Scott Benner 9/24/23 Scott Benner 9/24/23

#1018 Diabetes Pro Tip: Pregnancy

Scott is joined by Jennifer Smith who shares her immense knowledge on the topic of type 1 diabetes and pregnancy.

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

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

Scott Benner 0:04
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 Penn Find out more at G Vogue glucagon.com forward slash juicebox good and fresh.

Jennifer Smith, CDE 2:25
Because I'm not gonna sing. I don't say

Scott Benner 2:28
oh no, no, because this episode is going to be basically me going uh huh. And you saying a lot of different things. So I want to if I can, yeah, do a pro tip episode about pregnancy. And I mean, like, pre planning leading up to it, what to expect out of prepare what to do, what's going to happen if this happens, what I do, and if we can, how do I do it without a glucose monitor? Is that all doable in the next hour?

Speaker 3 3:00
Without a glucose. Alright, well, let's do the winning without a continuous without physically without knowing anything.

Jennifer Smith, CDE 3:08
That's possible. But

Scott Benner 3:10
isn't it funny? I call them glucose monitors or blood glucose monitor. Why do I do that? I don't know. Anyway, without a CGM, gotcha, gotcha. Okay. Because I would like to, I want to do that as well. So anyway, I am, I'm going to be on the outside looking in here for this. But I do think that the place to start, if you agree, is understanding what the pre planning is like? Because you can't, or you shouldn't I'm guessing if you have type one diabetes, if you're the lady, you should not just if you can help it be in a situation where we got bored on Friday, and now we're going to have a kid. Right? Right. There should be some more planning to that. So how far out? Does the planning have to be in is that maybe person to person based on their situation?

Jennifer Smith, CDE 4:01
Yeah, and kind of like we always talk it is sort of person to person. Uh, you know, overall, if you've all along had pretty good management, you've put lots of play, and you know how your insulin works, you know, how food and activity and all of those things work for you. Maybe three months, maybe, you know, maybe you get married, and it's a quick turnaround. And you're like, Yeah, we're ready. And like you're, you have everything in place. And, you know, you're where it should be. And I mean, there are other parameters to check to, especially with diabetes, things like thyroid. All of those things should definitely be checked and analyzed and evaluated prior. But everything checks out. Great. If not, then yes, it could be three months, it could be six months. It could you know, if you're somebody who's starting out you, you know that you and your partner really want to have a child but you don't really have things in place to do that safely from a discussion maybe that you've had with your doctor or your OB team or whoever, then it might take a long time. I think it takes going back to really like the pro tips episodes, really, if you're trying to get things contain and that's, that's the starting place. Because while while you know where you need to maybe get, or maybe you don't glucose target range for pregnant should really be started prior to conception. Because then it's not such a big change over from saying, Okay, well, I've been aiming for a target of 80 to 180, let's say, right, while pregnancy target is, you know, fasting 65 to 95. That's when you wake up in the morning. Is

Scott Benner 5:49
that is that anyone see in the fours? Is that is that high fours to look

Jennifer Smith, CDE 5:54
for the E one C listing because what I think, Zack, they were that

Scott Benner 5:59
I think what we're talking about here is that you have to know how to manage your blood sugar's tightly and see some consistency through weeks and months. So it's not just a fluke, like one month, you're just like, Oh, I did it. And you have to be able to do it without low blood sugars that are going to be dangerous for you or the baby to write, you know. And so yeah, get it right, and then prove it over and over again, over and over again, through your period through different meals, because you also could, I just finished what I really enjoyed, I haven't, I did a four part series with a pregnant person who has type one. And we interviewed together after her first trimester after her second after a third and just yesterday, when her baby is three months old. And so I went through the whole process with her to try to understand it. And her agency was like 4.8, during her pregnancy, and she was describing needing insulin, more than double than what she normally needed. And that like swallowing that pill of like, oh my god, there's way more insulin needed here. I have to do it. And yeah, and I want to get to all that. But But yeah, to me, what you're saying is, you can't be a person who's got an A one C of nine and say I'm going to have a baby. I'll just get pregnant now. And I'll fix it. Because what could those things lead to, like what Ohio one sees in pregnancy lead to?

Jennifer Smith, CDE 7:29
So that's where the typical national standard is? A one c less than 7%. At conception, right? That's, that's the broad goal. We aim for a little tighter than that. Because as you're kind of getting to, it's easier to have things tighter to begin with. Oh, goodness, I've not really done anything, or I didn't plan it. And I also haven't done anything. And now I really have to tighten everything up. That's a lot of change all at one time, along with a load of hormones impacting things at the same time. Yeah, so it's a lot, right. So the standard center conception is really because what they've seen in research is the risks of things like early miscarriage, or many of the genetic problems that can come up from those early weeks of forming all of the different body. All of the different body organs and everything. That's what's happening in that first trimester. So the goal being under 7%, your risk is is about even with the general population who doesn't have diabetes, for those same types of problems to have, okay? Okay, the higher the agency, the more potential for early loss or or miscarriage, the more potential for the heart to not form the right way or any of the organ systems, you know, a lot of those genetic types of things. Then also a lot of things that are not specifically genetic, like they don't come from down the gene line, but they just happen because glucose levels aren't allowing the cells to divide and form into what they're supposed to do.

Scott Benner 9:23
So anywhere from a miscarriage to birth defects, correct. Okay. And is it a mortal lock that that's going to happen? I mean, you know, how you know how some people are like I smoked all through my pregnancy and he's fine like that, like it are they're dumb luck people. And I'm not that I'm saying roll the dice on that, but, but were you definitely going to see something or maybe not even know like, is it possible? You know, is it is it out of this world to think that you could have a high one C and your child could develop asthma and that even though you're never going to know it could have something to do with that? I guess that would be some speculative, but that's

Jennifer Smith, CDE 10:00
it is complete speculation, because there's really not. There's a lot of research done on later outcomes in kids who've, I guess, born from women who have had diabetes, right through pregnancy, but a lot of it is more assumption of putting information together, right? Really, no, you're never really going to know. And, you know, on the opposite of that, let's say you, you did plan to really take care, just and make changes, and, you know, things do happen, people get pregnant,

Scott Benner 10:35
and it happens. I've seen it happen personally.

Unknown Speaker 10:38
Yes.

Scott Benner 10:41
And no one's planning on it. And the next thing, you know, you're moving to a place to have more space.

Jennifer Smith, CDE 10:47
Because you're gonna need it. There's gonna be another person,

Speaker 4 10:50
someone by mistake got knocked up, because, you know, long day everybody missed each other. And the next thing you know, I gotta leave my condo. That's all.

Jennifer Smith, CDE 10:58
There you go. So you know that it happens, right. And I mean, and I've worked with a number of women through pregnancy, who that has been the case while they were planning events. Really right now, and a one C really was not where we would aim to have it be the highest I've had someone start a pregnancy, which was really not planned. It was a teen pregnancy was 11.3.

Scott Benner 11:28
Wow. And now they come to you right away. And no, it took too long. They didn't

Jennifer Smith, CDE 11:33
they, you know, they came in early second trimester it was you know, they had gotten through their first trimester, with OB TM, and some endocrine, I can't even remember how the family found integrated to, you know, get in contact and get. But I worked with her through her whole entire pregnancy. And we pretty quickly got her agency down. Yeah. And then, you know, by the end of pregnancy, her agency was 5.7. That's great. So I mean, and she has, she's a beautiful little kid now that there are no. So can things be okay? Yes, they can. But the risk increases dramatically as the a onesie. And the glucose levels are not managed

Scott Benner 12:21
it to me, for me personally, and given that you can get pregnant by you know, not on purpose. By breathing out someone, hey, that's what I was told. But I think what we're saying is, is that, you know, say you live in a nice, safe town, you don't really need to lock your door, but you do anyway, there are certain steps you take, just because why would we take the risk if we don't need to? Like if we know we're going to have a baby, why would we start with a seven a one seat and go, I bet I can get it down before something weird happens to the kid like, you know, like, let's, let's not do that if we don't need to. If we get caught in that situation, then, you know, figure it out, get it down? It's correct. It really is. It's such a it's I don't know, I just I'm thinking back now to the conversation I had, that the person who I mentioned from the, you know, the four different interviews through the pregnancy came to my attention because her first pregnancy ended in a mask a miscarriage. And so and I've been contacted by people who there's a person I'm still hoping to get on the podcast, she found out that she had diabetes, because she was pregnant. You know, like, she got pregnant, they ran a blood test. And they were like, Oh, you're not just pregnant. You have type one diabetes. And yeah, did not know prior to that. That person is doing terrific has a really cute kid. And, and I'm hoping to have her on one day. But anyway, it's just, you

Jennifer Smith, CDE 13:47
know, the other thing I wanted to mention here, too, is that all the things that you can do ahead of time, sometimes things do happen anyway. Right. I mean, I I'm I'm actually my personal is our my first pregnancy I had a miscarriage. So, you know, and I did everything ahead of time. I had been doing everything for several years. We're like, yes, we're like, finally ready to definitely have a child. Right. And I had done everything. And in fact, my my maternal fetal medicine, which is a high risk OB doctor that typically manages through high risk pregnancies. You know, she was like, this has nothing to do with she said many, many early pregnancies back she said many women, they kind of their visit late especially, they've been pretty regular. They're a little late in their in their, you know, period starting and then it starts like five, seven days late and they're kind of wondering, she said, oftentimes those are very strange where the body actually didn't even start up anything truly. Many miscarriages in terms of For a person without diabetes, and a person with diabetes who has managed well, there just because the body knows that there's not something quite right,

Scott Benner 15:08
just feels like a false start. And that's what happens. Oh, that's sad. No, of course.

Jennifer Smith, CDE 15:13
Yeah. And so, you know, I mean, it's sad in any regard. But I think if you can do the things ahead of time to prevent it, then you know that you've done everything possible,

Scott Benner 15:24
takes away from the idea of is this diabetes? Or is this something else that you can see yourself as more than having type one, you can see normal things that happen to people, I just saw someone recently who had a seizure, and thought it was because of their blood sugar, but then figured out, it wasn't, you know, but that was their first thought was, oh, I must have my blood sugar must have gotten very low. And it turned out not to be right, you need to see yourself aside of diabetes. And the best way to do that is to make diabetes a lesser impact on you so that you're not always worried about is this happening because of that, right.

Jennifer Smith, CDE 16:00
And I think that that's a good point, though, for the pre the pre conception, the pre planning stage, to know the impact of this versus, versus, you know, I do this activity, and this happens. There's a lot that goes into that, beyond just having well managed blood sugars. Yeah, there are a lot of other things to consider in that right. Nutrition is one of them. And then the other factors that are very rare autoimmune disorder is, are your other autoimmune conditions? If you do have them? Are they well controlled? Thyroid is another very big one that's really, really important to have tightly managed prior to conception. Because thyroid levels do change. They will manage and evaluate and do more blood tests and adjust your medication. But you also have chi, you have to have kind of a baseline right? To know coming in. Yes, things are good.

Scott Benner 17:02
You know, it's funny, you mentioned that because just an hour ago, I took art and to get her blood test, because we've been managing her thyroid through her endo forever. But it's always just like, well, she's in range, it's fine. It started with still having a lot of, you know, side effects of what you would consider hypothyroidism. And so I finally found an endocrinologist who doesn't care exactly what the number says they care about how you feel. And so she's doing all these other things with her and I hope to have that doctor on at some point when this process is done with Arden, but it's fascinating. She's taking so often uses terrorists and and the amount of tariffs that that her first doctor had her on is half of what the second doctor had her on. And she looked and she said, Yes, her numbers fine, but her symptoms are terrible. And she said, given her weight, I would think that this should be more medication like so she was just she's very tuned into it. I just think that I would like to do a lot more about thyroid. On the podcast, I just you have to find the right people to talk to and they're difficult to locate, you know. But yeah, so that as well. So what do I do? I've, and I don't want to skip over what Jamie just said about nutrition too, like, don't get so focused on your blood sugars, that you're like, wow, look at me, I've got a four, eight, I can eat all the Twinkies I want. I learned how to keep my blood, the kids gonna need like some greens and protein and stuff like that to grow it. But I don't want to tell you how to pray in your family. What I am wondering is I've decided, I've got some money, I found a space I can put the kid nice. The safe closet, if I want to go out maybe that break can't get hurt, you know, and moving forward. Do I make with the bangbang fun part? Or do I go find a doctor first? What's the first? Yeah.

Jennifer Smith, CDE 18:51
The other part of it is not only your management, having a team in place, prior to conception is really, really important. Because I've had a number of women that I've worked with who have thought that they would just go with who was preferred with their insurance, right plan. And a number of them have transitioned once or even twice through pregnancy because they were so unhappy with the care that they were receiving. A lot of it's specific to diabetes and the consideration of diabetes in the pregnancy. I mean, and definitely higher risk, maternal fetal medicine teams, they know pregnancy, but it really takes the right team to know pregnancy and diabetes together. And pregnancy and diabetes with type one diabetes is very different diabetes. And so if you've got a practitioner who you know says yes or there you call and you ask around to a couple of offices talk to their nurse Horses and get a bit of an idea about how the clinic runs and how appointments run and the doctor and experience and oh, we've got lots and lots of experience with diabetes. diabetes, is the question you should be asking, because they may have a good amount of gestational diabetes management experience. It's very different with type one,

Scott Benner 20:22
you don't want to get caught up in the medical equivalent of Oh, my aunt has that. Yeah, correct. Right. type one, your and as type two, it's different. Thanks for Yeah,

Jennifer Smith, CDE 20:31
so do your shopping is really, you know, the case. The other piece when you're doing your shopping essentially, for your care team is, if you've got a really great endo that you're working with already, that would be a first, like, stop to actually ask them. Are you going to be my diabetes Backup Manager through this pregnancy? Because I've had some endos who differ to the maternal fetal medicine team, which, that's okay. As long as the maternal fetal medicine team has got it, man, they understand the diabetes pieces, and they understand the diabetes pieces. Well, I've also, you know, games differ, you know, some OB is, once you get pregnant with high risk anything, they're hands off, they're like, you're going to high risk, high risk is going to manage the pregnancy for you. We won't see you. Right, we will see you until baby is born and you are post delivery time, right? Other teams, the OB sees you for the base visits just for the monitoring and that kind of stuff. You'll be shuttled away to maternal fetal medicine potentially then for the high risk types of things. Anatomy scans, fetal heart echoes all of the higher risk types of evaluations, especially in the third trimester. So it it around, it pays to even see if offices have a preconception consultation that they will do. So you can talk to the doctor and you can bring them this is how I manage I'm well managed. This is what I've done to get to the point of being ready. Because the more that any team like that what you know, and how well you're doing, the more comfortable they're going to be helping you to manage the right way. Yeah, so yeah, it takes it takes looking.

Scott Benner 22:25
Okay. So we have to do some shopping, find we find the doctor. We, we we decide to move forward. We start doing what we're doing. I ended up pregnant. Me. I don't know why I didn't see you in this scenario. Hopefully you don't pretend I'm a lady for a sec. And I'm pregnant now. And I have diabetes. So pretend everything about me is different. I'm a lady I have diabetes. I'm pregnant. Now. How soon do I start noticing like well, I noticed that my blood sugar's before I noticed in my pregnancy test.

Jennifer Smith, CDE 22:57
For the most part in the first several weeks post conception, blood sugars are going to start to look wonky. wonky and I think the easiest way to describe it is if has experienced a rise of any kind in blood sugar during their normal monthly cycle, whether it's the three to five days before the couple of days of once they get it or even around ovulation. Hormones from the start of pregnancy are significant. A big difference in blood sugar most women in about the first week to let's call it five to six weeks will experience a rise in their insulin need because of those hormones and the impact that they have. So you know if you have been trying that you've been trying as soon as you know you're done try get on the these are my diabetes pregnancy targets that I'm aiming for if you haven't been doing it you know so tightly prior to trying then definitely do it as soon as you're done try you could be pregnant.

Scott Benner 24:10
Alright, let's take a detour for a second and and let Jenny rant for a minute. Why it's might be something I know about her that she's never said here but why are there different ideas of health for pregnant people with type one diabetes and non pregnant people with type one diabetes if it's great for the baby, isn't it great for all of us.

Jennifer Smith, CDE 24:33
There you go. Yes, it opens up a whole can of worms Pandora's box, so to speak. We have

Scott Benner 24:39
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Jennifer Smith, CDE 28:00
It's a great question. And it's one that's always kind of been like in the back of my mind even before my husband and it's like, we definitely want to have a child within the next year. Right. But I had already prior to that readiness, I had already been focusing on much tighter targets than my endo ever told me to aim for. Knowing what I know the research that I've done about long term outcomes of blood sugar management and control, right. And it was several years ago actually that I worked with a woman through her pregnancy and postpartum she said to me, so my doctor wants me to loosen up my targets. And she's like, No, I'm through pregnancy, managing the way that I did. And knowing what people without diabetes, what their body manages for them. Yeah, she's like, why would I go back to loosened targets? Why would I do that? And it was, I mean, it really like brought it to the front of my head from like, love. That's what I always aim for. So I guess I didn't really think about it. But that's right. It's it's a it's a great question. Why are we not overall consistently aiming whether you're a man or a woman? Why are we not consistently aiming for blood sugars that are in the nondiabetic? Why why is that the case? Now, outside of this? There are some good reasons things like older adults, hypoglycemia unawareness. There are some medical types of conditions or certain scenarios, let's call it that could meet a range and or a higher range for safety kinds of reasons. But the general population it's a good thing to bring up because that's it's true. It why are we aiming for less than 180 after meals, and I really it should be lower.

Scott Benner 30:03
And I brought it up. Because in my sort of peripheral understanding of this, this whole time that I've been in the diabetes space, I've always thought of it as people would people with, I was gonna say people with pregnancy, people who are getting pregnant, are somehow asked to do some superhuman thing with their health. That's not even necessary. And it took me a while to realize that's not what we're really saying. What we're saying is that every Listen, there's a lot of people that have type one diabetes, and we all have different access to different technology insulins, all these different things. And so there's a, there's a blanket statement out there, like, if you're a one sees, you know, under this number, you're probably have a really great chance of being okay. As it gets lower your chances of problems get differently, you know, maybe they lesson, but then once in a while someone will put out a report, this is all there's no benefit in having a one C under this number for some reason. And I every and we've talked about on here before and I see that and I think I don't, I don't believe that that's true. And I think that that's going to be one of the things that 10 years from now someone's gonna say, oh, there was a report 10 years ago that said this was wrong. Yeah. But oops. You know, and I also think that it's a, it's an emotional idea. Like, if someone has a seven, you don't want to make them feel like a failure, because they're not five and a half. Right? Right. Because they're not, but it doesn't mean that they should stop trying for the other day not make themselves crazy, or you know, like anything, but write better goals. It's, I don't know, right? It just, you know, it's like if I went out and ran a 300 yard dash today, I think I'd finish it. And I don't know, probably an hour and a half. And so right. Now, that might be my personal best, but I saw on the Olympics, it can be done. You know, it about seconds, about 15 seconds. And so I can't just sit here and say, Oh, I did the best ever, because that's my best because it's not and it's your health or your child's health. And you can't just I mean, I think that one of the underlying concepts of this podcast is that you can't just say, oh, that's fine. It's good, or it's good enough. 300 after pizza usually go to 400. That was a huge win for that.

Jennifer Smith, CDE 32:21
Was that right? And maybe that was a win. Maybe that was a win, you know, but if it's,

Scott Benner 32:25
yeah, it's totally better. Again, try again, try it.

Jennifer Smith, CDE 32:27
Right. And that's it. So yeah, that's a very good point to bring, I think target targets in pregnancy are in a way they are tighter, because we do have certain parameters such as, in the post mealtime period, the targets are at one hour post meal, the goal is at two hours post meal, it's less than 120. Yep. And really, if meals aren't in the picture, you should be averaging somewhere around, you know, like the 65 to like, 100 ish range. That's, that's, that's what you should be aiming for. Now, the person who's not pregnant, if they're sitting at 21, great, they might feel really good at 121. In pregnancy, that's the high end of really where we would want to hover long term. So there are some parameter differences. And I think it has to do also with everything that the mother is doing to her body. Yeah, that's the impact on the developing baby then,

Scott Benner 33:30
right? And keep in mind why that is to 121 blood sugar. If if you're a person, like we've been able to see my wife's blood sugar in the past, my boys blood sugar sits at like, 75 Most of the time, right? Yeah. And so if, if, if that's what your normal is, and you're 121, I'm going to tell you some quick math tells me that's 46 points higher than what your body would have done without diabetes, which is a significant difference significant. It's a significant concentration of glucose in your blood, messing with the development of that baby. That's what I'm, or if you're not pregnant, messing with your life, you know, so

Jennifer Smith, CDE 34:11
as far as like messing with the baby, I think another piece to bring in is once the baby. I always find this concept really interesting that a pregnant woman who has diabetes type one diabetes specifically has a pancreas that's doing right, the betas are either almost completely dead or they're all gone. Right. What they have and are growing this little person that has a working pancreas inside of its body. Yeah, right. I mean, that's, it's amazing just to think of like a developing baby to begin with, but then to think of all the little parts and pieces growing and working the way that they're supposed to, in that like little being. It's amazing to me so when you consider blood sugar in pregnancy as well. Your baby has a functioning pancreas. is very early on, right? And it starts to make insulin in response to what? Telling it's blood sugar. Oh, right. So the flux of your blood sugar tells then how is it kind of it goes along with how much glucose or how much food gets funneled in to the baby, the higher your glucose levels are, the higher glucose levels will get Now, baby's glucose levels again, they're being controlled well within a normal non diabetic target, because that's what its body is doing. But the more the pancreas has to work to combat your high glucose levels, the more like swapped in glucose the to be continually. And that's why like, later on post delivery, if the baby's body has been so used to pumping out excess insulin all the time, as soon as the baby is born, and you've heard about babies have been born with really low blood sugar. Yeah, soon as that umbilical cord is cut the mother's food source to the baby, it is gone, right? And if the baby has come into delivery, with a pancreas that's spitting out excess insulin because the mother's glucose levels were so high, its blood sugars are going to plummet.

Scott Benner 36:26
Interesting. So that makes sense, obviously, but that's Yeah, interesting.

Jennifer Smith, CDE 36:31
So that's another piece of like, we talked about the tight control in pregnancy. Tight is it's, it's there for a different reason, really. And so the ranges and how long glucose should stay at that elevated like one, then be back down, really into the normal range. There. There's reason for that.

Scott Benner 36:52
Yeah. It's funny, we all talk about it. So academically, like you know, 140 in the first hour, or 120, in the second hour back down and stable until I work glucose monitor and watch my body do it. It really didn't mean as much to me as it did, saying it out loud, right? Because my understood my entire understanding of insulin is through Arden's perspective. Like I've never thought about it before about about somebody else's ever once, and there's no lie, your blood sugar just sits in the 80s, you know, and then all of a sudden, pops up a little and comes back down and comes back down and levels out. And maybe you see a protein rise or something from fat later, it comes back up a little bit, but boom, right back down again, I ate my face off and couldn't get my blood sugar to go above 145. One, you know, 130 by the cage or something, totally took in as much food as I could, and I couldn't get over 135. So, you know, so, but how do we? You know, it's interesting, right? Because this podcast works, because we talk to people honestly about stuff like this, but most people's perception of how to talk to people. So don't make anyone feel bad. And I don't want anyone to feel bad. Like, I don't want someone to hear this and think I can't do that. Because I think you can. I think that I think that it's very possible that Jenny and I could have cottoned on and said this is a diabetes pro tip episode about pregnancy, go back and listen to the other protests, and then have sex. Yeah. Right. We'll see you next time. Like it may be could have been that really. And so if you're in the scenario, right now, where you're listening to this, you're like, Oh, I can't do this, or I have a different kind of diabetes, you probably don't, you know, like, you know, a blood sugar, that's it's stable, it's 7075 80. That's Basal insulin, that's just getting your Basal right. And so it's real doable. So if you've made it this far, you must really want to have a baby. And, and it really is doable. I really do say go back to Episode 210, find the beginning of the protests, or go to diabetes pro tip.com, where they're all listed, and listen through them, I think you could change your management. Now. Here's the thing. You've been pregnant, like you said a number of times with type one, is it more difficult? And by difficult, I mean, intensive with your focus and paying attention to your diabetes while you're pregnant, or while you're not pregnant? And what's different about it, like what are people going to find once they're pregnant? So I've got my three months where I'm doing great, but now all of a sudden, there's a baby in there, what changes?

Jennifer Smith, CDE 39:35
It's more intense, I think, because of the impact of the hormones once you are pregnant, right? So you knew what you were doing? You knew let's say you had your list of 30 Awesome foods that you had figured out or three pills and you knew what to do for them and how to Bolus and you can knock out your 10 mile run, you know, twice a week and whatever you figured it out. hormones in the picture change that okay. And so and that sounds kind of scary, but it's, it's kind of a roll with it sort of. Okay, you and if you've learned things again, from the pro tips, you've learned that don't let it just sit there fix it, right? Don't wait six days to see is this really a trend? If you've got a high blood sugar in pregnancy, okay, one, it might be hormones great. Okay, but then let's get it down in the tested that you know how to get your blood sugar down, use those tools, you may need to use the tools in a in a more hyped up way, right, let's say you always knew that an angled arrow up or a straight arrow up required an extra half a unit of insulin, oh, with pregnancy hormones in the mix, maybe it requires to offset that, because those pregnancy hormones cause some insulin resistance. And in early pregnancy, it's a very quick, noticeable rise in insulin need. The end of the first trimester typically things dip off a little bit, they plateau as there's a transition, where the pregnancy hormones are made transitions from ovaries into your placenta, there's a little bit of a transition there. You see, you might run some lower blood sugar's in late first trimester, before second trimester starts. And this is where I kind of call it like, if you've ever been at a theme park, and you get on the roller coaster and you're right at the bottom just starts to get you going up and you're up and you're up. And you keep climbing and you keep climbing. That's from second trimester or about like 18 ish plus weeks, that slow steady climb and insulin resistance, thus requiring more insulin and more. And then over time, I mean, the heaviest resistance is definitely the third trimester, typically somewhere between about 30 to 32 weeks until about 36 weeks is the heaviest resistance. So you accommodate by making adjustments. And again, this is where that team to begin with should be a huge advantage to you. Because during pregnancy, pregnancy brain or mommy brain is not a myth. Yeah, it is something that is there, you might get lost in in data. And so having a team that's really, really good and willing, and frequently through pregnancy with adjustments, despite you making your own, you may need a second set or a third set of eyes looking at things and being able to say that was great, but I think we could bump this a little bit more, we could change it a little bit more here. Oh, this looks like it's happening now.

Scott Benner 42:48
That's well, I was just as you were speaking, I there's this conundrum around more insulin like, you know, my body needs more all of a sudden give it more and we call it insulin resistance. And I'm always resistant to call it insulin resistance. I'm always thinking of it as just more need. But how do you convey that to a person? Right? How does a person who believes that their Basil is one unit an hour? How can they make the leap to now believe it's two units an hour or that a meal that was three units is six units all of a sudden, like that's such a huge leap in your head? And I wonder if it wouldn't help people just to think of insulin resistance as magical carbs that just appeared inside of your body? Right? Like so, you know, like, instead of insulin resistance, pushing your fasting blood sugar from 85 to 150, think of, well, how many carbs would have moved me that far? Right? And how much insulin would I have used for those carbs? So that's in there, there's a math equation of how much insulin do I need. But what I realized most about the podcast is that people need a way to think about it, right? They need a way that it makes sense to them. Because otherwise, they want an equation that's going to tell them when I'm pregnant, I need this percentage more, or the food's gonna need this much more. And I don't know that anyone's gonna give you that answer the way you want it. So

Jennifer Smith, CDE 44:11
I think it is it's more but I think if you know when you're talking about like the math, as you said, if you know that your typical fasting now in pregnancy has been like 7881. And now all of a sudden, you're waking up when I was nine 110 That kind of range. How much of an insulin adjustment is needed in that overnight Basal then and where did it go up and what to adjust because again, if you've done your homework ahead of pregnancy, you have an idea of where things started. And as you changes, you're more attuned to them in pregnancy. You just you see things on a super highlighted level. Let's call it that You know, you're paying more and more and more attention you asked, you know, what's the difference between paying attention outside of pregnancy versus B? I think just the pregnancy itself drives a woman to think I'm now caring for another little being that's growing. And I have, I have the ability to let this baby develop really healthy from the get go. And I'm a big part of that, right? So you become really kind of like, hyper on evaluating what's happening to your blood sugar. I mean, I looked at my I looked at my Dexcom. More than Well, while I was pregnant, I was constantly like clicking to see, you know, what was going on? Where was it going? What was happening? Because, well, the see, is this normal, or have I gotten a new load of like pregnancy impact? And do I need to make a shift now? Oh, look, this is like, day two, that I've now had to correct my blood sugar with a little more after lunchtime. I need to obviously add more insulin to my Bolus, I need to change my

Scott Benner 46:07
did you have anxiety around that? Samantha mentioned in the episode that she sometimes felt like she was hurting the baby when her blood sugar would get high? Yeah, it was hard to deal with sometimes. And then I think

Jennifer Smith, CDE 46:18
that's a I would say, 95% of the women that I work with their pregnancy that's at at least once it's mentioned, well, my goodness, my blood sugar. Again, we we had like a baby shower, and I had like a bite of a cupcake and my blood sugar was 201. Or, you know, I got it down really Rino right away. I'm like, okay, that's that's okay. And they're, you know, they're very, I think the worry really is one they need to voice it because it was concerning to have worrying about that baby did that really high blood sugar for one hour? Cause my baby to now have three eyeballs now weigh 12 pounds? No, it's It's more understanding that the consistent lengthy, high blood sugars, that's problematic. Right off, I mean, was my blood sugar sitting at 83, the entire pregnancy dislike flat, beautiful, I actually go back to my Dexcom records from that time because I printed them out. But I have them in like my pregnancy file.

Scott Benner 47:21
Just let everybody take a second to say to themselves personally, whether they're doing chores, the House working out or your grocery shopping to go. I knew Jenny had her Dexcom grafts from her pregnancy.

Jennifer Smith, CDE 47:33
They're good. They're reference for me, as I work with people, and I was really glad having done that my first pregnancy, because we knew that we wanted more kids. Yeah. And I wanted to have a reference to be able to say, tested. So once you get through a first pregnancy, and you get an idea, yeah, I needed more around 20 weeks, I needed more, again, in Basal and in Bolus, and I needed to lengthen my Pre-Bolus. That's another big one that shifts through pregnancy, you might you know, pre pregnancy, you might do 1526, things are stable, that works really great. Once you're pregnant. As you get more pregnant, the time of Pre-Bolus gets longer and longer and longer. So by about mid pregnancy, you should be pretty minute Pre-Bolus For most meals,

Scott Benner 48:31
how much of what's happening to a pregnant person is in regards to their insulin use is that they're pregnant, that they're cooking a little person inside of them, they've got a bunch of hormones going on. And by the way, all of you have to be so impressed that I talk about this stuff so much. And I've never told that joke from the 80s. How do you make a hormone? I keep it inside every time I hear it, just so you know. And so how much of this has to do with that? And how much does it have to do with gaining weight too? Is that a part of it? So like a side of the diabetes piece or a side of the pregnancy piece you are gaining weight as well, right?

Jennifer Smith, CDE 49:08
Gaining weight and you shouldn't you should be gaining weight and that is a very big piece of it. Yes. And you know, Healthy Weight Gain if you've if you're at a really good target, happy healthy weight prior to pregnancy. You could gain somewhere between 20 to 3025 to 35. Okay, in pregnancy that would be considered normal. You have to expect or I guess you have to understand where does that wait to come from? Because in both of my pregnancies, my first pregnancy I think I gained I think it was 26 pounds. My second pregnancy I gained 21 pounds. And you have to you have an eight pound baby. That's like a third to maybe half of your week. Depending you know, that's a big chunk of that already. Now, like put on the floor plucked out at You're you delivered right? Hopefully that the floor but right, it's like not on you anymore, right? And then you have to expect development for lactation, you have a placenta, you have all the amniotic fluid, your fluid levels in your body doubles through pregnancy. That's why a lot of women experience swelling and whatnot in their legs by the end of the day at in late stages of pregnancy, your blood volume increases to pump all of that extra blood through you, pink tissue and the bat. So you've got a lot of gain that disappears, literally once you deliver the baby. So really, women end up you hear people complaining on this last five pounds, I can't seem to get rid of it after break. That's really it is that gain? Yeah, most women gain someone seven pounds of fat gain through pregnancy. And it's normal, your body should be doing that. Because if you plan to nurse or breastfeed your child, your body needs a reserve. So it's packing things away. So you can make plenty milk to supply this like never are empty baby

Scott Benner 51:11
hungry all the time, it was about to show off and say that that was for breastfeeding. But then you beat me to it. I was like, Oh, I know something. Finally that's yeah, prove it now. So it doesn't matter.

Jennifer Smith, CDE 51:22
And typically, as long as you nurse, you're usually most women are going to retain about that. Once nursing is done, depending on how long you plan to nurse, usually, as long as you return to your normal activity, and you haven't been eating bonbons crazy, just because you want to typically that weight does come off once you're through nursing.

Scott Benner 51:45
Alright, so we've gotten through the pregnancy things have gone well, the day the delivery comes, please talk to your doctors well ahead of hand and understand that just speaking to your doctors doesn't mean that the nurse that the hospital's going to know that you're taking care of your blood sugar during your during your delivery, right. And it's going to, if you've been doing such a good job thus far be really weird to hand it off to somebody, you know, in the last 50 yards, when you're like I can see the end, now you take care of my blood sugar. So you know, if you have a spouse or a family member, that you can, you know, teach how to help you or she'll be there with you right in case something gets funky and they end up putting you out or something like that, I guess obviously, if they go to a C section, you're gonna get handled like a surgery case then too. But if you're just having a regular vaginal birth, you should be able to manage your blood sugar through that time pretty well.

Jennifer Smith, CDE 52:42
potentially even a C section, you know, really? Yeah, really. And I think this is where protocol, like you said initially, it's, it's really important to have this talk with your team much sooner than delivery could possibly happen. I mean, there are always certain instances delivery at like 28 weeks, or 30 weeks or whatever. And those are really, it's not often. And that's a very feel of management, right. But for the most part with women that I work with your pregnancy, we establish and detail a labor and delivery plan, okay, and it goes through, these are the expectations of glucose management, this is where you should target through dip through every, this is how much insulin adjustment you could expect to need to make. And again, every woman responds to laboring and delivery a little bit differently. Some women's needs with the active nature of laboring, some women's needs go down by 50%, great use a Temp Basal decrease. Some woman's needs go up a little bit with the stress of all of the contractions and everything. Great. So you might need a little nudge kind of Bolus of insulin in order to get a little bit, right. A little bit extra. Whenever you're correcting in delivery, our recommendation is typically about 50% of what your pump is recommending to correct a blood sugar while you're laboring because, again, you're you're active. I mean, it's not like you're out running a marathon. But a pregnancy can take long, or a delivery can take a lot longer than marathon takes a person, right? So you can expect that that now is gonna get active pretty quick, and it's going to have a faster impact on your blood sugar. Right. So those are some of the things that we highlight. We also have a pattern established in the care plan so that the doctors know where your rates are, what your sensitivity is going in delivery. And then there's also a postpartum part of the delivery plan that notes now insulin needs are decreased considerably. This is what your postpartum pattern should look like a lot of the women I work with take it into their OB team, they get it signed off, it becomes part of their medical record. And once they go into the hospital, that's the plan of care. The nurses know the targets. They don't have to continue to explain it over and over and over and over to all of the nurses as they're rotating through their eight to 12 hour shift.

Scott Benner 55:22
Yeah, yeah, that's Samantha brought that up to that the first nursing staff was great after the pregnancy. And then when they switched over, the next group didn't know what the first group knew. And then now you're explaining about your blood sugar's and that all gets and you've just had a baby said she was wasted from having the baby, the whole thing. Okay, so I have a couple more questions. And I know we're running up on time a little bit. Oh, we're good. Okay. Make the baby baby comes out. Everybody comes to the hospital. They're like, Oh my god, the baby made a baby. It's great. You see your friends of yours who you're like, oh my god, they shouldn't even be near kids. Somehow you let them hold your baby. If you're younger, trust me that will happen. One of your 25 or 30 year old friends is going to be hold them in your like, that's probably a mistake letting Jimmy near the baby. And so that all happens. Your home now. Now, you've got to take care of a baby. Yeah, I see a lot of people say well, it's hard to take care of the baby and my blood sugar the way I was taking care of it before. But it did you find I'm using you as an example here because you're very good at handling your blood sugar. Did you have trouble after you had a baby keeping carry yourself?

Jennifer Smith, CDE 56:30
I think you know, this is where again, planning your care team kind of thing comes into play. And while your mom, your aunt, your best friend, you know your uncle's brother, who isn't really your uncle, but is a good friend that you whatever it is, whoever's going to be there anyone post delivery that you trust, not Jimmy, who

Scott Benner 56:55
like drop the delivery of the baby to get the

Jennifer Smith, CDE 56:59
baby to but somebody you're going to trust to be there once you come home from the hospital. Yeah, that is a really, and something for at least a week, maybe even two weeks for someone to really be there to help with things because one delivery in and of itself is it's a labor. Yeah, that's why they call it labor, right? It's work you you may with a vaginal delivery. Okay, you may not be in the hospital for very long. If you have a C section delivery, C sections typically are about a three to three to four nights stay. It it depends on healing and how things are going and all of that kind of stuff, right? But definitely when you get home. It's harder because you're now not taking care of just you and diabetes. Now, it's like you've got a second child, even though if this is your first real child, I always considered diabetes, kind of like a toddler that never really grows up, like constantly sort of like caring for it. So it's almost like this first child diabetes gets pushed off in the corner and you're like, Yeah, you're just gonna have to sit there for a bit, because mommy's gonna take care of

Scott Benner 58:15
it fine. He can do his homework by himself.

Jennifer Smith, CDE 58:18
That's right, right. So you know, some things to kind of along with that care person, they're beyond your spouse or your significant other, you know, somebody else that can be there. So you can focus a little bit because in that time period, especially the first month, things will change considerably with insulin sensitivity, especially if you're nursing. There are a lot of changes that will take place and blood sugars are going to look a little bit more rollercoaster we want how important

Scott Benner 58:49
our blood sugars to the breastfeeding process does that impact the milk at all?

Jennifer Smith, CDE 58:55
So there's a lot of like thoughts around it a lot of research that sort of like a 5051 of the big things is high blood sugars can actually good lactation. So if you leave your blood sugars sitting high one, as we've talked previous episodes about like hydration, your blood sugar's are sitting high, you are not well hydrated, you are in a and milk is liquid, not only more coming out as your nursing, blood sugars are drinking enough. Oh, I see. So Right. So hydration is really, really an important part of not only the blood sugar, but also continuing to be able to supply enough liquid that's going to get sucked out of your body. Your

Scott Benner 59:41
mind too. If you've never had a baby before. They don't sleep the way real people sleep. So there's a tired factor that is really hard to put into words. It's not easy. And so there's a lot going on. I mean, listen, we've gotten this far I should put I'll be telling you having kids is a huge mistake. I don't mean that having them is great. It's getting them and taking care of them and keeping them alive and being, you know, good to them and teaching them things. All that is a harsh show. But the kid itself is lovely. Like, when you walk through the room, you're like, oh, look, the kid. That's nice. Yeah, in that moment, you don't think about when they're yelling at you when they're eight, or that you paid a guy who was probably homeless to be spider man and a third birthday party or something like that, like, that's the thing she you know, they want you to have a dog. And then you get a dog because you like, oh, the kid should grow up with a dog. And then it's 630 in the morning, everyone's asleep, but you and you're outside with the damn dog. You know, I'm saying kids are great. A lot of what goes with it is hard. And hard. And especially right after a

Jennifer Smith, CDE 1:00:51
baby is hard. Especially if, again, it's your first pregnancy. Yeah, it's it's a harder time. And this is again, where help comes in the form of also, like, pre planning, for the post delivery, the time period, you know, we number of like soups, and things that I could put in the freezer, that were easy to pull out. I knew the content of them, because I knew what was in them, I either made them or my mom made them. And I froze them, it needed a heck of a lot easier. Also, some of those foods that are definite, no one foods and how are you react to them? Yeah, can be a huge help in the aftermath. So it's just not it's not more struggle, as you're already managing. Nursing a child putting a child to sleep, learning how to not like have poop all over the place as you change them.

Scott Benner 1:01:46
You could experience postpartum depression, which is incredibly common. There's a lot that could happen. And by the way, a lot of guys will eventually turn into good fathers, but it doesn't, they don't have a nature provided switch, like I'm telling you, you're going to have a baby and be like, This is the most important thing in the world I watched might happen to my wife, she almost didn't even care that I was alive. When the baby came out. She was like, the baby's here. And that guy, you know, like, it was you if you're, you know, lucky, you're gonna get a great connection, and you're gonna feel that desire to take very good care. It takes guys longer to figure out how to be fathers than it takes women to figure out how to be mothers, generally speaking, even if you've got an even if you're listening right now you're like, now my guy is a good guy. Listen, I'm a good guy. It took me like two years to figure out how to be a good dad, right? Like, you have to watch it and go, Okay, this is what I think they want. But this is what they actually need. There's a difference in there, I still struggle with to this day, I'll probably be struggling with it on my deathbed. I'll be 80 years old, just drifting off, and I'll hear someone in my family go. He did that wrong, you know, there's that there's a lot that's going to happen to you and you have a baby, and you're going to have diabetes too. And it would be very much my hope that you don't take all this wonderful stuff that you've learned pre planning for your pregnancy, through your pregnancy through your delivery, and just do that human thing of going that baby's more important than I am and so I'll let my stuff Wait.

Jennifer Smith, CDE 1:03:26
You know, I think it will also has type one, she had a son prior to our first son. And she gave me some really good advice and said, You know what? If inter we're talking about like, low blood sugar's around nursing, right, she was like, You know what? is low, and the baby is screaming, that the baby is safe. Not sitting like on the edge of the counter waiting to fall off. Right? But like, fine. I am important to take care of myself. It's important that I take care of myself. I'm important too. I have to manage. Yeah, I have to manage my high blood sugar and the baby screaming. It's okay. Yeah, maybe it's gonna be okay screaming really? I mean, you're not going to let them scream for like three hours. But yes, in the case of 510 minutes while you are taking care of you treating a low blood sugar or even just for your meal before you actually sit down to eat it. That's another piece that I we talk a lot about Pre-Bolus thing and the timing in this podcast and that's a piece that often goes out the window because depending on what your schedule is like what your significant other schedule is like, you may at times be whole your maternity leave with the baby

Scott Benner 1:04:50
yeah, I there's a part of me that believes that we should be making a sign and selling it through the podcast that just says that's a real homie. You know how like you see those beautiful signs and people's kids It's like The cook is blah, blah, blah, there should just be one that says Pre-Bolus. hung in people's homes so that it gets drilled into your head over and over again, because this is the easiest thing to mess up. Like, tip, forget, you know, I did it this morning, this morning, we got back from the blood draw. And art is like, I'm gonna have eggs and turkey bacon and toast. And I was like, does that mean I'm making it for you? And she's like, Yeah, so I'm thinking, Well, I have an hour till Jenny and I record. And I can get this done by then. And I started focusing on getting it finished. And then I turned to her and handed her a plate and thought, Oh, I didn't give her any insulin

Jennifer Smith, CDE 1:05:34
damage. And of course, she didn't think of it either.

Scott Benner 1:05:36
Nobody thought of it. No, we'd gotten up super early to go to this blood draw place. And you know, like all this stuff. So I said to her, we're going to Bolus now and please eat the toast last. That was like the best I could come up with, you know, in the moment, and we ended up having to use an extra unit to overcome that offset. Yeah. So okay. Did we miss anything? Is there something in the back of your head burning?

Jennifer Smith, CDE 1:06:00
I'm trying to think of, maybe, I guess the one last thing along with it is definitely stay connected to your care team. You know, because that's, as you mentioned, already, there is potential for postpartum there's a difference between just being a little bit like down in the aftermath of delivery. And true, like, you crawl in bed, and you're like, I don't to do anything else I, I will nurse the baby. But then the baby goes over here, it's almost like a, it's a disconnect that happens in true postpartum depression. Yeah. And so staying connected to your care team, is really, really important. Making sure you have those postpartum follow ups kind of scheduled. Leave the hospital, it's really, really important. Maybe staying connected with your diabetes educator or your endocrine doctor, whoever was also a really good advantage through pregnancy, stay connected with them so that, you know, they can even nudge you maybe to say, hey, you know, can you just pop in and upload it and I can take a peek and I can make some recommendations for you let somebody help you. Let somebody help you really? think, oh, go ahead.

Scott Benner 1:07:18
If you think it can't happen to you, my wife and I, we were just talking about this recently, she said for the first two weeks after our son was born, she had no feeling at all about having a baby. Like she just felt like we brought home a lamp. You know, like it really she's just like, I don't know, if I like this thing or not. Plug it in over there. Leave it Oh, we'll see how it goes. And she said that all of a sudden, one day, a couple of weeks in, I was at work. And she said she just was holding call and just started crying. She's like the baby is the most important thing. Like it all hit her at once. It was almost like you expect that to happen when you need it, but it didn't happen to her right away. And then she had that like, oh my god, I have a baby and I don't care. Like we're not even not care but like there hasn't been this ramping up connection connection immediately. Right? Yeah. So and that's a rabbit hole people could fall down especially if you've been depressed in the past or something like

Jennifer Smith, CDE 1:08:12
that, especially with another condition to manage like diabetes. Yeah, there's there's more to manage than just connecting with this new little person. Yeah, so

Scott Benner 1:08:22
So stay connected to somebody that can walk you through it and if you're feeling that way have to tell somebody like don't hide it. Just tell somebody just tell ya then I should say here as we finish up, if anybody wanted to buy a book about pregnancy with type one diabetes, should they buy one called pregnancy with type one diabetes your month to month guide to blood sugar management available on Amazon and written by ginger Vieira and Jennifer Smith CDE. Oh, okay. Yes,

Jennifer Smith, CDE 1:08:49
they should absolutely. I think the farthest I've heard that somebody's purchased. Our book is Bally Bali or Bali? Yeah. I'm in Bali. Yes. Bali

Scott Benner 1:09:03
place in Vegas where I can lose my money in the slot machine. Ali. Ali's Ali. Yeah, there's someone in Bali right now has a little baby a Bali baby. Yeah, she's pregnant. Oh, look at that. All right. Well, all I know is Ginger has been on the show before you obviously know, Jenny, the books only 12 bucks. It definitely is worth your while and it goes

Jennifer Smith, CDE 1:09:24
through everything kind of in a much more. What we've touched on kind of in each of the sections of print planning pregnancy, whatnot. It's, it's a good book. I'm glad that we did it.

Scott Benner 1:09:38
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 juice box free meter while supplies last US residents only if you're enjoying the remastered Two 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 g vokeglucagon.com. Forward slash juice box. If you're living with diabetes, or the caregiver of someone who is and you're looking for an online community of supportive people who understand, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, there are over 41,000 active members and we add 300 new members every week. There is a conversation happening right now that would interest you, inform you or give you the opportunity to share something that you've learned Juicebox Podcast, type one diabetes on Facebook, and it's not just for type ones, any kind of diabetes, any way you're connected to it. You are invited to join this absolutely free and welcoming community. 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 1009 teen explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025, we talked about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer, he'd really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning that Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active. Took me already from a decent 6.5 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 You can learn more about her at that link

#1017 Diabetes Pro Tip: Bump and Nudge II

Bump and Nudge II expands on episode 1017.

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 Penn Find out more at G voc glucagon.com. Forward slash juicebox. So let's start like this. I just put up like the 340/5 episode of the show, which is mind bending to me honestly,

Jennifer Smith, CDE 2:34
what was the first first year first, cuz you've been blogging for a long time before

Scott Benner 2:40
I blogged from 2007 consistently until 2015 When the podcast started. And now I have to admit the blog a little more of a way of me sharing, I don't sit down and write from my heart as much as I used to because, right, it's so much easier to do on the podcast, and you reach more people. But I blogged for that many years the blog was strong, it was a million million and a half clicks a year 111 block of maybe two or three years, I got to like 2 million clicks, which was really big. But then I saw it kind of like trending away. And so in 2015 I started the podcast. And I really thought it was going to be I guess this isn't maybe a neat place to say this. I thought I was going to go back and read my most popular blog posts like into this microphone. Because that was my expectation for us. Like, you know, some of these blog posts are really helpful to people. I'll read them and make them audio. I did that for 20 minutes one time, stopped, deleted the file and was like, This is stupid. Yeah, yeah, nobody cares about this.

Jennifer Smith, CDE 3:44
And well, I can say there are some people that would care about that. I've actually got a couple of clients who really, they love the podcast because their their audio. And when they read things, it doesn't stick. And so they have to reread and reread. And finally some of the adults that I've got are like, I just put the book down because they're like, I can't keep reading. I'm not retaining it. But if I hear it, it's there. It's in my brain. So

Scott Benner 4:12
no, I hear that I should just felt boring to me. Like I thought someone would like it. But I mean, if I'm being honest, I was trying to reach more people, not just, you know, people who literally be willing to listen to somebody read something dry, you know what I mean? I mean, at least put some music behind it. You can imagine how funny that would be if I was reading with music behind me and there's like this guy's talking about It'd be terrible. And then it picked up and picked up. And, and like, you know, but for people who are maybe coming in late to it. After a number of years of the podcast, I started thinking there's like a real system here. Like I knew that while I was blogging, but when I could hear it I thought Oh no, it's this piece and this piece and these these four or five ideas and when you bring them together, there are five five a one seat like you just do these things and that's what happens, you know. And I, and I had had you on the show, maybe twice. And I always wanted you to be back. And I thought she's the best guest I've ever had. Like, I mean, honestly, you, when you when it comes to diabetes, you and I think exactly alike about it from two completely different perspectives, which is weird and interest. Nice, right? Yeah. And it's nice. And so I was somewhere one day, and I thought I know what I'm going to do. I'm going to take the tenants of the podcast and break them down with Jenny, if she wants to do this, I'm going to get a hold of her and see if she wants to do it. And that was a weird leap for me, because until then, my real belief was that if you just listen to all the episodes, you'd hear things come up very kind of organically, and they would stick to your brain better, because you heard them conversationally, and I was a little scared to do. Specific, more bulleted specific topics. But then I realized I could do it with you. Because we have a rapport. Like, I've talked to other people in the podcast, and I tried to talk to him about stuff. And I find I'm stopping and starting and like, I'm like, Oh, they're talking over me. I'm talking over them. I can't find a vibe, you know, I knew I had that with you. So I contacted you. And you were like, I'll do it. And at the time, I was like, it'll be like six or seven, Jenny. And I sent you a little list. And you were really great. Like you took the list and you're like, I'd put them in this order. I think they make more sense in this order. And I was like, Okay, great. And now I'm going to look, I'm actually going to diabetes pro tip.com. Now, because that little idea now has its own website, which is even strange. It's great. 1-234-567-8910 1112 1360s, there are 17 pro tips. And this is going to be the 18th one, and then we're going to do pregnancy and we're going to keep going right? And it spawned like defining diabetes, which I never thought was a thing that was needed until this one person sent me a note that said, Hey, I wanted to thank you. Because until I listen to the podcast, I didn't realize I was on MDI. They took and you told me that right. And that made me think, wow, there's some people really not understand some of the terms we're using. Let's define the terms for them, but simply not an hour conversation. Right. Right, a little bit. Anyway.

Jennifer Smith, CDE 7:25
So not a not a dictionary definition. I think, as I said, you know, before some people get things because they hear it in a different way, or they read it in a different way. And I think the great thing about the podcast too, even with the pro tips, part of it is that it's broken down much more like layman's, applicable, it's, it's not what you get in a typical Doctor education clinic.

Scott Benner 7:49
And we did it a couple of times. And I was like, damn, this is good. It went so well that I was like, give me your address. Jennifer, I am sending you a microphone. So it sounds better now. Let's go. But one of the things that we did was bump and nudge, it gets talked about in the episodes, but it doesn't have its own episode. And I always kind of thought that was okay. Until in the last year. I looked at algorithm based pumping and saw how my bumping and nudging was too much. It had gotten out of hand and it didn't realize it because it was so easy for us to do that. We never looked back at the root cause of why we were bumping and nudging. And so this has been bothering me for like six months now. And I said that Jenny, I need a pro tip episode on this because not that bumping and nudging is a bad idea. It's a terrific idea. Right? But you need to understand it more. It's a bigger topic than I thought it was.

Jennifer Smith, CDE 8:53
And I think you really I think you really like realized it when you guys started using the do it yourself, right?

Scott Benner 9:02
As soon as day one came.

Jennifer Smith, CDE 9:05
We talked and I was like, how much are you using Temp Basal? Yes. How much? Are you adding little micro corrections or adjustments or whatnot through the day and you're like, oh,

Scott Benner 9:14
I don't know. I never thought about it before. So So Jenny's the one who said it to me because we were trying to find it was such an easy thing. Like you guys would hear me say before, like, I don't know Arden's insulin to carb ratio doesn't matter to me. I don't know what anything is. None of it matters, right? I know, we're Basal rate. And I know food. I look at food and I see food but

Jennifer Smith, CDE 9:35
you're like, Oh, that looks like five units up up. That looks like I got to split it off and give some now and a whole bunch later and right.

Scott Benner 9:42
Being flexible, which is terrific and important. What I didn't realize it was doing to me. You have to kind of like step back and look at a timeline of months. Maybe the developing two years is that at some point, you know, meal X took two units. At this Basal rate of whatever it was, and then it took two and a half and three, and three and a half and four, but it happens so slowly, I didn't notice, I didn't realize that I was now bolusing six units for something I used to Bolus four units for. I mean, I did. But I never stopped and thought, I wonder how much of this meal insulin is attacking the food and how much of it is staying in our system for hours afterwards and maybe acting as Basal. Right. And so I had bumped so much with insulin that I lost track of what Arden's baseline need was, it didn't matter because we were doing so well. But it did matter. And I learned that when I when I said I don't this algorithm won't work. This is ridiculous, her blood sugar's all over the place, right? It's just crazy. And it's because I had lost track of how much insulin we were actually using versus how much my setting said, we were using that did I say very clearly how much

Jennifer Smith, CDE 11:01
was actually needed, versus how much you were just intuitively correcting with right, adding a little bit extra because you needed it, but not really realizing. In general, I'm always adding extra here. And it probably is a setting issue. It's an I shouldn't be adding this much more all the time,

Scott Benner 11:21
right. And it becomes such a way of life. Right? I didn't think of it anymore. So now, I want to leave that thought here. And we're going to come back to it later. Because I do think that being fluid around diabetes is incredibly important. And that you can't just keep resetting your Basal rates every day for all the variables that are going to come up in your world. And I noticed a long time ago, that idea that concept is what causes people problems, right? The idea of like, well, I'll go to my doctor, and we'll find a Basal rate and Oh, my doctor was great. They saw between 2am and 4am, we had some highs. So we moved our basil up at 1am or 12:30am. And it worked. But then they started getting low, you know, a couple weeks later, but I just fed the lows for two and a half months and went back to the doctor, the doctor moved the basil again. And that's how people that was considered a successful use of your physician and your insulin right. It probably still is in many people's minds. I saw that and thought this doesn't work. I don't want to be involved in this and I've said it before and I'll say it again this podcast is a it's partly in place because I don't like the math around diabetes. I don't like the waiting. I don't like the we'll wait and see. I don't all that stuff makes me uncomfortable. Like all the things that you're supposed to do. I just was always like, Oh, that seems wrong. Like I don't I don't want to do that. That 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 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 in 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

Jennifer Smith, CDE 14:49
within it I think you also have to say that the technology that we have available today makes it more user friendly for people to learn how to make their own adjustments in the here. And now. That might work then for a while, and then they make more adjustments. But, you know, years ago without technology, going to the doctor every three months, every six months, like I used to do when I was younger, that that was the way to make adjustments now. Could we have taken and done more data, more data analysis in between the doctor visits we could have? And my mom actually did, she was like, this isn't working anymore. Let's just adjust here, let's Nope, you need some more insulin here. And I don't think she ever like to set it like that. But her explanation was always like, Well, this was just too high. And if it's going to be too high again, tomorrow, then you're just gonna use more insulin for the next meal. Right? Right. Okay, my whatever.

Scott Benner 15:49
I'm with you, you're cooking, right? So you seem to care. So I'm gonna go. And another issue in the space of people talking about diabetes in the past, it's kind of it's a number of folds, but one of them is that nobody ever wants to say too much, right? They're always like, worried that they'll say something, and it won't apply to the third person that hears it. And I so that was part of what the protests were for was to take information down to a point where, you know, this really does apply to everyone, like not saying things that only worked for you, or me, or noticing that my daughter needed something different after she started getting your period than she did before. And taking the time to talk through those differences were writing about it is hard, because you write something down, it's static, you know, I write a blog post around about my nine year old daughter, somebody reads it, it now feels like a rule. I don't spend time for my

Jennifer Smith, CDE 16:46
nine year old child, this is going to be the applicable method that I use.

Scott Benner 16:51
And you don't take time to philosophize out that I bet you this will be different when she's 15. And you just writing doesn't work that way. But you can conversate that way. And so a lot of people in the past who were impacting the diabetes space, were parents of younger children, who until your child gets older, you don't realize you think this is diabetes, but this is diabetes. In a kid that's not, I don't know, like, coursing with hormones or growing as much as you think. Or as active as you believe they are. Like, you know, like, when you're eight, you're like, Oh, my kid plays baseball, like Yeah, okay, well, you know, your kid really plays baseball, like, like, we know, they weigh 200 pounds, and they're flying around, and it's 110 degrees outside, and they're throwing things through walls, like it's an impact on your body weight, or your kids playing ice hockey, as a high schooler. Like, you know what I mean? Like, we got

Jennifer Smith, CDE 17:47
practice from six until eight in the morning, and they've got practice, again, from you know, four until eight, six o'clock at night. I mean, sometimes, those practices I'm amazed with the kids that I work with, their parents are like, Oh, she's got tennis for you know, from six o'clock until 730. And then she goes off to school, then she's got another practice from four to six and like, like, seriously, like, she's the tennis thrower.

Scott Benner 18:11
That's how you make a tennis pro. One in a million times. The other 990,000 times is how you make a kid who hates tennis eventually, right? So Right, exactly. But so these people were doing great stuff. And they were talking about these these ideas, but they didn't realize how specific they were to the age group they were talking about. And, and I think that that's why this longer conversation while I mentioned how long the podcast has been up has been important, because in my heart as crazy as it sounds, I think if you want to have great success with your type one diabetes, you go back to Episode One, and you'll listen through, because you'll take a journey through somebody who's talking about a kid with a nine or 10 year old body that you know, you actually can hear in this podcast art and get older art and grow art and have problems her start to get out period, changing devices meters, like all the way through. And I know it sounds crazy, but in your 347 hours as of today. I think when it's over, you'll go who Okay, and then your kids just gonna have an A one C and the fives it like if you want it to be or maybe you you'll make an adjustment and it'll be in the sixes. Right. It'll also works for adults. And that was that was really cool. I hadn't had that like greater expectation. I thought it would but it didn't have a lot of a lot of adults weren't reading me as a blogger. You know what he mean? There were some, but there weren't a lot. Anyway, at some point, I recognized that was really long winded, but I guess the people there I guess there are used to that at this point. But it's a very long way of saying that you can't just set your Basal rates up, set up your insulin to carb ratios and go with that's what the pump told me and that's what they've done. After told me to put in the pump, right? Because things are going to change, sometimes day to day, sometimes hour to hour activity to activity, there are going to be too many variables. And you can't stop every time. Like imagine if I had to get up tomorrow and go, today is going to be a sedentary day. I will now go fix all of my Basal rates for sedentary and change my insulin to carb ratio for sedentary by the way, do you realize that that could end up for some people meaning more for some people meaning less, it could end up meaning less for basil and more for insulin to carb or vice depending who you are and what you eat. And so when all that exists, what ends up happening to people is they just go Ah, today was a good day. Today was a bad day. Yeah, right, they leave the settings, and then they have good days and bad days. And what I thought was, if we stay fluid enough, you can almost be ahead of what's happening and make these adjustments. Okay, right. All right. That's a long, long explanation. But to me, that's what led me to bumping and nudging. Now, for context, while Jenny and I are talking about it, I think of bumping as using insulin bumping your blood sugar down. And I think of nudging as nudging your blood sugar up with carbs, Jenny thinks of it the exact opposite way. So don't get confused. If one of us says one thing and one of us says the other. But in the end, the idea is to keep yourself between these smaller parameters, a range, a smaller range, and the range is defined by you, right? Doesn't matter to me what range you choose, right? It's

Jennifer Smith, CDE 21:41
it's your chosen range. But the idea is to use food in an insulin in a good advantage in both directions, so that you can stay within that

Scott Benner 21:52
target, right. And so some of the things I learned is, I wish people could

Jennifer Smith, CDE 21:55
see us by the way, our hands

Scott Benner 21:59
around good and bad. Oh my god, you keep saying that out loud. Someone's gonna ask you to turn this into a YouTube thing. And then we're going to be on camera, and neither of us are going to be happy about that. Because you're gonna have to hang up that stuff behind you. And I'm gonna have to get a haircut.

Jennifer Smith, CDE 22:15
Which by the way, is just like bags. And you know, it's not random strangeness. It's like bags and like colas. That's it.

Scott Benner 22:21
Jenny is now apologizing for something you can see. That's very Midwest of you. By the way. You're like, oh, it's it's not unclutter. It's nice people. It's a very important thing where the children hang their bags.

Jennifer Smith, CDE 22:36
The easiest for them to get to

Scott Benner 22:39
Off topic now. So anyway, so I'm going to do a little thing here. And please jump in whenever you want. In my mind, I take the I guess I should first say that I understand this would be more difficult without a continuous glucose monitor. I really do. What I'm saying would be harder, you could do it. I still think you could do it, you'd have to do it a little less aggressively, probably. And you'd be testing more but But what in my mind, what I see is that graph that goes along my daughter's Dexcom has a high line and a low line. And I take those lines from running. Oh my god, which way is this? Is this parallel? To the ground? Yeah, it is. Right? Correct. Yeah, I was asleep a lot in high school. listening to this podcast, just so you know. So I take those two lines that are spaced apart evenly, that run parallel to the ground, and I flipped them up on their end. So they're vertical, they're running vertical in my mind. And now they are a video game. To me. They're like driving, right? There are it's a football field, I don't want to run out of bounds on the left, or on the right. That's all it is. To me, there's in play an out of play. So when I describe it, and like talks, I discussed that like driving is interesting because it's um, you make a lot of imperceivable moves when you're driving, but if you jerk the wheel around, you swerve and you don't want to do that. So as you notice yourself approaching a, you know, the shoulder, you just turn the wheel back a tiny little bit and you come back into tow again, right? Like you're, you're it comes back. Same thing with you know, if you're gonna cross into the other lane, you just come back a little bit, you don't jerk the wheel around because if you jerk the wheel around, you end up in the in the ditch or in the other lane, where you end up with much higher or lower blood sugars than you mean. Right? So I bumped myself back, I bump. You know, I nudge back. I use that insulin to help art and stay in range. The problem that comes with jerking the wheel is that once you're in the ditch, you have to overcorrect again. And then you're on the roller coaster right now I've said roller coaster which now takes the graph back to being you know By the way, it belongs in your mind for a second, not vertically, but you're up and you're down and you're just overcorrecting the whole way with food with insulin, and you get the timing of the insulin so far off that some people it doesn't stop. It goes, it goes into

Jennifer Smith, CDE 25:17
keep going that way. Yeah. Yeah. For

Speaker 1 25:21
for not just for a day, for weeks and months and lifetimes of just that's what my blood sugar does. It bounces up and down. And people say that, and it's heartbreaking me like no, just turn the wheel a little less like, right, like, it's okay. I understand how it happens.

Scott Benner 25:38
And I think there are ways out of it. So I want to talk about some functional ways out of it. I guess people should understand the difference between a following and a drifting blood sugar. So why don't you talk about that for a second?

Jennifer Smith, CDE 25:52
Yeah, drifting is slow. And dropping is fast. I think that's the easiest way, drifting down and or even drifting up, happens gradually over time. So again, if you're using a continuous monitor of any kind, you'll see this slow continual change in blood sugar, little little nudges, kind of happening over the course of time. And since on all CGM, each of those little dots on your graph represents about five minutes, each little drift up or down, could be a change in glucose over a five minute time period, right? Yeah. So drifting being slower, means you have more time to implement a change right now, that could also be a smaller change, than having to make drastic adjustments with food or insulin. When you're dropping or rapidly rising, kind of the opposite. That requires more whether it's more insulin or more food, it requires more because the change is happening very quickly now. And usually I see drifts happening either with a horizontal arrow on your CGM, or you might get that slight angled arrow either down or up. That's I consider those drifts, I consider drops or rapid rises, when you've got arrows pointing straight up or poor straight down. That's fast. So you need to do something now.

Scott Benner 27:36
So to start with lows, if you're 75, straight down on a Dexcom, that could mean two or three points per minute, is that right? So every five minute change, you could go, you could end up moving 50 up to 15 points or something like that. I don't hold me to that. But fast is the point. Correct. So you don't like you know, when you're, when you're 80, straight down, you don't say hey, you know what I'm gonna just going to, I'm going to do a Temp Basal off for a half an hour here, that's not going to work. And there's reasons prior in the diabetes pro tip episodes, seriously, listen to them in order that will make sense to as why. But if you're just drifting down one of those situations where it's noon, and you're 100, and then it's 1215, and you're 95, and you just got this little drift happening, you could possibly be at the end of a Bolus that ended up being a little too strong, right. And maybe there's, you know, an imperceivable amount of insulin left in there a quarter of a unit, a half a unit, depending on your size, maybe it's two units if you're an adult, right. And if you take away your Basal insulin right there, it's possible that you can trade that extra Bolus that's left and create what I sometimes talk about as like a black hole of Basal, right. So keeping in mind that everything you do with your insulin now is for later because insulin doesn't work immediately. Like, what if at noon, when you started to see that drift down, you took some basil away, and that created a level. So now, the end of that too strong Bolus was acting as your basil and your basil wasn't there. But keeping in mind if you shut your basil off at noon? It's not going to probably start impacting you for at least one o'clock. Yeah, right for a while. But at the same time, you were only drifting anyway, it was probably going to take you an hour to get from 100 to 60, where either you'd then be drinking a juice but instead, as you're hitting that 70 Mark, you're all the sudden into the timeframe where there's no Basal insulin, and you just level out that doesn't always work. I've done it and thought I'm a genius and I've done it and thought oh, I missed that like but trial and error will teach you because there are a lot of different

Jennifer Smith, CDE 29:57
and I think some some visuals into that, too, as you said, you know, sometimes it works. And sometimes it didn't quite hit the mark, but you weren't necessarily wrong to take the basil away. I think especially again, with the technology that we have today, not only can you see the drift, but if you are somebody who's using an insulin pump, you also have the visibility of insulin on board, right. So if you have an idea how much insulin is left, like you said, an earlier Bolus of maybe you were a little heavy handed in it, or it was just you know too much, because you haven't quite figured out your ratios, or maybe it was, you know, a guesstimate completely, or whatever it was, you still have some insulin on board, if you have an idea of where your basil is right now. And you know how much insulin is on board, taking basil away, could substitute for some of the iob that's left? Absolutely. And like you said, it could nicely smooth things out and you just drift into a stable blood sugar. That might work if you've got iob of one and your Basal rate at that point is like point eight or point nine or even one that could absolutely smooth out if you've got three units of iob and your Basal is at point five, not going to help you to have you in a way it's going to help a little but you're still going to ask him to

Scott Benner 31:13
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Jennifer Smith, CDE 36:14
I think you know in to have you want to do if you wanted to add some definition to like people always ask, well, how much? How much when I start to see this drift? How much should I add? Well, you know, one, again, everybody's ideology is a bit different your sensitivity to insulin. So a point one might be what works for you a point seven might be what needs to be in, you know, somebody else's case. But I think if you give definition to direction of blood sugar, again, using today's technology, beneficially. And you mentioned before, kind of the directional arrows, and what that indicates as far as a drift up or a drift down, and how much is happening. If you're wondering how much to add with insulin, when you do start to see a drift up, the angled arrow is really kind of a rate of change of about one to two points per minute. Right? So if you're aiming to see, okay, I'm at 90, I've not done anything. And now my blood sugar, it looks like it's starting to come up. I don't know why, but it's happening. If you excuse me, you know, experience that a 90 with a angled arrow up one to two points per minute in the next 30 minutes. If you do nothing, your blood sugar could be 30 to 60 points higher. Right? Right. So if you use that to your advantage, and you say, Okay, I could be on the low end 30 points higher, I could be one at 120, I kind of know what I would use to offset, you know, a 50 point rise in my blood sugar, maybe I need to just add a little bit like point two, or maybe I need to take a point five extra, you know, that's kind of a way that's a little bit more, if you're the math person right, may help you to get a little bit more precise and not worry about then ending up on the down drift later.

Scott Benner 38:08
And if you were me, what you do is you try something and then the next time you try something different if that didn't work, right, less or more, yes, just more or less whatever try. And it's important to remember that it's not, you're not going to get it right the first time. And even if you do get it right the first time, the variables may change the second time it becomes an art, like it really does like just knowing how much to push just a little bit like you know, you squeeze too tight, and it's too much not enough and you let go. And using Jenny's example right there and flipping it to getting lower. You don't always need the whole juice box, you don't always need every piece of candy in the package. Sometimes you can nudge with food, right. And I know that 15 carbs 15 minutes is the rule of thumb. But if you're using a CGM, you can see it better. You don't have to 15 carbs to 10 minutes is when people are blind to what their blood sugar is. And they're trying to stop themselves from having a seizure. That's important. I'm not saying no. Okay, and I'm not telling you not to do it. But I'm telling you that if you do it, and find yourself to be 300 Later, you didn't need all 15 carbs, right. And by the way, if you do get into a panicky situation, and you've got to just Horkan carbs, I'm not going to tell you to not do it. What I am going to tell you is that when you when the dust settles, you need to figure out how much insulin you've got to Bolus for that food you just took correct Right, right. Like maybe not for all of it, but some of its going to need insulin. You have to stop the bouncing. You gotta make sure you can't get on that roller coaster like don't get on it. It's maddening. And the only way off of that roller coaster, by the way, in my opinion, is you stop taking in carbs and you get back to level again and like, like, I can listen, I can knock Arden off that roller coaster while she's still eating. But that is a ninja level event, like, like you need to be really good at that to stop to stop a roller coaster in between food. And you'll get it

Jennifer Smith, CDE 40:16
takes understanding sensitivity, right? You very well know and I'm sure Arden does as well, you guys know her sensitivity, and you've paid enough attention to say, Okay, we need this much right now because of all of these other variables in the picture, or you need this much less right now or whatnot. And you do get to that level when you start to pay enough attention, you know, to your personal sensitivity and the precision that you need. I think you know, the 15 and 15 is age old. I mean, that's what I started with 32 years ago, is 15 and 15. And we didn't have the visibility of blood sugar changes at that point, we did it or even just a meter,

Scott Benner 40:55
by the way that only takes a tiny drop of blood right isn't and this beautiful lands that, you know, it doesn't hurt that badly while you're doing it, you were stabbing yourself with a sword and dumping or dumping your blood and

Jennifer Smith, CDE 41:11
called it the guillotine and it was like this big ol drum that like hammered down on your finger. And like I would like I would like inch my finger like slightly away from like the little underneath platform from where it like jabbed my finger I would like just hold it back. So it didn't quite jabot. That was my like, adjustment to the lancet depth. Right? That was the only adjustment I had at that point. But point being really that you have some tools now that allow you a lot more precision and how you bump and nudge you do. And with smart tools. Today, too, I think this is a good place to mention it is with our with our smart hybrid closed loop systems that are on the market today. That adjustment with carb, the 15 and 15 is 100% Too much 100% Too much with most of these systems on the market today. When you're adding a little bit of carbohydrate, we're talking like a little bit of carb, because the system has already been helping you coming into this drop in blood sugar. So 15 grams, 100% is going to be way too much. You might need two or three skills, which is like two or three grams of carb, you might need half of a glucose tablet, you might need a quarter of a juice juice box.

Scott Benner 42:34
So well, you know, I want to go a little deeper into this, like faster rises and falls. You see people online every once in a while it's very common, actually. They're injecting and they all put in the measurement for their slow acting insulin as fast acting by mistake like oh, I take like you'll see an adult like I take 20 units of Lantis every day. And I just gave myself 20 units of Novolog. And they're online. What do I do? What do I do what I do? And I'm just like, figure out how many carbs that takes and eat them. Like, that makes sense to me. Right and give that a try. So say you do that. Not that but say you have a meal that really needed five units. And for some reason you thought seven. And the next thing you know, 40 minutes later, there's an arrow down on your CGM, you're falling fast, you need to eat the carbs to stop that. So it's a much bigger nudge, right? It's more like a nudge with a sledgehammer now, and you need to eat the carbs to stop that. In the same thought process. If you miss greatly with that insulin, it should have been seven and you use five and 30 minutes later, your two arrows straight up. I don't mess around there. Like I am stopping those arrows. Right? And you think well, okay, see, I don't know say it was literally like a mistake you meant to do seven and you did five. So you think oh, okay, two units, that two units isn't going to do it anymore. Because you have all this momentum, right? Like there's this momentum, you have to stop the momentum, you've got a higher number than you thought about when you decided on the insulin the first time. There's a lot to think about. There's the number, the momentum and getting you back without making you Well, there are times that I'll take what I think the amount is that's going to stop the arrows plus the amount that's going to change the number back to where I want it to be. And I realize if I give her this insulin right now, she's going to end up low later, but I still give it to her. And then there's a moment where I take the basil away away, right to try to do what I mentioned earlier, eat up that extra so I needed all that force from that insulin upfront because of the situation we're in. But I don't need the tail of it later, but details going to be there. So what if I took her basil away so that it wasn't basil plus the tail, right? And so I get the benefit of the oath upfront without the kick in the pants again, what comes later? Right? Right. That's another way to think of bumping and nudging, in my opinion. So there's no

Jennifer Smith, CDE 45:21
learning the tools, it takes learning the tools to use, you know, things like people who are using MDI or multiple daily injections, it becomes harder because you can't take basil away, once it's injected, it's there. So if you are heavy handed with a correction, because you really want that double arrow to stop, you're gonna be have to be, you have to be ready on the back end with carbs to stop,

Scott Benner 45:47
you want to do you want to know what a pump does that multiple MDI doesn't do, it stops you from having to take a bunch of injections that allows you to do temporary Basal increases, decreases, extended boluses. That's it, then you don't have to carry pens with you and wonder if your insulins getting warm while you're at the waterpark. Like like that's, that's, that's it? I mean, I think to me, it sounds like a very little bit. But it's a lot. If you're going to be reactive like this and stay flexible and things like that. I'm not saying you can't do it with injections, I know plenty of people who do. Yeah, they very commonly are adults, or, you know, kids who just don't care about the injections, because there's going to be a moment when you're going to put in a little insulin and realize it's not enough and have to put in a little more. And now that's two needles, you know, instead of two pushes of a button, I think certain kinds

Jennifer Smith, CDE 46:42
of food, which we've talked about in other episodes, leading a pump to cover differently over a longer period of time. With a with an injection, you can't do that, unless you're willing to just take more injections with more insulin.

Scott Benner 46:55
So now here's the next thing about bumping and nudging, you get what you expect a little bit. And I want to just before I tell you about that, I wanted to tell you that what Jenny just said, shouldn't have been glossed over. There's other parts to this, I'm talking about bumping and nudging within a fairly perfect system, meaning I have my daughter's basil, well in hand, I'm not that far off with her meal. boluses if I miss, like, we're not just like running around with our hair on fire. And I'm like, Yeah, you know, like, and I just hear

Jennifer Smith, CDE 47:23
feed here, give more here.

Scott Benner 47:27
Insane. And I do mean this without sounding like I'm trying to pimp the the content, if you go back and start at the beginning of the pro tips. Or if you want to power listen to by the way, those of you who start at the beginning of the podcast and listen right through, you have my respect, I thank you very much. Because why the downloads are so good. And I really helps me. So thank you very much. But at least go back to the protests, and listen through, because then you'll get to a point where bumping and nudging really is a good tool. But it

Jennifer Smith, CDE 48:00
doesn't happen not 100% of the time. It's

Scott Benner 48:03
not always gonna work. Right, right. Like there are gonna be times where it doesn't work. And it happened to me last night with Chinese food. So we came out of a pump change and went right into Chinese food, which just shows my arrogance, really, because I was like, this won't be a problem. But what I didn't take into account is this for the past 72 hours, Arden has just needed more insulin, like there are foods that don't make Arden spike that are making your spike for the last three days. I don't know why it's not important, why it's just happening, you know, like, like soup. She's having like, a clam chowder out of a cannon. I can't get her under like 250, like 45 minutes later, like, like what's happening, you know, and it'll go away. Because the day before this started, her blood sugar was like 85 for 17 hours in a row. So, you know, it'll, it'll cycle through, we'll figure it out. Maybe it'll end up being a variable that needs adjusting. I don't think it will be but I'll see. But that's not the point. The point is we came from a pod change, right and do Chinese food. And boy luck with that. I did not do well with that. And so I want to first tell you that when I say oh my god, I did not do well with that. What I mean is her blood sugar was between like 175 and 210 for a number of hours afterwards. I know you're thinking Shut up. I would love that. Right? You're hungry? Yeah. Yeah. People People are like, really? That's your complaints? Not a complaint. It's just I missed Right. Right. And there was a time five hours honestly, where she needed. I Bolus a bunch of times and I never once got it right. I was never strong enough with it. And I have to admit, it was because I was tired and I didn't want to be up all night. So I just I erred a little on the side of caution not a lot and and I kept pushing. So but I did not cause her to get Low afterwards, which was, which is a winner. It felt like that to me. And I'll tell you why. And I want to put this in this episode too. So very recently, I wore the Dexcom pro continuous glucose monitor and I was very happy to find out that I am apparently not pre diabetic as I was texting Jenny's ice put it in, I'm like, you know, this, I'm gonna find out I have type two diabetes, right? Like I'm I was very happy that I didn't. Obviously, I was grateful. But I got to see what a pancreas does, what it's doing what it's supposed to do. And I have to tell you that there is nothing I ate no matter how low glycemic or high glycemic, they got my blood sugar over. I mean, I told you that I had eat two pieces of cake to get my blood sugar to like 135 141 time, right? But as I look back over the day, my standard deviation was like 11. You know, my, my average blood sugar was I don't know, like 90 or 80 or something 85 or 90, right. But I still went up a little gracefully 120 Most of the time back down again. You know, that happened when I ate. And I had already changed my mind about my expectations for Arden over the last couple of years, and you guys have heard me loosen up on the idea of like stopping every spike like I don't, I'm not a flatline person. I don't feel like my daughter is butchered it needs to be a flatline, I do believe that she has type one diabetes, and that letting a flatline get away from you turns into a disaster that takes way too long to fix, which is why all this is important. But I don't care if she eats and her blood sugar goes up to 121 30 and comes back down again. I think that's fine. As long as she's not low on the other side, I start getting a little hinky over 140 In my heart, I'm a little much, you know. And it's not to say I wouldn't try to stop a 120 If I thought I had the answer to it. But I don't know it just it seems important for me to tell you that if your pancreas is working your blood sugar is not always at five, it you know, it just isn't. So be a little easy on yourself, have good expectations, but understand that my daughter, you your kid, Jenny, you don't have the mechanism to just, it isn't just going to put the brakes on for you. So that's why you can't you know, I say you'll never get high if you don't get high. That's sort of what I mean by that, like stop the arrows stop before it starts, right?

Jennifer Smith, CDE 52:32
Well into this kind of experience that you had to I think one of the funny texts was relative to Pre-Bolus.

Scott Benner 52:42
Yeah, I was tested on you're like,

Jennifer Smith, CDE 52:46
I Pre-Bolus better than my own tank Kurious Pre-Bolus. This, I think is what your text was because you had seen a difference in what you had done for the same meal for Arden with her Pre-Bolus Yes versus what your own pancreas was doing. And I think you said something like, I wish I could get my pancreas to Pre-Bolus. And I was like well, your pancreas kind of does actually do that the working pancreas body kind of does do this like pre Bolus Bolus, right?

Scott Benner 53:16
So Jenny's tried to explain to me and I got if this is true, she said that sometimes when you smell food or you get hungry, your body anticipates that your blood sugar is gonna go up and it gets a little working on things prior. That's really cool. But what she's pointing out and I am a little embarrassed is that after a couple of days, I would look at, like I haven't be cooking. And I think to myself, like I think rubbing my stomach wherever I thought my pancreas was, you know, I don't even know. And so I was just like, man, now do it. Now brother. We're about to have pasta. Go, you know. But no, Jenny's not wrong. And I'm not bragging. I was better at stopping spikes with Arden that my body was for me. And I was really, like, comforted by that. You know, I was like, Wow, this this bolt on that podcast really works. And I was I was just really, I was really thrilled. You know, I was like, wow, I because it felt like it wasn't overkill. Do you know what I mean by that? Like, I thought oh, I'm not taking this too seriously. I'm taking this the right amount of serious, right and it just really was it was a it was a great experience. I want to thank Dexcom for letting me wear the Pro. And it was really nice. I was the only that was only worn by national media outlet people. And me and I was very grateful and I really appreciate the Dexcom appreciates the podcast and sees it as what it is. Yeah, not not just not a guy with a podcast like I was like wow, they really like oh, it made me feel good. Anyway, point is the last point I guess of all this is Is, is that bumping and nudging is terrific. It's great while you're learning things, while you're learning about how to Bolus for meals while you're learning about activities, you know, all that stuff's great, but it's not a long term, everyday solution. And I didn't recognize that people wouldn't translate out of it eventually, like, just go like, Oh, okay, um, didn't happen to me. You know, I said at the beginning, I didn't realize it wasn't happening to me. And then finally, and again, I have to thank the people listening, because we started the private Facebook group, which I'm not particularly active in. But see, every day, I started watching and this is when I said to Jenny, I need a pro tip on pumping and nudging. I was like, Oh, my God, these people are doing this all the time, like constantly and like it's not for constantly. And so here we are. So if you heard us do defining diabetes, bumping nudge, which literally just came out last week, I said in there, what I didn't realize about bumping and nudging when I started doing it was that it says much of a diagnostic tool as it is. Yeah, a tool for keeping your blood sugar's in order. Correct. So Jenny, when you start seeing yourself bumping and nudging too much, what should you be doing?

Jennifer Smith, CDE 56:22
Then you should be going back. Personally, what I do, and with the people that I work with, what I do in in data analysis is, I look at a cumulative and I say, over the course of this time, whether it's a week, or three days, or two months, or whatever we want to look at together, we can say, well, goodness, we've had a lot more use of Temp Basal, that are not specific to like activity reason, or a food based reason, like you always eat Friday night pizza, or whatever it is, and you need that kind of a tool for but goodness we're having, there's a lot of corrections happening after meals all the time, or there's a lot of you know, you're using Temp Basal is to cut off insulin all the time, if that's happening, and while it might be proving to give you the results that you want, there's a bigger picture, they're saying there's either not enough insulin for some reason now. So we need more in the Basal or we need to add a change to the year ratios so that you do get more robust type of Bolus for food. And then you shouldn't have to follow it so heavily after an adjust with extra insulin all the time. So that becomes looking at information and saying, for whatever reason, I just need more basil. Now, let's pop it into place for whatever reason, my ratios look like they're not covering Well, or they're covering too much. Let's take some away, let's add some in. And let's make sure that I'm not bumping and nudging now 100% of the day, because that shouldn't be the case. Right? You shouldn't have to work that hard, essentially. Yeah,

Scott Benner 57:57
one of the I think one of the benefits of the podcast is that it eventually should make the management of diabetes simpler and less impactful on your, your moment to moment, you shouldn't constantly be like, Okay, a little more, a little less, a little more like, that's, you know, algorithms do that. But you shouldn't have to do that. Right? If you find yourself doing it, looked back and just tried to separate a variable from constant and address the constants and keep bumping the variables. That's, that's all it gets that easy. I took me a while to figure it out. And that's why I'm here saying it to you because I thought, oh, gosh, what if people don't figure it out? Like I started having this heart in my head that people would just be like, bumping

Jennifer Smith, CDE 58:47
following my child until they're 50. And I'll be 89. And you know, what's happening to their

Scott Benner 58:53
picture, people in my head that haven't seen the sun in three years, have their hair all wired, like they've been electrocuted, and they're like, my kids, my kids at once he was 5.5. Her blood sugar hasn't gone over 110 and six years, I'm fine. Like, please don't be like, Oh, my God, it would break my heart if that's what's happening to you. And don't get me wrong, by the way, in the beginning, while you're starting to figure it out. You may be

Jennifer Smith, CDE 59:18
that is one field, you

Scott Benner 59:19
should be able to get past that. Right. And I hope this has been helpful. Did we miss anything, Jenny? Because you guys, don't you really everyone listening should should just take a second to realize that Jenny and I don't have any notes in front of us. Like we're not working off a list. And I still think we got in the timeframe through everything I wanted to say. Do you feel like Absolutely. We did a good job should ring a bell. I'm going to spike a football. That's right. I want to say this is something I was going to say later when I was editing it together. But I want to say it was Jenny here instead. I appreciate that the people listening care about this. Like I really do like I I think it's wonderful that you all want better or easier or simpler, and aren't just throwing up your hands and saying, I don't know, there's good days, and there's bad days. I think it's really wonderful. I think that we're creating a feeling throughout the diabetes world that's going to help people in the future, it might not help you as much as it's going to help someone else. But I got, you know, it's funny, it's not a note, but somebody posted this on social media the other day, and I'm not going to put their comments and their name into it. But I want to tell you like how amazing I thought this was. This person is relaying that their child, a 13 year old who's only been diagnosed for four weeks, listens to the podcast with their parents went into the doctor four weeks later, advocated for themselves for a pump explained, explained that she wanted to use extended boluses. She tried it with MDI showed her doctor how she tried it, explained that she wants to do Temp Basal adjustments in the anticipation of exercise and activity, and started rattling off everything she learned from the pro tip episodes. Wow. And even rolled in with her on the pod demo that she passed, and persuaded the endo to approve the pump at the next appointment. And that's awesome that endo normally makes you wait six months. And that's from these episodes. And so I imagine not just the happiness for that child that's coming. But that maybe now the doctors like Hmm, why am I waiting? You're not making people wait, couldn't I just do this with them? That's exciting for me. And it's so it's everyone's desire to do better. And then your willingness to say it when you get to the doctor's office, it's,

Jennifer Smith, CDE 1:01:55
well, then maybe even from that doctor's perspective, maybe you know, this person obviously went in and said, Hey, I've learned all of this from this one place, maybe the doctor now has a reference to say, hey, you know, if you want a little bit more, and you come back to me knowledgeable enough and can say, hey, this is what I know. Now, this is what I want to be able to use why I want to be able to use it. Again, I think a lot of clinicians are just conservative, because they're worried right there. They're conservative, for many reasons, but I think worry is a big one. And they want some outcomes showing. Yes, my patient is now ready for this. And unfortunately, I think again, with the technology we have today, I think people are more ready earlier than they may have been years ago. So

Scott Benner 1:02:48
I think that I don't think that people should make the mistake that this is some special girl. Do you know like she is seriously it's, it's it sounds self aggrandizing I really don't mean it to be she just listened to the 17 or 18 pro tip episodes. And in four weeks, look where she is. And and I don't know that everybody could be but I think my experiences are that a lot of people are and so that it's possible. I'm in my heart. I hope right now that doctors listening to this going well, that sounds like something that happened and like I hope he went in was like, I wonder what that kid listen to you. Right? You know, right? Like, that's what I want. I want everybody to be healthier, and easier and less encumbered and anxious and all the crap that comes with having diabetes. So, Jenny, I want you to hear that. Thank you.

Jennifer Smith, CDE 1:03:33
Yeah, no. And I think that's a good cumulative of kind of, I mean, my overall when I had set out, going to college, knowing what I wanted to go to school for and eventually what I wanted to become just it was a very, it was a very, like, General, I want to become a diabetes educator, because I had had really awesome educators as a kid myself. But I never like I didn't have a broad like idea of what I really wanted. I just wanted, I knew I wanted to be able to share what I knew, with people and I wanted it to make a difference. Like it made a difference for me when I was younger, you know, and didn't have the technology or anything that we have today. Right? So, you know, in what I get to do every day, that's, I love it. But what I like more is that I love this connection that I've that I've had because of you because of the podcasts and the end what you've put together. I feel like I've reached so many more people than just the individual people that I get to work with every day. You know, I feel like kind of especially these pro tips what we've put together it's just able to reach so many more people in a way that's it's free. Yeah, you know, it's great.

Scott Benner 1:04:51
Um, thank you. i You made me. I felt like little butterflies and I looked. I looked away from Jenny while she was tucked away embarrassed that I couldn't keep looking at her through a video screen while she was saying something nice. I need therapy. Thank you i It really is terrific. It would obviously not be the same without you. So I really appreciate it. Okay, cool. All right. Well, we did a good job here. I'm gonna go back to your life which is probably just talking to somebody else about diabetes in a second.

Jennifer Smith, CDE 1:05:20
Actually it will be my husband went off to work and my my kids are out there watching I think they're watching dyno Dan right now and I could hear my little man outside the joystick. Mommy, I want us now. Like, okay, well, I'll be there in a minute.

Scott Benner 1:05:37
Work. Go back to what you're doing. Go take care of him. And thank you very much.

Jennifer Smith, CDE 1:05:42
Yeah, absolutely. Have a great weekend. Thanks.

Scott Benner 1:05:46
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 voc glucagon.com. Forward slash juicebox. you spell that GVOKEGLUC AG o n.com. Forward slash juicebox. Chan 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 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.

#1016 Diabetes Pro Tip: Long-Term Health

Scott and Jenny discuss optimizing long-term health 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 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.