decent 6.5 A one C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.