#846 Best of Juicebox: Bolusing Insulin for Fat
Learning to bolus insulin for the fat in your food with Michelle from Waltzing the Dragon. Episode 471, Bolusing Insulin for Fat was first published on Apr 26, 2021.
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Scott Benner 0:00
Hello friends, and welcome to episode 846 of the Juicebox Podcast
welcome back to another episode of Best of juicebox. Today's episode you may have heard on April 26 2001. It's called bolusing. Insulin for fat. It's with Michelle, from the popular blog waltzing the dragon. And Michelle and I spend this entire episode talking about how fat sometimes needs insulin. Do you ever see a rise after a cheeseburger and fries and not know what's happening? Hmm. I bet you have. Listen in you're going to find out more and find out how to take care of it. While you're listening today. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. Please Always consult a physician before making any changes to your health care plan are becoming bold with insulin. Don't forget to take the T one D exchange survey please complete that survey AT T one D exchange.org. Forward slash juicebox. And these episodes don't have ads on them right now. So I'm doing something special. I'm going to tell you about it as soon as the music's over. But don't forget that generally speaking, the podcast is supported by a ton of great advertisers, all of whom have links in the show notes of your podcast player, and at juicebox podcast.com.
I have this idea, since these episodes don't yet have advertising on them, although I'm open to selling it to someone who intend. But since they don't at the moment, I thought I would give some ads to people who live with diabetes in their life. So with that in mind, today's episode of The Juicebox Podcast is sponsored by balanced Chiropractic and Wellness. Dr. Jen is a longtime listener of the podcast. She has a young child with type one diabetes, and she's a chiropractor. So why don't you give her a? I don't want to say why don't you let her take a crack at your back? I said it anyway. Balance Cairo and wellness.com If you're in Iowa, I believe in the Des Moines area. Look Jen up 515-255-5330 All right, let's see who we have next. Oh, here's a good one. Lauren Powell. Powell, Law Offices. Dallas Fort Worth. Personal legal issues demand personal attention legal solutions that protect your future. 972-584-9382 Lauren's young child was just diagnosed very recently, just a couple of months ago. Here you go. You need an attorney. Head to power law. offices.com Let's do one more Ed. Oh, here you go. Ed. Oh, is a family garden center in 44. Pennsylvania. 44. Pennsylvania. That can't be a real place. I'm sure it is Edwards garden. center.com. I'm going to check out where this is. Oh, lovely photos. Let's see contact. Oh, yeah, I'm not lying. It's in 44 pa 570-287-4329. Edwards garden center.com. Check them out. Looks like they have ponds and water garden gift shops, gardening supplies, lawn care. They have some animals on site. You can see there's bunnies. Edie says his brother who's a part owner has been a type one since age 12. And Ed's youngest son was just diagnosed in May at age three. So if you're looking for garden center supplies, type stuff, average garden center.com. And I mean, otherwise, you just want to go to a place called 40. Fort for 40 Fo RT y fort fo RT. Fantastic. What a great name for a town. All right. We'll do more of those next week during the next best of, but for now. This is Episode 471, which originally aired on April 26 2001. With Michelle it's called bolusing insulin for fat. Hello, everybody, and welcome to episode 471 of the Juicebox Podcast. Today, we're gonna talk about bolusing for fat in your food. And it might be easier than you think to figure out. Michelle is here from the website waltzing the dragon to try to help us understand. If you're thinking right now Wait, that doesn't make any sense. There are no carbs and fat I only Bolus for carbs. Well, you ever eat pizza and get a weird high three hours later. French fries, milkshake, anything like that? Where you think it's gone? You've handled it but suddenly two and three hours later, this persistent high. If that's happened to you, you're gonna love this episode. And let's be honest, if you're using insulin, this is how Until
we're gonna get started in just a moment. But first, I'd like to remind you that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please Always consult a physician before making any changes to your health care plan. We're becoming bold with insulin. I'd also like to say right up front, that I've put a link in the show notes and a link at juicebox podcast.com, to Michelle's website. And that link will take you directly to everything that we've spoken about today and the way Michelle talks about it on her space. But I think this conversation will be enlightening. I hope you enjoy it. At the very end of this episode, I will actually read for Michelle site in case the conversational nature of today's show. Didn't let you take notes or, or kind of walk through things incrementally. So after you hear the whole thing at the very end, I'll walk you through it one more time. All right, little more music and we'll get started.
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. Podcast is also sponsored by the Contour Next One blood glucose meter, you can find out if you're eligible for a free meter, check into contours, tests trip program. Or while there's a lot more you can do so I can't just list it all but all the information you need about the Contour Next One meter. It's a contour next.com forward slash juicebox. There's links in your show notes. Links at juicebox podcast.com. Let's talk about bolusing for fat now with Michelle.
Michelle 7:10
My name is Michelle and I am the mom of two kids. Gemma who is 12 just turned 12 And Max who is 13. It's Max who has type one diabetes. He was diagnosed at just over a year in 2007. Actually 14 months to the day. Wow. Was how old he was.
Scott Benner 7:30
Wow, that's that's pretty damn Young. Geez.
Michelle 7:34
What is young? It was tough. I think it's tough at any age. You know, I think they're just different challenges.
Scott Benner 7:41
I agree with that. Yeah, I agree that it's that it's not like, Oh, I got lucky. I was diagnosed at 46 perfect age to be like, it's that's not how it is. But but that 14 months thing with a low body weight not being able to communicate well, it's just an end back then. I mean, he didn't even have the ability to break boluses down into smaller bits. And
Michelle 8:05
no, although he got his first pump at three years old. So that's when things really changed in terms of being able to break it down. But before that, for the first two years, we use diluted insulin to try and get smaller boluses. Like really half as much as you could drop in a syringe. Yeah, I don't know if you did that with Arden. I know she was quite young to where she two years old.
Scott Benner 8:26
She was yeah, she was just after her second birthday. What I did was I took expired insulin, squirted it into a dish, added food coloring to it, I drew it up into a needle and I would practice pushing the plunger slightly to make a drop come out. I just use the food coloring so I could see the liquid and then kind of think about okay, this much pressure made a drop come out. And that way when I used insulin for real, and the needle was in Arden, I could put that same pressure on.
Michelle 8:59
Interesting. Yeah, yeah. So it was
Scott Benner 9:01
a it was a good motivator to put weight on her. That's for sure.
Michelle 9:06
We're still trying Max's skinny as a rail. And I'm like, Where can we put these infusion sets? We need some fat.
Scott Benner 9:11
No kidding. Yeah. Well, do you know how you ended up on this podcast today? Do you listen enough that
Michelle 9:20
you messaged me, and I responded. So I'm guessing Jenny had something to do
Scott Benner 9:25
with it right? So Jenny and I sat down. So I knocked up I mean, I can pull the curtain back here a little bit like you people listening here, Jenny, like every couple of weeks on the show or something like that. She is awesome. She's my favorite person. But what but what I do to make that for everybody is Jenny and I carve out some time and we power through topics. And I do not tell her what we're going to talk about first. So did you say that? Yes. So I said okay, like we finished the topic and I said Hey Jenny next I Want to talk about how to translate fat into carbs for Bolus Singh? And she goes, I don't think I'm the right person for that. And I said, Oh, okay, that's no problem. And I just put it on my list, like find somebody else. And she says, Do you know that blog? And then she told me about your blog, which of course, I know because of the, the unique name to tell people your your, your blog title.
Michelle 10:25
So the website is waltzing the dragon. And it was started in 2011, with another diabetes mom, Danielle, and I started it. Because we realize that when we talk to other parents, we just got the most helpful tips. Like other parents knew how to put the theory into practice. Yeah, they knew what kind of infusion sets worked. They knew you know, how to get around things, like you're talking about, you know, food coloring and making some really small boluses. When you're still using syringes, that's the kind of stuff that we learned from other parents. And we just thought, wouldn't it be awesome if we had a place where the theory and those practical tips existed in one place where I could look up? I don't know illness management strategies at 2am. Well, my kids throwing up, and they would be there, I wasn't like shuffling through that junk drawer looking for that handout that I got. Yeah. So that's, that's where Walton dragon came from.
Scott Benner 11:24
It's interesting. I don't want to go too far into the weeds here. But it's interesting that you can't just devise one repository, and it exists everywhere. Because that's not how people find out about things. Don't I mean, like, the best movie I've ever seen in my life, you may never have seen or ever heard of. And so that other places keep popping up is a is a gift to people, because the internet is sort of, it's sort of cyclical, and at the same time, it's bubbled like you're in a sphere, you don't realize it, you're not seeing the whole internet, you're seeing the part of it, you see. So if somebody you know, has a blog like yours, that's great. And it can be frustrating for people listening. I imagine Michelle has felt this before too known how valuable the information you have is, and there's just you can't figure out how to get it to more people. Because you're not in charge of that. It's and I figured that out a long time ago, if the if people don't know immediately to go to the ADA to get information about something right, then that means that the ATPase information isn't so amazing that everyone who's ever seen it runs around telling everybody else about it, right, which is not to denigrate their information. It's just that that's not how it works. It's why you see somebody who's incredibly popular on Instagram today, who 11 months from now, you'll never see again, because everything just keeps going. But I always felt badly about like all this great information that just, you know, just kind of it cycles away. And so the podcast for me is, is an idea of like, how do you bring it alive. So that it it keeps existing and it keeps drawing people in and they keep finding it. So as soon as Jenny said the name of your blog, I was like, I've heard that name a million times. Now I don't read diabetes blogs. And I never have. But that was always a creative decision. I didn't want to, I didn't want to read something you wrote and then find myself saying it not realized that I had heard it from somebody else, right? So I always stayed very kind of insulated around it. But immediately is like, because how can you not remember that name like waltzing the dragon is just so unique. So anyway, I go there, don't please. And there's all that information. And I was like, Okay, I'm gonna send someone an email and ask. And I picked around I think I think I figured out how to get to you through Facebook. So I really appreciate you doing this. Because I want to take what you know about this one specific subject and kind of blow it up and leave it here inside of the podcasts for other people. So awesome. Yeah. So tell me how you first realized that fat made blood sugar go up.
Michelle 14:05
What would happen is we would go somewhere like McDonald's, like we had good control. You know, I wouldn't say it was fantastic, but you know, our overnights for good. We knew how to handle the kind of foods that we made at home. Max was pretty little so we weren't eating a whole lot of high fat food. And then when we started to, like I said go to McDonald's or have a pizza. We would have these incredibly high persistent highs that I just kept correcting and correcting and correcting and he wasn't coming down. And it was changing. Like it was frustrating for me. And it was changing our family's lifestyle. Like I felt like diabetes was winning. I felt like okay, we're no we're not going to go to McDonald's to get fries today because I don't want to deal with the highlighter. We're not going to have pizza tonight. Because I don't want to deal with being up all night and correct. correcting and correcting. And that was incredibly frustrating to me. Because we've always lived like diabetes, we have to pay attention to it, but it's not going to control us. And it was definitely controlling our family. Yeah. So. So I went looking for ways that I could cope with that. And within a couple of weeks of each other two different people brought up this idea of bolusing for protein and fat. Shannon, who was one of the CDs, one of the nurses at the Alberta Children's Hospital diabetes clinic, which is where Max is seen. And also Lorraine Anderson, who is a registered dietitian here in Canada, she worked for at the time animus was my son's pump company. And so I'd had contact with her over that. They both brought up this idea of both protein and fat, which we had never done. But it seemed perfect. And it seemed almost divine that they were both talking about at a time when I really needed to hear it. Yeah. So we started experimenting, as a family. And just to backup, I guess that's, you know, I remember talking at a conference and people said, Well, wait a sec, you know, I guess I should start bolusing for fat, because we've never done that. And you through the conversation, it came to be that they didn't really have post meal highs due to fat or protein. So So I was like, well, then you don't if it ain't broke, don't fix it. I mean, you don't, you don't need to do this unless you're seeing this pattern. That is one aspect of of diabetes management that you would like to address. But many people I mean, if you eat the same amount of protein, and most meals, or the same amount of fat and most meals, then you don't need to do anything different. Your insulin to carb ratios and your Basal rates after that are probably covering it just fine. I think the problem for us as a family was that we tended to eat low fat, but we didn't binge very often on things like pizza or, you know, burgers and fries at McDonald's. And so when we did I can really see the difference. Yeah.
Scott Benner 17:07
Well, almost divinely. Yesterday, Arden had a Five Guys double cheeseburger with bacon, french fries, and a milkshake. So she took her LSAT, and she came out of the LSAT and she's like, I want some food. And I was like, Okay, actually, she took a LSAT prep class and the guy said, when she's done, she's gonna want to eat and take a nap. And I was like, Oh, you don't know Arden, right? Like she won't boom, she ate this food, walked upstairs and fell asleep. What I've seen a few of these kids, he's aware of what was gonna happen, but what I knew for certain was much like you are not gonna have a cheeseburger every day, right? It's not going to be a meal like that every day. So now we have these fries. That are potatoes, which we know are difficult to balls for soaked in peanut oil. There is the protein in the burger plus the fat in the burger. There's cheese, there's bacon, then there's bread. And then she has it's a milkshake, a real milkshake like real ice cream, you know, milkshake. And she says
Michelle 18:08
not ice milk. But ice cream.
Scott Benner 18:10
Can I get an ice cream? Can I get a milkshake with Oreo pieces and Oreo cream. So they put the ice cream in, and then they scoop in chunks of Oreos and extra cream. Right? So what that tells me in my head, the way I think about it is, is that the the range of time that this meal is going to impact her in my mind goes right up to about five or six hours. Like that's how I first think about it. And then and then I just dump in as much insulin upfront, as I think she can handle. And then any indication that there's going to be a rise gets re attacked along the way. The problem is, when people are saying, well, how do I Bolus for fat and protein? That's not a real, you know, that's more of a here's what I do, you can try to see if it works for you. Do you have more of a formula for something like that? Absolutely.
Michelle 19:01
It's not my formula. No. But let me back up. Because you know, I've heard you talk about how you do like a Temp Basal, to deal with those sorts of rises that come from food. And we tried that. Danielle, the other original co founder of waltzing the dragon, that's what she did with her son, right? If she would set a Temp Basal after the meal for, you know, whatever, and her gut said was the right amount. And she had done all this experimentation. But when I tried it was an abysmal failure. Like, I tend to be very systematic anyway. I'm not a I'm not a kind of, you know, let's see what this does. I want I want to have something concrete. You and I are probably the yin to the others Yang but in any case, we tried it a couple of times and it just didn't work. Either he bottomed out, or he was still super high later. And I thought I do not have the mental energy that it's going to take to experiment with these rates and ratios and, and you know, pull numbers out of the air for the next two years until we get it right. I just don't. And so what both Shannon and Lorraine had brought to me was what's called the Warsaw school program. In Eastern Europe, they Bolus for carbs just like we do here in North America. But there's also more of a practice of bolusing for protein and fat. So they've spent some time figuring out well, what does that look like? Yeah. And so that was the program that I did more research on. And so what they basically say is that protein is kind of complicated it protein creates in your body creates some insulin, but it also stimulates the release of glucagon, which we know rises, raises blood sugar. And so the effect of it is, like, if you if all you ate was protein, the effect is a longer rise in blood sugar longer after you eat it. So it might be three to five hours, if all you ate was protein without carbs, it might be three to five hours, you give them maybe an extended Bolus, or a Temp Basal of, I don't know, maybe three hours, I think Jenny said something like 50%, I'm trying to remember she had a great way of looking at it. You do that after the meal, and then it covers that slow rise of protein. So that's part of what they talk about. Then they also talk about the effect of fat, which is not at all unpredictable, that raises blood sugar. And the reason is you get insulin resistant, you've got fat in your bloodstream, that makes your insulin less efficient. But you've also got that fat is harder to break down. So it takes longer to digest. So what we found with Max was that when he would eat a high protein slash high fat meal, he would go low first, and then he'd be storeyed. me high. And the reason was, if we gave all of that Bolus up front, so let's say he had cheeseburger and fries. And that would be think like, maybe at that age, it was like the McDonald's Happy Meal. So it might have been like, I don't know, 3640 grams of carbs for the fries. And then the burger might have been another 20. So we're talking about, let's say 60 grams of carbs. And with that would come maybe 3040 grams of fat, I'll say 30 at that age. So we would give the Bolus for the 60 grams of carbs, which you would think okay, that's great. If he just eaten the bun and potatoes that weren't, as you say, soaked in peanut oil, then that Bolus up front would have covered that. And everything would be great if we do the correct timing to the insulin and all that. But what's happening is because there's such a high fat content, it's digesting more slowly. So that initial Bolus is all getting in before all the food gets in. So he'd go low first, which of course we would correct. And then that correction would add to his high blood sugar later, right. So then we were fighting both
Scott Benner 23:15
because it's so incredibly difficult to say to yourself, Oh, I've gotten the meal insulin ahead of the impact of the meal. Now I'm going to correct with food, I actually have to Bolus the correction right now that is a hard leap to make in your mind. But
Michelle 23:28
I have to Bolus that correction with an extended Bolus. Or perhaps if you're still on injections with like a split Bolus because I need it because if I Bolus it now, he may go low again. And we found that that depends on the amount of fat to like, we don't do this. We won't even consider the amount of fat if it's under about 10 to 15 grams. Okay, so under 10 I don't even think about it. 10 To 15 Maybe depends what else has been going on in his day. Has he been you know, fighting some highs is he been exercising hard? Whatever then I might consider but over 15 We will almost always Bolus for the fat.
Scott Benner 24:05
Yeah, that makes
Michelle 24:09
because that's where we see the impact. Right? So getting back to this Warsaw schools, what they do is they talk about fat protein units. And there's this process that they go through to calculate fat protein units and I don't know Do you want me to it's all on waltzing the dragon. Do you want me to go through it? Yeah. Okay, so I'm gonna go through it basically.
Scott Benner 24:29
Yeah. I'll just tell people now Oh, geez. Alright, so it's your Canadian so it's waltzing the dragon.ca.
Michelle 24:37
And I'm actually today, although the.com will get you there too.
Scott Benner 24:40
okay.com will get me there too. But on this specific page, it's got kind of a long title. So is there a quick way that you can tell people to get through your website to get to what you're going to
Michelle 24:51
waltzing the dragon.ca/fat/fat
Scott Benner 24:54
Okay. I'm doing it to the wall to the dragon. dot see a forward slash fat. Okay? How fat and protein affect blood glucose? Okay, I'm here.
Michelle 25:09
So there's two articles. The first one that how fat and protein affect blood glucose is sort of the introduction, it just talks about the fact that what we just talked about, protein will raise blood sugar, slowly, fat will make you insulin resistant and give you a resistant high later, okay. And then the second article is how to reduce those spikes. Or avoid them might be a better word like, if you if you use the Warsaw formula, then you can, you can have a pretty close to flatline, if you you know, sort of tweak it enough for your own personal needs. Yeah,
Scott Benner 25:47
if you actually go through and figure this out. So this, this episode really is for people who want to look at a nutrition label, and say, I want to apply this to that. And I do want to agree with you, before we start, that I don't Bolus for all the fat art needs. I do think, though, that it's an elusive idea to people because I'll take I'll take a very basic example, every once in a while, like once or twice a year, I make my own potato chips. That's how bored I get. Okay, so you start with an amount of I use peanut oil, because it holds a nice steady temperature, right. And however much peanut oil you start with, you make your potato chips, you put your potato chips aside, each one's thin and crispy and doesn't even have a hint of oil in it. But then you go back and look at how much oil has been absorbed by the potatoes. And it's a fascinating amount of oil, right? So if you eat handfuls of these potato chips, you might as well take a cup, fill it with peanut oil, and drink it because what you're doing eating those potato chips, right as an example, or cheeseburger, or you know, all kinds of things like that, that have grease in them have way more grease in them than you imagine. And so, you know, did I know, fat from ice cream plus fat from cheese and fat from beef and oil from French fries and potatoes and bread was going to crush Arden. It did. And if I told you that based on the carb count of that meal, even though it was an insane car mount, I mean, gosh, by the time you go through the burger, the roll the role is the role is like 25. And then I just throw in five for the burger, because why not and a couple more for the cheese. And now I'm at 35 and then the fries are probably 50. And now I'm at 85. And the milkshakes probably like 80. And like, in my mind, I'm like It's like 180 carbs, right. And even though you give that insulin for that, it comes back to haunt you like a bad acts Absolutely. You know, every couple of hours, it's and you're putting in another, you know, oh, it's gonna happen again, here's two or three more units before you know it, you've used by half more insulin than the actual carb count kind of window.
Michelle 28:04
Absolutely. And the amount I've found since we've started bolusing, for fat, I found that the amount of insulin we use upfront as an extended Bolus is a fraction of what we will have to use to correct it. Right. It's absolutely insane. Like we might add a I don't know, like a three unit extended Bolus. If we you know, do it at the front, if we forget to or when we were learning this, we might have to use like eight or 10 units to get him back down to range. And so the difference is just striking, right? There's all kinds doing it proactively is is a huge benefit.
Scott Benner 28:40
You will being ahead of it, you're using far less than you will if you chase it. And absolutely when you're ahead of it, you most likely won't cause a low later because it's almost like that food almost precludes a low from happening. You know, it's almost the it's sort of the antithesis the idea when people are newly diagnosed, someone will tell you like, Oh, give them like a little protein and a fat at bedtime if you don't want their blood sugar to fall like that kind of no battle chest not, but except you're doing it times like 30. So yes, so you're very aggressive. You know, the way I think about it is balancing the impact of the insulin or the impact of the carbs with the action of the insulin and trying to keep everything working at the same time. So that when the foods finally digested and the insulin is finally gone, you don't crash later. But yeah, once you're chasing fat and protein like this, especially high fat, you're just it takes so much more insulin than you could imagine. And your Basal rate is nowhere near up to the challenge that you've that you've given it. Absolutely, absolutely. I'm sorry. I love our conversation, but I'm not letting you get to what you're trying to say. So,
Michelle 29:50
no, that's okay. I just want to back up for a minute because you mentioned a lot of things like if people are curious what sorts of things that we do this for. You've met spend a lot of them like we talked about pizza. We've talked about burgers, cheeseburgers, french fries. Funny if we have french fries, if we have homemade frozen french fries made in the oven, they don't have enough fat and we don't need to worry about it. But any restaurant we go to those fries will need a fat Bolus. Max loves nachos lately. So the tortilla chips have fat, which we don't really notice if he had say, tortilla chips and salsa or hummus. But if he has nachos, so he throws all that cheese on top of it, and sometimes even like ground beef on top of that. Absolutely. He'll need a fat Bolus for that. Yeah. Real ice cream,
Scott Benner 30:39
right. Yeah, go ahead and jump on your Nacho thing. Arden loves queso for most which, which might not be all over the countries and everything but it's a it's a restaurant you go into They fried the, you know, the tortillas right there for you. She buys the case. So we throw the chips away. And she uses like a toast Tito's brand, like instead. And it by half makes this an easier project for us. Absolutely. I don't know how, let me hear I'll say this to people who really are probably believe in me listening to the podcast, I I can't figure out how to Bolus for most chips for Arden. Like I haven't had the nerve to put in enough insulin yet that those chips need and pretty aggressive. You know, so I'm sorry. And you were gonna say ice cream in a second real ice cream. And that that's where people's confusion comes in online. Somebody will say, Hey, you have to do this for ice cream. And another person will say Oh, no, you don't. We don't have to, except there's no context the one person might be actually eating ice cream. And the other person might be buying something out of the freezer section that's 17 chemicals and might actually have very little ice cream in it to begin with. So right
Michelle 31:48
or what we do we have here in Canada a brand called Chapman's, which their frozen yogurt tastes just like ice cream. It's awesome stuff. But it's got a fraction of the fat. So when we're having it at home, I buy Chapman's frozen yogurt because then we don't have to stress about it. McDonald's for example, their soft serve is ice milk. It's not ice cream. So if you had a huge one, and maybe we might have to but like if we go to Dairy Queen, their soft serve is ice cream. Right? So it's got a much higher fat content. What peanuts if he has a great big bowl of peanuts, we might have to Bolus fat for that. compared to any other nut like not almonds, not even walnuts. I mean maybe he doesn't eat enough walnuts. But like he'd sit down with a bowl of peanuts, you know, like salted roasted peanuts, those we would have to Bolus for sometimes chocolate bars can it depends on how much fat is in them. Do they have things like cocoa butter or coconut oil in the ingredient list will make them kind of perk up. Oh, all the meats, pepperoni sticks. You know, if you have like a footlong pepperoni stick, they could have 1418 grams of fat in a single stick. Bacon. Yeah, baked ham. Like if we have ham for supper, probably that will have to be Bolus for and on the idea of pepperoni sticks to like if you can get turkey pepperoni. It's much lower fat. So sometimes we'll do that instead. Sausages. Yep. Sausages. Absolutely. Yeah, they have probably like the lighter Turkey ones even have like three grams of fat per like regular breakfast sausage.
Scott Benner 33:27
Do you know what I do that? Doesn't know. I keep Turkey and regular bacon in the house. And if she has pancakes or french toast, I put the turkey bacon with it. And if she has eggs, I put the regular bacon with it. And I don't know, I don't know that I tell her that I do that. And they're actually now well, she won't listen. That's good. So there are times when she will specifically say I want to have french toast with regular bacon and I'll go okay, then Bolus now. And you know, and I don't, she doesn't see the difference yet. I'll tell she'll be on the show one day, and I'll tell her little stuff like that. So she knows. But that's just the kind of stuff that I think is intuitive for you a person who paid so much attention to this or to me somebody who talks about it so much that I it's hard for me to forget it even you know, but for most people, most people are not going to think, oh, there's a higher carb value here with some more fat. I won't pair it with the same fat as I you know, I just think that's it's a bridge too far, especially when you're first diagnosed. And in your mind, you're thinking bacon, no carbs. Good. Right. You know, I'm sorry, I keep cutting you off. But you're doing terrific.
Michelle 34:35
No, that's That's great. Good. Good. Yeah. So what were we talking about? Well, listen, I want to talk halation I want to tell you to do about all that. Right. Before
Scott Benner 34:44
we get back to the calculation. You're gonna have to thank Michelle on your own mind here, or at least by visiting your website because she's got lists in front of her and I have never sat down and made this podcast without anything written down in front of me ever. She's trying very hard and I am just over here going like
Michelle 34:58
Scott yin and yang I got to be systematic. That's why this process works for me.
Scott Benner 35:04
And that's why I love you being here. Because there are, listen, I think there are a fair amount of people who pick up what I'm putting down, like they used to say, in the 80s. But I think there are also people who hear it and whose brains work like yours, and they're like, you gotta tell me a number or something, you know, and I just don't, I don't know how to do it. I am literally a person who looked at a plate two nights ago, it had chicken and carrots, and rice on it. And I looked at it, and nothing was measured. And I just looked at it, and I was like, chicken 10 Carrots, I don't know, 10 rice looks like 40 do 65 carbs. I literally counted the 60 and then said 65, which made me wonder why I counted? Like, why did I just like, just look at and go
Michelle 35:54
to get there Sure.
Scott Benner 35:55
Weird thing. And, and that that's, uh, you know, I do believe that most people can, with most meals get to it. But there's some of these things that we're talking about today that are just, they're just too much, you know,
Michelle 36:09
and just on that idea of looking at a plate, like, I think we've had to teach ourselves systematically over the last 12 years, how to do what you do intuitively. So what I would do is I would measure that whatever pile of strawberries or that, you know, mashed potatoes, or whatever it was French fries, I would, I would guesstimate what I thought how many carbs were in it. And then I would measure it and see how far off I was. And then from there, if you do that enough times, now you can start looking at a handful of cantaloupe. You know, a handful of potato chips, you can start looking at that and going, Oh, this is what I think. But I had to get there through very systematic like teaching myself, this is how far off you are right? Next time, guess a little higher, gets a little lower. So I had to get there very systematically, and you do it very intuitively, which I admire. But I would never be able to do with that kind of pull a number out of your bum approach.
Scott Benner 37:06
I imagine that that's my skill. If I put that on my CV, I'd never get a job. You were able to figure it out in a way that's quantifiable trust me I don't need to quantify it is to tell people stories about potato chips, and then get something out of it. Alright, so this. So just
Michelle 37:25
to point out, I didn't figure out how to make it quantifiable. I took a program that already exists. And I applied it to our family and it worked. That was a huge,
Scott Benner 37:34
you're very, you're very kind to give attribution where it's deserved. And I didn't mean that you've made it up out of thin air. I know. But you still went and found it and put it into practice. Like you could have showed me that at a certain time and Arden's diabetes, and I would have been like I didn't read that. That would have been like the end I've been
Michelle 37:50
told I can complicate things a little bit. Yes. And it's my nature to go into it and deep, deep detail. And this is an aside all of the information on the website. So it's it's less of a blog and more like a collection information repository and only because what you do very easily sharing your personal experience does not come as easily to me, I'm much more comfortable sharing the information than I am sharing my life which is why I kind of have a love hate relationship with social media. But there's a whole other topic for a whole other day. But what we've done on waltzing the dragon is set things up as beginner intermediate and advanced articles. And this one is solidly in the advanced. It's like not for the faint of heart because it does look intimidating. But if you follow it through, follow the example through it makes sense.
Scott Benner 38:42
Well, let me tell you that anybody who's made it 34 minutes into this wants it so give it to them.
Michelle 38:49
No holds barred let me tell you what you do bad.
Scott Benner 39:01
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Look, if you're the kind of person that's here learning about how to Bolus for fat in your food, then your data is important to you. And that data begins with your blood glucose meter. Are you using a good one? Is it accurate? Is it reliable? How do you know? You just take the one that doctor gave you or buy the cheapest one at the farmacy maybe you should check into the Contour. Next One blood glucose meter. This is the meter that my daughter Arden uses, it is absolutely the most accurate and fundamentally easy to use blood glucose meter that she has ever had. You can find out more about it at contour next one.com forward slash juice box. The Contour Next One blood glucose meter has Second Chance test strips, meaning you can touch some blood and not get quite enough, go back and get a little more without changing the accuracy of the test. We're wasting a test strip might not seem like a big deal. But can I get 3am It will be is the light on your meter nice and bright. The one on the Contour Next One is no allow you to see in low light situations. And the screen is simple and easy to use. And if you'd like you can connect the meter to your phone, they have an app that will connect by Bluetooth. And you can share your data back to your phone and make better sense of it later if you want. But if you don't want to use that app, you don't have to, you can just use the meter, it's absolutely up to you. Go to contour next one.com forward slash juice box to learn more about the meter and all the products that you'll find on the site. You know it's possible you'll even be eligible for a free meter. It's possible that the meter and the test strips will be cheaper cash out of your pocket than through your insurance company for other meters. This stuff is mind boggling. My mind is boggled. Before I get you back to Michelle and she talks in depth about how she Bolus is for fat. I'd like to remind you to support the T one D exchange, please go to T one D exchange.org. Forward slash juicebox. Take a few minutes to answer some simple questions and make the lives of people living with type one diabetes better. If you are a type one who lives in the United States, or the caregiver of a type one who lives in the United States, this is for you. It is super simple to do you can do it right there on your phone or your laptop. Again, it only takes a few minutes. It's 100%. HIPAA compliant, is 1,000%. Anonymous. And the answers you give go a long way towards helping people live better with type one. That's all you need to do. When you do that. You're helping those people. And you're supporting the show. T one D exchange.org. Forward slash juicebox. Please take a couple of minutes. All right, you ready for Michelle, she's got a whole system here, she's gonna tell you all about it.
Michelle 42:33
Basically, you start with figuring out how many grams of fat and how many grams of protein are in whatever you were about to eat. So you know, for your, for your cheeseburger, and fries. Example, you could go to the company website and see what did they say is the amount of protein and fat in that meal, you could put something at home on a nutrition scale, you could look at the nutritional panel of the packaged food. You could look in a food database, like Calorie King has a book or there are all kinds of apps that do it think we and Calorie King and one's escaping me track three. Anyway, any of these ways, it will tell you the grams of protein and the grams of fat. You add those together. And then you can convert that into units of energy, which is just kilocalories I don't fully understand this, except that I know that they've given me a formula, which is to convert the grams of protein into kilocalories I multiply by four Y, I have no idea. Maybe Jenny is a dietician as a better idea. I don't know I just take it on faith. To convert the amount of fat into kilocalories, you multiply by nine. So let's say the example that I've given on the website is for an ice cream bar covered in chocolate with nuts, real ice cream, as we talked about, it's a Klondike bar, you know, ice cream chocolate covered. So on the nutritional panel, it says there's three grams of protein and 14 grams of fat. So I multiply the three grams of 14 by four, the 14 grams of fat by nine. And I come up with the total kilocalories, which I've got here is 130 830 for
Scott Benner 44:22
the fat, so that's 14 times
Michelle 44:24
138, for both, so it is 12 kilocalories of protein, and 126 kilo calories from fat. Again, those are just units of energy. You just think about how much energy your body can take from that. So then you add those two together, you come up with that 138. From there, you calculate the fat protein units, which is just dividing by 100. Again, why I don't know Gotcha. The Warsaw school people know dieticians. Now. I just do what they tell me to do. This gives me fat protein units. The reason that this is relevant why that number is important is because it tells you how long to extend your Bolus. Okay, so they have a handy little chart, that just tells you, if you come up with one fat to protein unit, you extend your Bolus over three hours. If you have four fat teen protein, your fat protein units, you extend your Bolus over eight hours. So they just got this chart that's got 123 and four fat to protein units, I just look at the chart. And that's what my extended Bolus is. So then we go, we got fat protein units, but how do we figure out how much extra insulin we need? What is the size of this Bolus that we are going to extend. And what they say to do is to multiply by 10, and divide by your insulin to carb ratio for that time of the day. I often don't remember what it is. So for Max, like his insulin to carb ratios vary from 5.2 to like, 7.5, I just picked six. Because I mean, it's sort of I'd like to be very precise, because there's so many variables with diabetes that I like to make as many of them a constant as I can, so that there's less variability overall and less, you know, mass in the system. But by just picking six, I sort of acknowledged that there is variability in this, that even if I'm absolutely precise, there's still a different day, it's a different food, it's a different, you know, he's eating different things with the meal, right? So I just pick six, because it can be complicated, and that works for him. But I like it. When I look back at this example, I was using 15. So when he was younger, his insulin to carb ratio was one to 15. That's a very different thing when he was six than it is now that he's 13. Sure. So that's where the insulin carb ratio does matter on an individual basis. But whether or not you call it six, or 6.5 or seven, probably doesn't change things,
Scott Benner 46:55
a heck of a lot closer than the way it was going to go without
Michelle 47:00
the gas. Right, right. Absolutely. So if you do that, you come up with a number of units. So in this case, if I took that 138, and I divided it or multiplied it by 10, and divided it by his IC ratio, which for this example was 15, then I come up with point nine units of insulin. So I would have given him point nine units of insulin extended over three hours, 01 100, nothing up front, everything extended over those three hours. For the Klondike candy bar when he was six years old, he was six
Scott Benner 47:35
years. And that was that the entire Bolus or is the point nine, the extra on top just
Michelle 47:41
the extra for fat, right. So whatever the carb amount was in the candy bar, I would have Bolus up front and Pre-Bolus. Again, depending on the amount of fat might not Pre-Bolus. But this doesn't have a huge amount of fat. This only had 14 grams of fat Gotcha. So all the carbs up front with a Pre-Bolus as you normally would. And then after he's eaten, and sometimes a couple hours after he's eaten. That's when the extended Bolus comes in. So when it becomes a couple hours after is if there's a huge amount of fat, then even setting this extendable is right after he eats means he will go first.
Scott Benner 48:20
Yeah. So you have to understand then when that second wave arrives, and be just appropriately ahead of it with a Pre-Bolus. So your Pre-Bolus thing, the second wave, but using a number that you can rock solidly believe is going to handle the impact of it. Because you use the formula,
Michelle 48:40
because they use the formula, and I did some experimentation, right? So let me take this one step further and say and maybe I should have said this earlier, for anybody who's not listening to the whole thing. When they use the warsop program, they get a really high incidence of lows. So if you use it as I just described, a, your chance of going low is what I think and what many people in Canada think is unacceptably high. This is not best practice, according to the clinical practice guidelines. And that's run one of the reasons why. What's the
Scott Benner 49:09
opposite? Yeah, so I, I'm sorry, I find that when I talk to people, one of the most fascinating things is the word low and high is not quantifiable between people. So we if you said if you said to me, this will make you low. Yeah, I would
Michelle 49:26
be saying under 3.9 millimoles per liter, or I think for you guys, I've got my chart here somewhere. That's 70. Right. So under 3.9 or 70 milligrams per deciliter. Okay.
Scott Benner 49:38
And so for me, if you see if you were talking to me, and you said oh no, this is going to make Arden low. I'd think oh, like under 60. You know, which would it could it absolutely can Yeah, and it could it's just it's it's tough to just say it's this the one thing I've learned from doing the podcast is that people's idea of high and low are different like when I say absolutely my garden got really high after a meal I mean, 180 to 200. And when other people say it, they're like, my graph is just flat across the top. I don't know how far over 400 I am. So we can't tops out at 22.2. We can't have an equal conversation when you think high means 400. And I think high means 180. Sure, right. So I just always like to make sure that we're talking about that way. So I'm gonna go back over this because I am not the target audience for this. And I think I understand what you just told me. So this is kind of exciting for me as a person who couldn't. You don't realize how bad I was at school. So
Michelle 50:35
you see, you take this and it hasn't hurt you a little bit. How's it I don't
Scott Benner 50:38
know, my wife mocks me openly about it sometimes. So in that, in that vein, perhaps. So you have this example here of a an ice cream bar that has three grams of protein and 14 grams of fat, it also has 27 carbs. So you would have taken this ice cream bar, you would have known from experience. I don't know it needs a 10 minute Pre-Bolus Not too much for your son, whatever. 27 carbs was in his insulin to carb ratio, you put that insulin and he eats the bar. But then you take this information, three grams of protein, you multiply the protein by four, you come up with 12k cows, which are our total K cow from fat and protein. what is k cow stands for? Why don't I remember? It's a
Michelle 51:26
unit of energy kilocalories kilocalories. Okay. So you come up
Scott Benner 51:29
with 12. Then you take the fat from the bar, which was 14, and you multiply that by nine 126. You combine these together, you get 138. You take that 138? You divide it by 100. Is that right?
Michelle 51:43
Yeah. Okay, that gives you fat protein units.
Scott Benner 51:46
So then you came up with 1.38 fat protein units, is that correct? Yep. Totally. You just rounded it to one, because the chart only really works because the chart says 123 or four, right? And one fatty one fat protein unit indicates a three hour extended a Bolus two indicates a four hour three indicates a five hour four indicates an eight hour. Yeah, so So you came up with using his ratio. Now this is the part where I got a little behind. So you took the 1.38 times 10? Because that was his ratio. Is that right?
Michelle 52:22
Nope, because there are 10 fat protein units. So that protein, fat and protein get converted to a certain amount like glucose. So one fat protein unit is converted in your body, about the same as 10 grams of carbs would be? Okay. So if you didn't eat any carbs, and you ate one fat protein unit, that would be like eating 10 grams of carbs. Okay?
Scott Benner 52:52
This is the moment where I'm going to say this out loud. And take advantage of the of how popular the podcast is. The person who made the conversion calculator for the website, if you're listening to this, and you think you could program this into an app for online, please contact for Yes, yes, yes. Okay. And that'd be awesome. And you would you would get that code for your website if you wanted it. So, okay, so then you see you do this, this last bit here. And you can you came up with, it's going to be point nine, because you round it again, because you came up with point nine, two, you rounded at the point nine because that's how the pump would do it. 1.92 and you extended that over three hours. Now in this specific scenario. How long after the ice cream is consumed? Did you end up putting this in
Michelle 53:42
one hour? Okay, we started the accent balls at one hour after he started eating.
Scott Benner 53:46
So is that an indication to you that that ice cream cone has about a four hour life in his body?
Michelle 53:51
Yeah, I guess so. Yeah. All right. Well, plus the free will be longer because at the end of your extended Bolus, that insulin is going to last for another three hours it's gonna tell as well. And I've heard Jenny talk about how fat can affect you for you know, she said eight or 10 hours we have at times found that Max is still resistant the next morning like we're talking 1215 Even 18 hours later
Scott Benner 54:20
they'll be there sometimes. Right?
Michelle 54:22
It depends on how much right not the current and and other things like how activity how insulin sensitive is he right now or has he been you know, as he had a long weekend and sit around and video games all weekend, in which case all of this compounds
Scott Benner 54:36
Hey, let me tell you a fun story while we let this sink into people's heads before we move forward. All right, two hours ago there is
Michelle 54:43
an easier way to do this to let me say
Scott Benner 54:45
we're gonna get to that take the whole thing and make it easier we're gonna do a funny story but Michelle, listen, you gotta tease it out. I want people listening through the whole thing. All right, am I listen through rate is important to ad sales just so you all know.
Michelle 54:59
So listen to the And I go
Scott Benner 55:01
pick up artists contact lenses today, there, they we placed an order and they had to be picked up. And they get there and I'm in a, in an office that. I mean, I've been taking my kids to for so many years. There's a lovely woman at the front who's been there for ever. And we're standing around talking, and I said to the person that was helping me, Hey, I gotta go, I have to go record a podcast. And he said, what's it about? And I said, Oh, we're going to talk about how fat and protein impact blood sugars kind of more long term than people who use insulin, but probably think they do. And the woman behind the counter goes, I have diabetes. I've literally known her for a decade, I had no idea she was I struggle with this all the time. She goes, What are you doing? And I started explaining to her, she's like, how do I find this podcast? And she's like writing it down and showing me her phone and asking where podcast apps are and stuff like that. And I walked out and I just thought like, how do I not know but there she was she had a Medtronic pump on her belt. She keeps it covered with her shirt, wearing a sensor, nobody can see it. And, and there, she was just like
Michelle 56:09
he's in the wild.
Scott Benner 56:10
She said this topic vexes me. Just it just controls my life. And she's like, even if I just eat a piece of chicken, I'm down to just trying to eat a piece of chicken. And two hours later, my blood sugar tries to go up 40 points. And I said, Well, yesterday, your body can take that protein from that chicken and it converts it and stores it as glucose and then impacts your blood sugar. And she's like, I have no idea. I've had diabetes for decades. It's like now okay, I said so Okay, common. Yeah, just it was crazy. I mean, very, like, if I told you, I just thought to myself, Hey, I have a little extra time here. I can make it to the store and back again to pick up Arden's contacts, like I just tried to
Michelle 56:48
squeeze and you were supposed to be there, because she's supposed to hear your podcast. So lovely.
Scott Benner 56:52
Like I had a very nice feeling about the whole thing. Okay, so we just went through something, which let's be honest, is not that convoluted. But it's more than it's Yeah, yeah. Right. So you're telling me there's a simpler way I could have gone through this. What would that have been?
Michelle 57:08
Well, first of all, as I said, we don't Bolus for protein. And there's a couple of reasons for that. Number one, because we found when we first started using this formula, including protein Max always went low. And one of the things about protein is that it really only affects your blood sugar in a significant way. If you're not eating carbs, and we're pretty carby family, I mean, I don't I think there are very few times when Max, like he wouldn't sit down and have like a steak and a salad. He wouldn't eat a burger without the bun, I would do those things. I have celiac disease. So, you know, I tend to be I would eat more just protein alone, but he wouldn't. So in a way, because carbs are the body's preferred fuel source. If he's got carbs in there, then it's just going to use the carbs for fuel, okay, and the protein isn't going to have the same effect as if he had protein without carbs. Okay. So like think, you know, steak and a baked potato, you probably don't have to Bolus for the steak, although it sounds like you do. And it works. So maybe there's something I'm just missing there. But still valid solid? Wood?
Scott Benner 58:20
Yeah, I don't do a ton, like read a little bit, you know, and if it's, if it's more lean, I do a little less. I just, I just throw five I'm always thrown five like because you know that kids will put like a little dip in a bowl like honey mustard or something like that. People like how much is it? I'm I don't know, five more. Everything's always five more. Because isn't it interesting? I think for everybody who's listening, think how specific you are with your insulin. Oh, this is 43 carbs. And it's going to be 14.8 units or something like whatever you end up doing
Michelle 58:53
preaching to the choir.
Scott Benner 58:56
Right. And you're more frequently never right? Too weak than you are too heavy.
Michelle 59:05
Absolutely. Right. Because everybody, you're speaking my language. Right? Right. We laugh because if we go out to a restaurant, and there's no carbon information you're like at a mom and pop place. So there's no you know, Boston Pizza website to go to or whatever, you're just, you're there and the food's there and you have no choice but to pull a number out and just go blind, this many carbs. And it's funny when we do that, quite often his blood sugar is much better than when we systematically counted. Yeah. Now that being said, we still systematically count it because I think if I did that all the time, it would miss necessarily work out and there'd be one
Scott Benner 59:48
where you'd be in the parking lot going, well, Max can stand. But no, I think I'll tell you a measurement I use very privately in my own head when you're out in a row. Restaurant. If it's a chain, it's more, because I always think there's more. Just stuffing it is not food. And the better at taste. There's more because the better it tastes always to me means food and means fat and salt. Absolutely right. So the better it tastes, the you know, the more hit your pleasure center and makes you go I don't care about anything else in the world, but more you feel like that the more insulin it's gonna take
Michelle 1:00:25
five units of insulin Yeah, more.
Scott Benner 1:00:30
I just it, it became, like evident as Arden got older. And now I'll tell you, you know, now that she's a full blown lady. There's a whole other aspect of it, there's a you know, there's some foods that hit her differently now that she's mature than they did when she was a kid. And I don't even know if that's if I'm right or wrong about that. It's just, it's what it is. And there's some foods lately, there's a simple one, she likes these little baked Ritz crackers, right, so, so not the regular round Ritz crackers that everybody thinks of in the in the sleeve, those those we Bolus pretty easily carved for carp. But these ones that come in a bag that are like rich chips or something like that, I just take whatever the carbs are and add half if it's 20. It's 30. If it's 30, it's, you know, it's it's 15 more on top of that. And these things just hit her. I don't know what's in them, but it ain't good. You know what I mean? Have you looked at the label? Well, no, that would take a lot more effort, I just figured out how much insulin I'm just curious
Michelle 1:01:32
about how much fat and maybe even protein is in there I'm gonna look at or if it's a glycemic index thing, like if they you know, if they digest super slowly, then
Scott Benner 1:01:42
something, they hit her like a truck. And then the truck stays parked on top of her for a while. Yeah, it doesn't pull off and go, I'm sorry, it just stays there. And the reason I don't look too deeply into it. And this might be helpful for people to with younger children, is because she will cycle through these. Like, I don't know if other people's kids do that to
Michelle 1:02:02
be gone a month from now. So be a moment where she'll go, Hey, did
Scott Benner 1:02:05
you want some of these crackers that you love? And she's like, I hate those. I'm done with those and then she'll never eat them again and the rest of her life?
Michelle 1:02:10
Yeah, you go donate those six boxes that you just got on sale.
Scott Benner 1:02:13
Yeah, like here. This will crush your blood sugar. Congratulations. They're free now. But yeah, but no, seriously, it's um, she doesn't do the same thing for when she's on a great kick. Right now. I have four pounds, a great admirer, four pounds of grapes in my refrigerator right now. Because she just two weeks ago said, Hey, everybody, I'm doing grapes now. Like, there are things so let's stay stocked. And I was like, okay, so no worse things. Yeah. Right. So I'm like, okay, whatever, and then they'll be gone. Like, you know, I'll try to give her grapes three months from now. And she like, Ah, I don't eat grapes. What am I gonna do? You know? Anyway, I'm sorry. So, okay. There's an easier way to do this.
Michelle 1:02:53
Right? Okay. So what we do is we first of all, like I said, we don't include the protein. So what it comes down to for us is that we just take the grams of fat, we multiply it 5.09, which is the timezone and divided by 100. And all in one step. And then I might multiply it by nine or 10.
Scott Benner 1:03:18
So that's what's the multiplication for?
Michelle 1:03:22
That's the 110 grams of carbs, for one gram, one fat protein unit. Okay? So we, because he still sometimes goes low, if we use this with the 10, if he's in a good place, and things are, you know, he's insulin sensitive, and all that is going well, then I will reduce that number. So when he was younger, I might reduce it all the way to eight. And so that's another way to make it more conservative, reduce that risk of bottoming out. Gotcha afterwards.
Scott Benner 1:03:54
Well, I like to ask you to go through it again in a second. But I like the way you just said if he's insulin sensitive, and you didn't mean that in a bad way, you meant if the insulin is working the way I expect it to work in this moment. So I'm gonna get a reaction that I expect. And by expect, I mean, ratios, Basal rates are all doing what we expect them to do.
Michelle 1:04:14
Absolutely. Okay. And as an aside on that, like, I'll notice that they have a long weekend. Like they just had a five day long weekend from schools, teachers convention things by the fifth day because he hasn't been walking back and forth to school. He hasn't had gym class. He's been spending more time on the computer or hanging around with us watching movies and that kind of stuff by the fifth day, but probably the third day really. I know that we need to crank things up a bit. Yeah. And if I forget that, then it comes back to tell me we need to crank things up a bit
Scott Benner 1:04:45
being sedentary to me hits exactly like an old instruction set. You know what I mean? Yeah, you know, when you're at the last part of your infusion set, and it's starting to get like, suddenly like this should be a unit but it's two units and and you know, it almost feels like it It almost can feel like a leaky sight. It's almost like Oh, everything I'm putting in there. It's not getting in there is it like, but it's wrong. Yeah. But instead, it's everything I'm putting in there. It's not having the impact that it should, because he's been sitting around for a week or etc. i Right. I'm glad people can follow this. This is good.
Michelle 1:05:18
So on those days, I will absolutely lose use 10. So using 10 would be more aggressive because you're multiplying it by more. Okay, so eight would be more conservative.
Scott Benner 1:05:28
Do it. Do it with me one more time. So let's just put 10 grams of fat in this imaginary thing we're eating? Yep. How do you do it?
Michelle 1:05:37
10 grams times point oh nine. Okay. Should I times 10. Okay, divided by the IC ratio, which for him right now is six, we just use six across the board.
Scott Benner 1:05:52
So in that 10 times point oh nine times 10 divided by the insulin to carb ratio. Yep, that's it. Okay. So you're gonna
Michelle 1:06:01
come up with what nine divided by six? Did I miss something,
Scott Benner 1:06:06
I'm gonna second. Let's just do this the easy way, showing 10 divided 10 times point oh nine gets zero. 10 times point oh, nine times 10 divided by four. It's 2.25 2.25. That would be Ardens. Because our insulin to carb ratio is like four, four. So if there were 10 grams of fat in this thing that Arden ate, I would take 2.25 units and extend that over three hours.
Michelle 1:06:42
What did we come up with the fat protein, we have to pause at the grams of carbs times point oh nine because that tells us our fat protein in
Scott Benner 1:06:51
my stupidity. So that's
Michelle 1:06:53
So that's point nine. So just under one. So yes, it would be three hours, three hours. So now and I should point out that we never actually would do this for 10 grams of fat. That wouldn't be enough fat for us to bother. Right. But for example purposes,
Scott Benner 1:07:08
the first round numbers and simplicity, which is clear. But so that's a good point, though, because and why is that a good point? Let me Google something for a second. When I say five guys, five guys fries, fat.
Michelle 1:07:24
While you're Googling that, I just want to point out that they go to a local mall to do Pokemon Go to Brooklyn auntie, and they always stopped for lunch. This is my husband and Max. And nw is the usual meal on that day. And it has 64 grams of fat for a cheeseburger, fries. And a pop.
Scott Benner 1:07:45
Listen to this. This is from the Food Network, a large french fry has an unbelievable 1300 calories, 57 grams of fat, 1300 milligrams of sodium. So you're gonna get crushed if you eat if you eat this, because not only all of this, but the sodium is going to dehydrate you, which also slows down the insulin. We're
Michelle 1:08:06
never even take that into account just pulling numbers that are my bone like you just got because it's all
Scott Benner 1:08:14
taste good, more. So. So there's a good example 57 grams of fat in just those fries, just say so leave the milkshake out of it leave everything else out of it when I'm telling you, she used you know, just multiple 10s of units of insulin more, it really isn't that crazy because in this scenario here, if we just round this to 60, right, hold on a second. If we just round this to 60 grams of fat for Arden for the French fries yesterday and I do 60 times point oh nine, I get five five. That's right, times 1054 divided by her insulin to carb ratio is four. She needed 13 and a half units more insulin for the fat in those French fries than the carbs and those French fries indicated and think about how many carbs are in the French fries. So hold on a second in five guys, large fries carbs. Okay, there are 72 carbs. So So we've just decided Arden needed 13 and a half units of insulin for the fat in five guys fries. Now let's look at it as carbs 72 divided by 418. So while everybody's wondering why their blood sugar gets high, and they don't understand why it takes so long to come down. Arden needed 31 and a half units of insulin just for the French fries, but it had to be stretched out over the impact of the carbs because of how though, oil is holding it up, which we've talked about a million times this podcast and anybody who's listened to the program A series knows the food goes in, it starts digesting your leaching out carbs, the more fat that's in your stomach, the slower the digestion goes, the longer it takes, the longer you're slowly just basically infiltrating your blood with with sugar. So that really is telling honestly.
Michelle 1:10:21
And with that amount of fat, like I said, for the Klondike ice cream bar, we would start the extendable is one hour after and by the way, we just say, Alexa, she's gonna listen to me. Now, we would just say Alexa set a one hour fat Bolus timer, which usually results in hilarity because she often says five balls timer. But anyway, all that aside, we just set a reminder, right? So that we actually do that an hour later, if he had this much fat. If I did that, an hour later, he would bottom out first, okay, because the food would take that much longer to reach his bloodstream. And the evening the car be food,
Scott Benner 1:11:03
yes. And the easiest explanation for that, for most people is pizza, who, you know, you look up pizza and you go, this is 30 carbs a slice, you put it all in, and 45 minutes later, your blood sugar's 40. And you're like, I don't know what to do. And you drink a juice, and that doesn't work, and you drink another one, and then all of a sudden, the fat and protein hits you and the juice hits you and your 400. And you don't know what to do.
Michelle 1:11:23
Right? Right. And that wasn't a problem with the amount of insulin you took. It was a timing issue, timing that the insulin got in before the food did.
Scott Benner 1:11:30
I was talking to somebody the other day. And I said to them, in the end, all the things that we just talked about here, all we really said was right amount of insulin at the right time. It's all timing and amount. It's always it's always timing and amount.
Michelle 1:11:43
And fat messes with that in a big way. Because it's not just that you get that high, it's that it takes so much longer for it to digest, that you can go low in the first place. Okay, or like you've said, on other podcasts, you got this beautiful number, and you think I nailed that. And then four hours later, you know, you're through the roof. And that's why, because you might have nailed the first two hours of it, but not the next eight.
Scott Benner 1:12:09
All right, Michelle, there's one thing I'm still lightly confused by. So it's the idea of one fpu, two, three, when we did it in the short version, and we just said 60 times point, or nine times 10 divided by insulin to carb ratio. Yep. How what would How would I know if it should be over four hours or five? What number would change in that so we stopped,
Michelle 1:12:33
we stopped at the 60 times point or nine. So that's the fat protein units. And that was 5.4. So for five units, now here's here's the other thing that we run up against with 60 grams of fat. The turtle then goes up to four protein units. Okay. So beyond that, I take the Scott Benner approach, and I just guess more. So for five units, I might say 10 hours because for fat protein units would be eight hours. So for five fat teen protein units, I might go 10 hours or maybe 12.
Scott Benner 1:13:04
Okay. i Okay. So my confusion was, is that our original number that we started with kept us in the three hour range. Right, right. Okay, right, because we were only at 60. If we would have gotten to, is there is there a cheat in there? Is there a number of FP use that makes it to like in your mind? I know you don't think of it this way, but pretend you were me for a second. And sometimes I do. Yeah. So like, how many? How many? How many K Cal's would tell you, Okay, this is going to be four hours. Do you have that number in your head? Um,
Michelle 1:13:43
no, but I can reverse engineer it, like four hours would be to fat protein units. Yep. So then two fat protein units would be 18 grams of fat. Okay. So if you were looking at somewhere around 2020 grams of fat, you might say, Yeah, let's extend that four hours. Okay, you can totally just do that shortcut. The other thing is insulin is insulin. So once you know that you're looking at a four hour extended Bolus, you could do a Temp Basal. That will equate to the whole thing to the same thing I would normally do that, you know, it's pump doesn't care if you do an extended Bolus or Temp Basal, it's the same thing. It just draws it out. It's whatever makes sense to you in your head and whatever you can, you know, work with.
Scott Benner 1:14:29
So with 60 for the French fries, that actually puts us up into the more of like the five six hour range, right?
Michelle 1:14:36
Yeah, yeah, when Max has a NW and he's 64 grams of fat. We extended over 12 hours, 12 hours, which I believe is the upper limit of his current.
Scott Benner 1:14:47
And when you're doing that with a small person, what you're really telling the pump is I need extra basil for the next 12 hours because it is a small it's a smaller amount of insulin once you break it up over 12 hours. Yeah, Okay,
Michelle 1:15:00
well, that's all you could convert that into Temp Basal. I guess my problem with that is like, he's still growing. So when he goes to bed, he's got growth hormone, and his Basal rates almost double. So for me to go, Okay, how much of this would it you know, to tell it a Temp Basal I would have to sort of figure out okay, well, between the hours of 11pm and 2am, his Temp Basal would be double. Yeah, but earlier in the evening, it's not going to be like, so I just go extended Bolus, yeah, just give me give me whatever, an extra five units over 12
Scott Benner 1:15:32
hours. Yeah, Michel, the way if you if I'm sorry, if you've heard me say this justice overthrow it for a second. But I just think of, I've found a number of different ways to think about it over the time, there's an impact range that the food has, you know, from the minute it goes until it's done, and I tried to cover that range, with a heavier blanket of insulin. Sometimes I think of it that way. Sometimes I just think, you know, just basically like, oh, it's going to be cold overnight, I need an extra quill. And so you know, my blood sugar is going to try to go up between here and here. Because I've eaten something with fat in it, I'll just lay something heavier in the form of Basal overtop of it to hold it down. I've described it as carpet bombing, before, you know, just picking the picking the range where the food is, and just try to decimate it, you mean just stay on top of it. There's all different ways to I mean, however, people can picture it in their minds. The idea here is that this fat is going to force your blood sugar up over, over hours, and the amount of hours is going to depend on how much fat it is and all kinds of other stuff. And and still, what we're talking about. While this while this method doesn't work for the idea still exists that for some of you, protein will cause a rise a number of hours later, too. And if you can learn that you can count on that that a chicken breast with my meal is going to mean the two hours after I eat my blood sugar is going to try to go up 60 points. Well, then an hour after you eat the chicken breast, you could do a Temp Basal to stop that or an hour and a half eat the chicken breast you could Bolus for it even
Michelle 1:17:12
so my problem was always how heavy of a blanket do I need? Yeah, and how long am I going to put it on? So do I need that? You know, that light summer blanket? Do I need the really thick? Do they? What do I need here? And and so for me using this formula, Toby? How heavy should the blanket be? And are you going to have it on all night or just to the beginning of the night or what? So for somebody like that, who is eating the chicken breast and a salad and no carbs, and therefore needs to Bolus for it, you can use the same formula. But just the same way that I leave protein out of the formula and only do fat. You can leave fat out of the protein out of the formula and only do protein. It's fascinating.
Scott Benner 1:17:50
And I do mean this in a very kind way. Like I I would imagine you could take this wrong, so don't but the people who I've seen asked me for this information, as near as I can tell through the internet, have a similar personality to yours.
Michelle 1:18:08
What a shocker. I don't take that the wrong way. Yeah,
Scott Benner 1:18:10
it's fascinating because we're, those are the people who hear me go, I don't know, put in more than just don't let it cause a problem. They're like, No,
Michelle 1:18:19
when I tried that, Scott, because my brain doesn't work that way. When I tried that, it just failed. And I was discouraged. And I was like I cannot put in the energy that it's going to take to keep trying and experimenting and figuring it out and trying this in China. I just can't. And the other thing is you have this incredible memory, I have asked to be introduced to people that I have met before people I have had in my home at my dinner table I have asked to be introduced to and so I don't have that memory. So if I don't write it down systematically and come up with a process that works, then I'm starting over every time I sit down with that food on labor time, I don't know what we're gonna
Scott Benner 1:19:02
try. So I can't take credit for memory. It just occurs to me. Like I just look at it and then the answers in my head. I don't have a process to come to it. And I can also that's awesome please It's an odd gift to have but I would much rather be cute you've got that's incredibly valuable to show what if I ran a sub for 60 and could catch on with six feet five then I could pay someone to do this we
Michelle 1:19:28
haven't different
Scott Benner 1:19:31
but but it isn't it this conversation has been in an extended way interesting for me because I can see now that you don't think in pictures. And I think in pictures Yeah, right. Yeah. And numbers and language right. And the people who I hear describe me as Oh, it's this guy. He's just really aggressive with insulin. I was like, Oh, they think in numbers. Not in pictures, right? I sound like a lunatic who's just yelling like pour it on and see what happens. But I don't think you
Michelle 1:20:01
do that based on your sense of what is appropriate. And I'm saying I don't have that sense. Yeah. So I can take this formula. And then once I know, then, I mean, you don't have to go through the formula every time. It's not like I spent all my time, you know, doing Warsaw calculations. Once you know, and you have that same food again, you just use the same thing. And, and I literally kept track. I said, so what was the result? Okay, he went low first. Okay, I'm gonna give maybe less upfront and extend it more. I'm, you know, I could tweak from there. But once we've tweaked it, and we get success, well, then when we have McCain's frozen pizza, this is what we do. Yeah. Or when we go out to NW on PokemonGo day, this is what we do. And so I think it gets us both to the same place, but just a different path to get
Scott Benner 1:20:51
that well, no, I think the last 30% of the process is the same for you. And I, I think it's the how we understood it, how we made the decision. And when we use it, that yours is more calculated. And mine's more like, that feels like five units to me. But you know, and it also
Michelle 1:21:07
puts me in a position then when I get one that I don't know, and I don't know how much fat is in it, I don't know how much protein it is, I can look at and go Well, it looks like an a and w meal or it looks a little closer to you know nachos, or it looks like then I can be in the ballpark, I can say well, I have no idea on this one. But I'm going to compare it to something I do know something we've done before. And I'm going to try this. And that gets me in the ballpark. And it makes Max's blood sugars post meal, manageable, so that now we can do the bumping and nudging that you talk about rather than this, you know, runaway freight train, but nothing has helped. There
Scott Benner 1:21:45
is nothing maybe more confusing than seeing a blood sugar that's 280 putting what you think is a massive amount of insulin on it and watching it go to 260 and then bounce back to 280 again, Oh, yeah. Then your brains just like fried, because you're only thinking correction factor, and not considering any of the other things that are happening. And then you're just staring before
Michelle 1:22:07
we started analyzing this had no idea like I might think oh yeah, it's fat. But then when you think 64 grams of fat. That is that puts my understanding on an entirely different level for me to go oh, that's why when one unit would normally work, and I gave him three units. Thank you. Let's watch for the low. That's why I didn't even touch his blood sugar. Because we're talking about this astronomical amount of fat
Scott Benner 1:22:32
right? Because and obviously Arden's insulin, insulin to carb ratio is different than other people's but because a large French Fry from five guys for Arden needs 28 or 30, like 32 units of insulin 32 units of insulin, her pump only holds 200 for three days. Right? So I can. And so anyway, this was really great. Did we not say anything that you wanted to say? Did I find a way through it all?
Michelle 1:23:04
I think so let me just look and see.
Scott Benner 1:23:06
Look at your notes, please. Oh, usually people with notes. So check it out.
Michelle 1:23:11
Systematic. One other thing to think about is there are times that we would have, he'd say he'd make himself nachos for lunch. And then we have pizza for supper, or, you know, we'd go to McDonald's for separate. If this happens twice in a day. The the effect is compounded. So like if I sort of imagined that, you know, his first is not just for lunch, there's some fat swimming around him his blood, and that's making things a little bit harder to deal with. But we covered it and things look great. But underneath the surface, he's still got that extra fat in his blood. Now we go and we pile on more fat, that's going to need even more of a hit. So yeah, you're more insulin, more insulin really applies if you're eating fat more than once a day, which doesn't happen incredibly often for us, but we've seen the effects. Yeah, and I think already sorry.
Scott Benner 1:24:05
I was gonna say I see it with Arden during her period, like when she gets like cravings, sometimes cravings. They match each other. So it goes, you know, I've had days that have gone from nachos to Chinese food, you know, and you're just like, well, this is gonna be like, it really does feel like, you know, like, like, the greatest football team of All Times has shown up the play you and you're like, Okay, I guess we're gonna lose. Let's try not to lose by too much.
Michelle 1:24:37
And that's where you know, when you if you'd normally do Chinese food, you go well, this is how many units it needs. And we need to extend it over this many hours. The day that you have Chinese food after nachos, you need to ramp that up. It'll change or at least we find that we do because the effect is is cumulative.
Scott Benner 1:24:55
I definitely see that too. Okay, I'm sorry to cut you off. You're gonna say something else. No, I think that that might B, I think we've, I think we've addressed that I've got here. Well, Jenny was right, you were the right person to talk to about this. So thank you. I have to say this to pleasure. No, I had a good time. But let me say this because I want to mention again, it's waltzing the dragon.com or.ca. There'll be links in the show notes for you to go find it. I'm going to try to talk Michelle into the day that this goes up to like popping up in the Facebook group and chatting with people about it if she wants to. I would love to, but I want to say this, and I mean, this genuinely. She would never say this out loud. But there are not that many places where Jenny directs people for diabetes advice.
Michelle 1:25:37
So you made my day because I really admire her she is a smart cookie. And as great advice is
Scott Benner 1:25:43
a big deal. She's I've outed her now she's only ever told me that privately but there are very few sources that Jenny will tell somebody about so that she brought was a big deal. So I that's how I knew right away to reach out to you because if she was willing to say it out loud, that I knew it was going to be a good conversation. So thank you very, very much. This was amazing. Thank you for your time. Scott. Are you kidding me? You stop it. This is this is all all the things go to you. A huge thank you to one of today's sponsors, G voc glucagon, find out more about Chivo Capo pen at G Vogue glucagon.com forward slash juicebox you spell that GVOKEGLUC AG o n.com. Forward slash juice box. The episode was also sponsored by the Contour Next One blood glucose meter. Learn more at contour next one.com forward slash juice box. There's links in the show notes and links at juicebox podcast.com. For these and all of the sponsors.
You can support type one diabetes research and the Juicebox Podcast. The T one D exchange is looking for type one adults and type one caregivers who are US residents to participate in a quick survey that can be completed in just a few minutes from your phone or your computer. After you finish with the questions. And they're really simple questions. I did them in maybe seven or eight minutes. You'll be contacted annually just to see if there's any updates to your information, and to be asked any further questions if further questions exist. This is 100% Anonymous, completely HIPAA compliant and it does not require you to ever see a doctor or go to a remote site. Now every time someone completes the process using my link, T one D exchange.org. Forward slash juicebox. you'll not only be benefiting people living with type one diabetes, but you'll be helping out the podcast. Just use my link in the bio, then click on Join our registry now. And then just simply complete the survey. T one D exchange research has led to increased insurance coverage for blood glucose meter strips, changes in the American diabetes Association's guidelines for pediatric agency goals and even helped get Medicare coverage of CGM devices. So if you've ever wanted to help out people living with type one diabetes, or the podcast, or maybe both, this would be a simple, quick and safe way to do all of that T one D exchange.org. Forward slash juicebox. Okay, now I'm on Michelle's website, waltzing the dragon. And she has examples here for you. This is very clear and easy to follow. She's got a lot of examples of what foods are high in saturated fat here. She talks specifically about the what the Warsaw approach is. And she walks you through an example number one identify how much fat and protein the food contains. And she has an example here that she used on the podcast. It's an item that has three grams of protein, and 14 grams of fat. Number two, you convert into units of energy. It's kg cow from protein equals protein, and grams times four kg cow grams. Now when you see that, you're just like, Oh my God, I don't know about you, my brain goes, ooh, I guess everybody's blood sugar is gonna be high because scouting and figuring this out. But if you've got the kind of brain who loves this, go look at it, because it is incredibly well. I know. When I look at it, I think if my brain work this way, I know I would appreciate how this is being shown to me. Number three, calculate the total calories. Number four, calculate the fat protein units. Number five, how long to extend the Bolus it walks you through it very easily step by step instructions, gives you the amount of extra insulin that you need step six, and then it talks about the end result. She says here to make a long story short, in this example to cover fat and protein. Her son had this bar after supper, she would first give the usual Bolus with the carbs before he starts eating. Then later, she would deliver an extra 2.3 units of insulin in this example, in an extended Bolus that covered a duration of three hours. So you've heard her talk about it now for an hour we've been talking about in the podcast. If you want to see her step by step instructions, there's a link in the show notes for this episode. And there's a link at juicebox podcast.com. For again for this episode 471. Now, in the meantime, I'm going to be paying closer and closer attention to how I'm using this idea in our life. And I'm going to come up with a way to say it that doesn't involve adding, subtracting, multiplying or dividing. I'm gonna come up with a way to talk to you about this. And I will be sharing it as soon as I absolutely can. You know me, I'm just like, there's a lot of fat in this and then I, you know, I just got a lot more insulin than I stretch it out. You've heard me talk in the diabetes Pro Tip series, you know how I do it. If you've liked this and never heard of the diabetes Pro Tip series, I really think you should check it out. Because if you like this conversation, you'll love those conversations. The diabetes pro tip episodes begin at episode 210. They're available at juicebox podcast.com. In your podcast players, or if you just like to see a list of them diabetes pro tip.com. I hope you found this interesting. If you did, please share the show with someone else. And of course, check out Michelle's website waltzing the dragon.ca or.com. And there's of course links right there in the show notes and at juicebox podcast.com to this exact article. I'll talk to you soon.
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#845 Ask Scott And Jenny: Chapter Eighteen
Scott and Jenny Smith, CDE answer your diabetes questions.
Is there an insulin that acts more like endogenous insulin meaning quicker acting than current options? Let’s talk about smart insulin.
If dehydrated and insulin is not working well, how much and how long does it take to get properly rehydrated?
What are the added risks of smoking to a person with diabetes?
School questions: How did Scott move from depending on a school nurse to directly communicating with Arden? How did she know when to pre bolus? Did she have alarms or did she only rely on her alerts? How did she handle texts in class? Did she wear a watch? What was your process if she missed a text? How old was Arden when she started to treat her own lows? What was your field trip protocol? Did she carry an extra pod on her?
Does a blood transfusion impact your blood sugar?
What are the settings that most often need changing when starting to Loop?
You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Music - Google Play/Android - iHeart Radio - Radio Public, Amazon Alexa or wherever they get audio.
+ Click for EPISODE TRANSCRIPT
DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.
Scott Benner 0:00
Hello friends, and welcome to episode 845 of the Juicebox Podcast.
It's been a minute since Jenny and I have done an ask Scott and Jenny episode. But here we are back answering your questions. That's right questions from the listeners, right the Jedi and just got answered for you to the best of our ability. Today we'll speak about smart insulin hydration has Jenny ever smoked, and much more? Check it out. Stay with us enjoy. While you're listening, staying with us and enjoying. Please don't forget that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please Always consult a physician before making any changes to your health care plan or becoming bold with insulin. Now if you have type one diabetes, or are the caregiver of someone with type one, you know what I'm going to say? Go to T one D exchange.org. Forward slash juice box and fill out the survey. It takes fewer than 10 minutes. It's completely HIPAA compliant. Absolutely anonymous, easy to do. And once you finish you've helped with diabetes research. You may have even helped yourself, like the T one D exchange might come back to you and be like, Hey, are you interested in doing this? Right. And then if you are sometimes they offer gift cards. Just go check it out T one D exchange.org. Forward slash juice box. This episode of The Juicebox Podcast is sponsored today. By the Contour Next One blood glucose meter. You guys are always so generous about clicking on the Contour Next One link, I can only assume that you love it as much as I do contour next one.com forward slash juicebox. You owe it to yourself to have an accurate and easy to use meter. The Contour Next One is just that. today's podcast is also sponsored by touched by type one and guess what I did yesterday. I asked her to save the date from touched by type one. See if I can find it here. It's February now. But I could find it. Save the date it says, Hey, Scott, I hope this finds you. Well, we have begun planning our next touch by type on annual conference. And we'd love to have you join us again in 2023. Our conference will be held on Saturday, September 16. Well, that's a little something you can plan for. Check it out at touched by type one.org touched by type one does way more than this event. You can check it all out at the website. But um, I'm just saying if you can plan to come out, I'll be there making all kinds of talky talk. We'll have a great time.
Jennifer Smith, CDE 2:46
Yeah, I'm up for whatever.
Scott Benner 2:50
Since the end of the year, almost almost well, for in my mind it is because I'm making the podcasts like way out in the future. And I just edited your how Jaime eats episode, which came out really well.
Jennifer Smith, CDE 3:03
I thought of so many additional, like, additional things that I would have really added to that like, like I you know, they're just everything that you think in excess, like, I eat this. And sometimes they eat this and sometimes I gave you like this general idea.
Scott Benner 3:21
Don't be in a hurry, we can do another one. I make a lot of episodes, so don't worry. Yeah, we can come back and do a part two. Fabulous. It's like getting all that stuff together and everything and
Jennifer Smith, CDE 3:35
I'm glad it turned out well for what it was there. No, it
Scott Benner 3:38
no it definitely did in the end. I feel like they're less of a, like a checklist and more of a vibe. And I thought you did that really well. Like I think the way you think about food came across and what you eat in general comes comes across, you know what I mean? And yeah, it made an impact on me the other day i i was in between something and I walked through the kitchen and there were cookies from Thanksgiving and I grabbed a Clementine. I was like oh, I think this was what Jenny would do. So good. Very good. Yay. And by the way, very good. This is the time of year for clementines. I don't know if people know that or not. But
Jennifer Smith, CDE 4:19
it is absolutely actually growing up. My mom always had like more tangerines or oranges or something and I asked her when I got old enough. I was like here we have them more often this time of the year and she's like when we were little and my mom grew up on a farm right so they didn't have a heck of a lot. But this time of the year her dad would always go into town. Right? And like get some tangerines and they were like the best treat my mom said at this time of the year
Scott Benner 4:53
yeah, they're just for some reason. Ended November December January I must be where they where they're grown in the world. It must be the right timing for it, which is what I assumed. But yeah, they're definitely better because in the middle of the year you get them and you're like these are
Jennifer Smith, CDE 5:09
my mom always called them punky is how she said the rest of the year, they're not as juicy. The flavor is not what it's supposed to be. And you get the ones like half of your bag might be really like, dry, rather than that really big, like burst of juice that you should get your like, dry.
Scott Benner 5:29
You know, I was I know, we're not talking about where we're supposed to, but, but it's okay. Listen to people listening will decide if it's okay, if I see them clicking off, I'll know this wasn't okay. But I was in the in the vegetable aisle the other day. And there's this sign that's been there forever that I've, I mean, I don't know how I haven't seen it before. But it's tattered. That's how I know how long it's been there. All of these, all of these vegetables have been sprayed with a wax coating to extend freshness or something like that. And I was like, Oh, I didn't know that happened. I did. Did you know that happen?
Jennifer Smith, CDE 6:12
Well, you can tell though, I mean, even even like oranges and that kind of stuff. You can tell when you peel it sometimes the ones that have been coated, you can tell because it comes off on your hand. Apples as well are a common one that have that like, like, you can feel it you can almost rub it off. Because of the amount of time it goes between picking and actually getting to the supermarket, and then getting home with you. They have to do something to keep it
Scott Benner 6:44
Yeah, that's what occurred to me is that none of these things are grown here in New Jersey. I imagined. Oh, no, yeah, I'm sure. At some point they were
Jennifer Smith, CDE 6:52
right. Do you have tangerine trees in New Jersey? No,
Scott Benner 6:55
no? Well, you know, like, when I grew up, it was it was the stuff that you could grow here was grown here. In the winter, there was less of it. And we got it shipped in from the south. And anything sweet and round and yellow or orange came from an island somewhere or Florida. And that's just how it was. So now I'm realizing that they might be shipping in bell peppers from Uruguay and covering them with wax that they don't go ahead. I did not know that before. I also don't know where your way is. For clarity, just the name of the country. I mean, I pulled out of my butt, right. Anyway, Jenny, I'm going to go to our ask Scott and Jenny list. Cool of which is It's oddly extensive. Yes. And, and just scroll through a little bit, ask you a couple of questions that have been sent in by people. And we will answer them, hopefully, and move on to the good. So hopefully, if it's possible, we'll be like, I don't know the answer to this. I
Unknown Speaker 8:01
can't help you there.
Scott Benner 8:05
Do Okay, who knows? This is from Lisa. Do you know if an insulin that acts like endogenous insulin, meaning is it quicker acting than current options? is in the works. So that's a good question. Our pharma companies I mean, fiasco is here and loom Jove and a Frezza and a threat? Yeah. But are there more? I don't know the answer to that question at all.
Jennifer Smith, CDE 8:30
I know, I can tell you that there are things in in that are being researched? Yes. Where they are, I don't know. I know years ago, I attended JDRF used to have like these scientific sessions, sessions where you could come as like people with diabetes. And you could see what was in the works, right. And this Gosh, this was like 12 years ago, there was a company on the East Coast that was working on something called smart insulin, smart insulin from what I remember to the degree that this insulin would be taken once a day. And it would have almost a almost like a thermostat if you will, but but not relative to temperature relative to the glucose levels in your body. So it would see when your glucose was going up and going to rise sort of above this sort of setpoint and it would turn itself on. And then once your glucose was dropping and coming down into that setpoint it would essentially turn itself off and it worked on and off sort of all day long like that. From what I remember, it was in like the, the animal based studies, but since that time, I have literally heard nothing about it. So that's like It's like research. It's like we hear all these things. means and then there's no more news about it like where did it go? Did it get like shuffled off to Mars or?
Scott Benner 10:09
Exactly, there's the the most recent article I found online is from diatribe and it's from June of 2022.
Jennifer Smith, CDE 10:20
Okay, so not too long ago.
Scott Benner 10:23
Oral it's an overview of a smart insulin. The development of smart insulin options means designing an insulin that responds to glucose levels. Okay. We got it all that. Dr. Weiss distinguished professor at Indiana University School of Medicine explained to potential ways that glucose responsive insulin could work. Though we are still years away from smart insulins making their way to clinical trials, Oh, okay. We are years away from clinical trials. Right. Which means, what, 15 years?
Jennifer Smith, CDE 10:55
We're at work. We're nowhere near getting it into the human body to Yeah, yeah. So I think the answer to the question is, what we have right now is called Rapid insulin. It's much more rapid than it used to be years ago, and it was just regular insulin. But we're nowhere near smarter insulin that's more instantaneous, right?
Scott Benner 11:18
Like, reacts. Right? Yeah,
Jennifer Smith, CDE 11:22
it's just not.
Scott Benner 11:23
Okay. Well, sorry, Lisa.
Jennifer Smith, CDE 11:26
I know I'm sorry, to everybody. I that's just not an uncommon question. I've, I've gotten that a number of times, you know, when are we going to have insulin that just works now? And I don't have to wait and it does it faster. And it finishes when it says it's going to be done working? We I don't know.
Scott Benner 11:43
Yeah, sorry. Well, way to start off with a bummer. April wants to know, about hydration. She says she she hears people talk about it, you know, like they see a bad pump site or something or you know, blood sugar, excuse me, that's not moving. And people always come in and say, Hey, are you hydrated? Because hydration is super important. We've talked about in the podcast for a long time. What she wants to know is, how long does that take to work? Like she's saying, you know, say I am actually dehydrated. And that's the reason why insulins not working well. Is it a glass of water and I'm on my way is it I have to rehydrate my body and it's ours, I guess it would depend on how I would expect
Jennifer Smith, CDE 12:26
it's a min an average of about an hour to rehydrate. I mean, a good way to determine hydration is really the color of your your urine or your pee, right. So should be very, very mild, like a light lemonade color, if you will, right. It should not be dark. Now there are also some supplements, B vitamins and whatnot. If you take them, they can also sort of discolor the color of your urine. So that's not necessarily a good time to check. But, you know, hydration is where 60% of our body is made up of water, right. So if that's the case, hydration also means that all of the nutrients in your system that flow through your blood and need to get into the cells, they need, consistently moving bloodstream. If you are dehydrated, your body tries to pull water from other parts of your body to rehydrate and keep things moving. And so if you're not adding water back in, and you're more prone to drinking things that are more of a like a diuretic that are making you pee it out, but you're not putting it back in, you're more likely to be dehydrated, so with less fluid in the body, especially from a standpoint of a CGM. CGM is work off of monitoring the glucose in your interstitial fluid.
Scott Benner 13:55
Here's something interesting. This is NIH. Just a simple sentence. 75% of Americans are chronically dehydrated. That's it. Wow. That's a statement from October of 2022. Why is the dehydration so common? This is from Mayo Clinic. Sometimes dehydration occurs for simple reasons, like you don't drink enough because you're sick or busy or because you lack access to safe drinking water. So is this really just people just don't drink enough water? That's it?
Jennifer Smith, CDE 14:25
No. In fact, many people you know, a good strategy we talk about even in just general weight management is if you feel like you're hungry. Drink a glass of water first. Okay, most often, you your body is giving you a signal that you're misinterpreting right? You're actually not hungry. You're thirsty. So if you drink a big glass of water wait another 1520 minutes. Many people find that they're actually not hungry.
Scott Benner 14:53
Some early warning signs of dehydration include feeling thirsty and lightheaded, a dry mouth tiredness having dark colored strong smelling urine or passing urine less frequently than usual. What's now I want to know how often I'm supposed to pay.
Jennifer Smith, CDE 15:09
How often do you get to look up? How often should I go to the bathroom? Well, I mean, in general, six to eight glasses of water intake a day. And if you're hydrated enough, you should be probably going to the bathroom, every couple of hours, at least every two hours,
Scott Benner 15:32
bladder and bowel.org. Which I don't, oh, just the first one that came up. Not a number of normal urination is per day, between six and seven and a 24 hour period between four and 10 times a day can also be normal if that person is healthy and happy with the number of times they visit. So if you're not paying a lot, so then back to the person in question, I would think that rehydrating would have a lot to do with how dehydrated you are to begin with. True, right,
Jennifer Smith, CDE 16:03
right. Absolutely. You know, if you're just mildly thirsty, drink a glass of water, that probably takes care of it. But knowing as well that mild, even moderate levels of dehydration can also increase your blood sugar levels by a certain amount. And I know you've said it before, when we've talked about things like just higher blood sugars, like you force art and drink some water, drink some water and you can almost at some point, even without additional insulin, sometimes you can see a curve. Yeah, right. As you get things moving hydration that helps your body pass the sugar out of your bloodstream and you can actually pee some of it out if your blood sugar is high enough to need to do that. So yeah, hydration.
Scott Benner 16:53
Alright, I'm gonna add a little more here. How much fluid does the average healthy adult living in a temperate climate need? The US National Academies of Science, Engineering and medicine determine that an adequate daily fluid intake is about 15 and a half cups are 3.7 liters of fluid a day for men, about 11 and a half or 2.7 for women.
Jennifer Smith, CDE 17:17
Which means it goes right along with the recommendation of 60 glasses. Most people's glasses are about 12 to 16 ounces. So that goes it fits right in there.
Scott Benner 17:28
Is it the same not for children who on how much water should
Unknown Speaker 17:33
a child
Scott Benner 17:38
stay well hydrated children ages one to three need approximately four cups a day. Older kids five cups four to eight years old seven to eight cups for older children. Okay.
Jennifer Smith, CDE 17:50
And, you know, I think an important piece to bring into that too is that may be a baseline. This is just you in your normal day, right? If you are active at all, or you live someplace that is very hot, very humid, and you are active, it's very likely you need more than just the base of six to eight glasses a day.
Scott Benner 18:14
My so my daughter's home from college right now. Which means all of our girlfriends are starting to flood back in the house. Lynn, one of the girls is playing God. I hope she never hears this. Because I'm not which which is the one with the little stick. And field hockey, right? The little stick with a little curve at the end. Jenny's that field hockey field hockey, yeah. Okay, she played field hockey at college. And she's walking around with a jug of water all the time. And she's just constantly drinking and I think back to when my son was in college playing baseball, and the boys would all carry around like a one gallon jug of they were constantly drinking. Right? And these are the healthiest people I know college athletes so I don't mean I'm not I don't think I'm gonna grab a milk jug and fill it with water. But I am motivated from this conversation to do better, even though I better yes. Because I'm thinking about like, how much do I drink a day and does and by the way, let me ask you this. Does it count if it's not water, like
Jennifer Smith, CDE 19:18
you don't ensure you get some water from again it goes along with healthy eating right so you get some amount of fluid by eating fruits and vegetables because a good portion of them is made up of water. You know if you have soup that's not terribly salty. Sure that's made in a broth that is part water right? You can get it by drinking non caloric and like sparkling waters, right something like that. You're getting hydration that way. If you like herbal tea is or you know, decaffeinated tea or something like that. You're getting hydration that way so it doesn't have to be that you're drinking it eight glasses of plain old, no flavor water,
Scott Benner 20:04
right? But this doesn't count if I'm having a Diet Coke or a Gatorade or
Jennifer Smith, CDE 20:09
like the Gatorade would be hydration or it wouldn't be an electrolyte drink that they you know, Gatorade. What's the other one? Powerade. They give them to athletes, obviously. I mean, Gatorade was developed in Florida, if I remember correctly for the Florida Gators.
Scott Benner 20:25
That makes sense. I don't know that that's true. But I believe you. And but like, what about soda drinkers? Like I, I? I don't drink a lot of soda. Meaning that it's possible that a half a dozen times every two weeks, I have a small glass of some diet soda. Like you don't need me like I'm just not a soda drinker. But it's not I mean, I think we all are aware that soda is not good for us one way or the other. But am I hydrating when I'm drinking it?
Jennifer Smith, CDE 20:54
Yeah, you certainly are. I mean, there's a portion. I mean, it's not just like I hesitate to say this, because most soft drinks that are sugar in are like drinking liquid water, but are liquid sugar. But why is it liquid? It's liquid, because there's, there's water, there's fluid in it, which does provide you with some hydration, despite the fact that the other stuff that's in it isn't good for
Scott Benner 21:22
it a little like I come up on my home is burning. And I find a bucket and it's half water and half gas. And I'm like, Well, I wonder what will happen here if I just throw this off. So you're getting you're getting hydrated, but you're also getting a lot of stuff you don't need don't need and don't want. And correct
Jennifer Smith, CDE 21:41
and some of some of these beverages, too. could certainly be more of it what's called a diuretic, right? Which just encourages you to actually go to the bathroom even more than you would normally go to the bathroom. Which means that you have put back in what you
Scott Benner 21:55
sow coffee. Do you drink coffee? Yeah.
Jennifer Smith, CDE 21:57
Um, yeah, I like coffee.
Scott Benner 22:01
I've never had a cup of coffee in my entire life. So I'm outside of my
Jennifer Smith, CDE 22:05
you've never had a cup of coffee. Never. I don't think I've well other than kids. I don't think I've ever met another adult.
Scott Benner 22:14
No, I just my parents drank so much of it. And I can smell it still. It was terrible. And I associated with cigarettes too. Because it's always like a coffee and a cigarette for my father and like I just not interested. But my point is, is don't something's dehydrate you even though they're liquid, like alcohol dehydrates you. Right.
Jennifer Smith, CDE 22:34
Yeah, I mean, in many cases, it's really the caffeinated effect, right? That is more of a diuretic, which is the reason that if you really want the complete hydration, you're going to do things that are not full of caffeine. So you know, the typical dark cola based sodas, regular coffee, again, have a tendency to have more of a sort of a mild diuretic effect. Okay,
Scott Benner 23:01
because I had I recorded today before you, which I feel like I'm cheating on you. No, no. I had a cup of tea, and a glass of water with me. And I couldn't drink the tea because the tea was driving my mouth out. And I was like,
Jennifer Smith, CDE 23:20
oh, black tea. So it was a caffeinated
Scott Benner 23:22
tea. Yeah, it was and so I had to get away from it while I was drinking. Anyway. I just Googled Why does coffee make you poop so we can round out this conversation? Because because this is a integral part of some people's lives, right? So coffee sends a signal to your stomach to release gastrin this kicks off a wave of cause of contractions in your gut called PERS WHAT THE HELL peristalsis Thank you. It moves that that thing Jenny said moves food and liquid through the intestines. For some people. This leads to a trip to the bathroom in just a few minutes. Get me here seriously? Now when you go I mean next time I have to go maybe I'm gonna. I don't know. Then you need some coffee. I don't think I'm doing that. I really don't think I can. This one. Make sure it's good coffee. Well, what's good? Some people tell me Dunkin Donuts is amazing.
Jennifer Smith, CDE 24:19
How do I if I've heard the same thing? I mean, I can say that Dunkin Donuts is to me, it's okay coffee. I have grown very accustomed. After having lived in DC. I've grown very accustomed to like coffee houses that do their own roasting like in house. Okay, like I consider that good coffee.
Scott Benner 24:43
Is coffee and cigars kind of in the same vein. Like I don't know. Maybe. Have you ever smoked a cigar?
Jennifer Smith, CDE 24:49
I've never smoked anything in my life.
Scott Benner 24:52
Anything through it. Cigarettes. No cigar. No crack. Okay. Nope.
Jennifer Smith, CDE 25:00
Marijuana No, nothing I have never has anything passed my lips. Now I've probably and I'm sure I've inhaled quite an amount of secondhand smoke. In fact, I'm quite certain in my freshman year in college, my roommate who would smoke out the window, not cigarettes. I inhaled a fair portion of marijuana. Yeah.
Scott Benner 25:30
But as I get older, I just keep waiting for it to come get me the secondhand smoke. Because my dad, my son and I were talking about the other day. And he said, your dad smoked a lot. I said my father would smoke three packs of cigarettes a day, three packs of unfiltered cigarettes every day. And I mean, he would open his eyes in the morning, and light a cigarette. He'd have it in the bathroom with him. If he took a shower. He had it right till he got into the shower. If he was driving, if you if you got to a if you got to a restaurant, and they didn't allow smoking, he sometimes couldn't make it to the meal. He'd have to go outside. Like it was, like really bad. That's yeah, yeah. And he still I know him seven days, by the way. So
Jennifer Smith, CDE 26:18
I know it takes I know, it takes a certain number of years to recoup. I mean, the body is a self healing machine, right? As long as you don't continue to batter it up, was only
Scott Benner 26:33
around me till I was 13. So okay, maybe.
Jennifer Smith, CDE 26:36
So maybe you've got a lot of healing that's taken place and your lungs are back to a base.
Scott Benner 26:42
I also had a crappy job when I was a teenager. So I don't know what I buried there. But anyway, I just think about it all the time. I'm like, This is what's going to happen. I'm not going to even drink a cup of coffee. I'm gonna end up with lung cancer one day. You don't I mean, this is my Yeah, I know what'll happen. Alright, we've gotten way off the hydration path anyway. Drink water. Drink water. Yeah, it'll make. It'll make your insulin work better, and it will make your CGM more accurate.
Jennifer Smith, CDE 27:07
Well, and I think you brought up a good point, if I'm going to plug for not doing something the not smoking thing. Yeah, there you go.
Scott Benner 27:16
How much? How much more dangerous is smoking to a person with diabetes? Like what are the added risks?
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Jennifer Smith, CDE 29:53
well, many of the things have relative relevance to what smoking does to the blood vessels which we know that So we already are at risk with increased potential for damage to our vessels and to our nerves and to how our body reacts to stress. Smoking creates inflammation in the body. And those are all the things that we're trying to bring down by having optimized blood sugar levels. So it's like, You're doing all these wonderful things to manage your diabetes. But if you're also smoking, that's kind of putting some of those. It's counterproductive. Thank you.
Scott Benner 30:31
Also, you have an autoimmune disease. So inflammation is already coming for you. So yes, no reason to give me a helping hand. I don't think this one is aimed towards me, but doesn't mean we can't talk about it together. PIPA asks. Oh, oh, that's nice. I'd love to hear more about how we moved art in from relying on a school nurse to directly communicating to me, How does she know when to Pre-Bolus? Does she have alarms on does she rely on her alerts? How does she handle texts in class? Does she wear a watch? What's your process? If she misses a text? How old was she when she was able to treat her own lows? What's your field trip? Protocol? Cheese? pipa. All right, hold on. Does she carry an extra pod with her? Let's go through it one at a time. Cool. Well, I can tell you that, you know, the story of you probably know if you've listened long enough is that I realized in the summer between art in second and third grade year that I could manage Arden remotely, which had everything to do with me and nothing really to do with her. She was capable of like receiving a text and carrying out a thing in a way that I could trust. So I don't think the age is important Arden's age, I think it's Arden's ability, because if you're translating it to your kid, you know, kids are gonna be analyzed what your kid can do. 100% So, one day, I just was lazy. I didn't feel like walking upstairs. She was upstairs. And I texted her to Bolus and she did it. And I was like, oh, like, why? Like, I can imagine diabetes in my head. Now, if you don't I mean, like, you know, I don't know, like, one of those movies like beautiful mind or something. I have no idea which ones I'm thinking. I can see her blood sugar in my head. I know how much insulin is happening. If I know what she ate, I can reasonably manage her without being with her.
Jennifer Smith, CDE 32:25
And you have the benefit of looking at a CGM, as well, you're not guessing. Well, her blood sugar was at 615 minutes ago, and she was down here. I don't know if it was going up or down. You've got to CGM to be able to see where is she? I can easily text her and tell her because you also know the context that's going into the trend.
Scott Benner 32:43
Yes, but back then no. Like back then, oh, she didn't have a CGM when she was that night. Yeah, it was just coming at where it couldn't share by then. We might have a follow, we might still have it in the G four. Is that the the egg receiver? So?
Jennifer Smith, CDE 33:00
No, the Ag receiver was? Seven. That was the seven. Yeah, the seven system and then it went to the G four. And then it went to the G five and then it went to the G six.
Scott Benner 33:12
What a naming system Dexcom way to go. And so fancy back then they were probably just like, here it is. But But anyway, I realized I could do it without being with her. And that the only tripping point for me was my own fear. Because I kept thinking like, why would I do this. So we just started practicing in the house. I would just text her diabetes. Even if she was just in the other room. I was really practicing for myself. And then she went back to school in third grade and stopped going to the nurse because of that. So she could test she could send me her blood sugar's she could look at a CGM. Once it was available telling me the number that was on it. I just kind of bounced it all in my head. Did that make dependent? No.
Jennifer Smith, CDE 33:58
I think another question within that, which is sort of implied in a way here as well might be, how did you navigate that with the school nurse and the system? Right? How did you navigate saying, We've got this? These are the hit points that you have to know being the school nurse. And if needed, you would step in, but otherwise, please hands off because we have this Yeah,
Scott Benner 34:26
I might go to was usually just I just assumed they didn't really want to be doing it. And that they didn't really want to be responsible. Right? Like if you gave a school the choice between being responsible for somebody's blood sugar and not I figured they would rather not. So what I told them was, it's on me, like if something goes wrong, I did it. You're not at fault. And they were like, cool, and that was the end of it. So we did re kind of massage what what my expectations were from them. And from there, and we adjusted her 504 plan for it. But really, I have to, it sounds cynical, but the idea that they weren't on the hook anymore, I think was attractive to them. It's just always kind of how it felt to me.
Jennifer Smith, CDE 35:13
I wonder, you know, having worked with so many families, I have heard probably a good 50 different ways that school systems will or will not let things happen. I mean, whether or not they prefer to be doing it, some school systems really seem to have this, unless you don't tell them your child has diabetes at all. They have a plan that has to be followed, and much of it relies on the kid having to check in with somebody at some points in the day. So and it's hard because that many people probably want to do what you're doing.
Scott Benner 35:53
Yeah, I would, I would say that. I am not, I am not wildly different in my personal life than I am on this podcast. But I am more direct and ne than maybe some people are, and I don't be, I'm not pushing you. I'm direct. I'm like, This is what's going to happen. And then it's not open for conversation discussion. Yeah, and not in a mean way. But just, I don't leave. I think that it's, I kind of think of everything as a negotiation. And if you stop and think about how to negotiate anything, the last person who speaks wins. And so if you don't set the conversation up, where the person across from, you can respond, you sort of win by default. I don't know. That's a little. They, you know, I don't know, that might be outside of what people are comfortable with. But you have to be comfortable in the silence. You have to be comfortable saying this is what's going to happen. It's not open for discussion and be able to sit there without feeling because as soon as you feel the thing in your chest, it's when you give something up. You go okay, and then you get nervous and you give something away. And then it goes back and forth. And before you know it, you walk out you don't have anything. So anyway, going through her. How did Arden know when to Pre-Bolus? Well, that was easy. I set a lot of timers on my phone. And in the beginning, Arden had those timers on her phone as well. So her timer would go off and then we would text each other. And I'd say What's your blood sugar? If she had to test she test? If she had to tell me what was on her CGM? She would tell me and then I would just you know, say, Okay, what's Bolus this much right now Arden was using on the pod and you know, we didn't let Arden go to school on MTI. So she's been using Omni pod since she was like four, four and a half like right before she went. So that's how we did Pre-Bolus thing. It answers the question about weather alarms. How does she handle texts in class? Arden handles texts in class the same way you hear me say? Like, what I just said, basically, this is a necessity for her. We're not embarrassed by it. She wasn't, you know, she she didn't try to hide it. I mean, she doesn't love. Like she was still a kid, you know, like she wasn't looking to be texting with her dad and stuff like that. So we also kept it to a real bare minimum. Sure, yeah. That was that was that she just never want to watch. If she misses a if she missed the text, and it was, what's the process if she missed the text, depending on the context. So if it was important, or emergent, then I would go from texting to a phone call. And if the phone call didn't work, then I sent a find your iPhone signal, which is very difficult to ignore. If that would have cascaded through then I would have called the nurse's office. Sure that would have been the the last thing. How old was she when she was able to treat her own Lowe's, that was your husband, he just walked in, saw you were doing something and walked right back? He got this look on his face like oh, no, not now. And then. I don't know the answer to that question. How old was she when she was able to treat her own lows? I mean, I guess she was in third grade. Because
Jennifer Smith, CDE 39:16
I wonder if it's a little bit more depth of the question in terms of most kids can when told treat your low blood sugar by someone? They do it without question. Well, many times without question, right? They'll just eat or do what they need to do because they've been told but I think the question is really asking, would she treat her lows by acknowledging and alarm that went off on her CGM without you having to follow up and text or if you did texter, she said, I've already got it.
Scott Benner 39:52
Yeah. Oh, so if that's the question, when did I stop wondering if this is not happening? Like it's She's not handling this. Hey, I don't know, I still want her son.
Jennifer Smith, CDE 40:04
You still wonder? Right? That's
Scott Benner 40:05
a hard thing to shake, you know? Right. But I
Jennifer Smith, CDE 40:08
wonder, you know, well, if she was playing with a friend and you saw her blood sugar was where it shouldn't have been, or it was dropping fast or whatever. What age would she have already taken action on that? And said, Dad, I'm fine. I got this.
Scott Benner 40:25
Yeah, I think the answer is I don't think the answer is that clear. I, as far as timelines go, I think that I've always I mean, since we've had a CGM that shared, like Dexcom does now. I'm fairly aware of hardens blood sugar all the time. You know, like she's in college, and I'm still fairly aware of her blood sugar, you know?
Jennifer Smith, CDE 40:46
Well, you've got follow and you've got all the things to be able to watch. I mean, most parents do. So I have a
Scott Benner 40:51
lot of things on my computer. I don't even know what this is called. But I have a pulling it up. See if I can figure out what it's called. Oh, actually, it's just I have sugar me on my desk. I was gonna say sugar me. Yeah. So up on my I've a Mac computers, but up on the on the bar. Artists blood sugar is there along with
Jennifer Smith, CDE 41:14
the trend arrow? Yeah.
Scott Benner 41:15
Yeah, everything that it needs. So that's there when I'm working. But the question about when does she? So I think when she was 12, like 1011 1213. If she felt low, she would have done something. The alarms, I'll tell you, Arden and alarms. The you know, like, I don't know. I can't tell.
Jennifer Smith, CDE 41:38
Did she ignore them more?
Scott Benner 41:40
Well, how about the other night, her CGM just shuts off after she's home? And I'm like, What do you How did you? How did this happen? I'm like, it tells you all day, it's shutting off in six hours. It's shutting off. He says he'd never said that. I was like, You're out of your mind? Of course it did. No, it didn't. I'm like, Yes, it did. And so you know, like, I
Jennifer Smith, CDE 41:59
promise, that's how it's set up to do it.
Scott Benner 42:01
She swipes things away so quickly, she doesn't even know what they are. What I will tell you is that my confidence level is at an all time high, as she was learning to drive. So when she got her when she got her permit, we had a really serious conversation about that. And since then, so I guess 16 and a half right in there. I don't think about it as much anymore. Like, I know she's paying attention to it. Does she push her high blood sugar's down? As much as I wish she would if I don't bother her. Not always. So, you know, there's that. Let me just get this last little question on here. What was our field trip protocol? I went on the field trips. Does Arden carry an extra pod with her? No. The way we handle extra stuff is at school, there was supplies, but not a pump, but but not insulin. And then if she needed a pod change, I would go do it just didn't happen that often. And we didn't like leaving insulin at the school. But I guess we could have she easily could have changed it on her own. And
Jennifer Smith, CDE 43:15
now you also though it just for context, you also live pretty close to her school. So it was convenient, right?
Scott Benner 43:21
It's a couple of blocks from my house. So if if she if it was farther than I would have put insulin in the school, but I always was trying to give Arden the feeling that that that the nurse's office was not a place that she belonged. I don't know if that makes sense or not. But like I never wanted her to feel like oh, I have diabetes. So I'm one of these kids who's always in the nurse's office. Like I try not to give her that feeling. Sure, in regular life, there's like a distance in my head. If we go to the mall, it's 20 minutes away and doesn't carry supplies with her. If a pod blows up, we'll drive home. Once the drive becomes irritatingly long. You know, you go into somebody's house, it's 45 minutes away than we bring stuff with us. So
Jennifer Smith, CDE 44:05
that's well and in context there. You know, you're going to the mall, who cares if you have to drive 20 minutes back home, you're going over by a friend or something that's more of a lengthy social kind of setting. Bringing it along as in, in I guess your best interest because otherwise you're going to ruin that event. Right? Not not for the other people but for yourself and why? Right? I just have to go big just grab it when you walk out the door and just take it along.
Scott Benner 44:36
Now that she's getting older. And I'm not always with her college. Now there are times when she goes somewhere. She takes stuff with her because for that same reason because there's not a person who's just like, oh, well, I'll bring it to you right now. And that's been pretty important
Jennifer Smith, CDE 44:52
or it's a bus ride across town in order to get back to where she needs to get back to to get her stuff and then a class might be missed in the inch. You're on there. And that's not purposeful either.
Scott Benner 45:01
No, no, it definitely has a lot to do with her age and, and the amount of people who are around her to help her. Oh, cool. Cool. Let's see if we can find another one here. That doesn't make any sense. Molina I'm sorry. Does a blood transfusion impact your blood sugar?
Jennifer Smith, CDE 45:24
Oh, that's a really good question. I think we're gonna I know I can answer a question that often comes up outside of this one is, can people with type one donate blood? Yes, you can. Okay, so but blood transfusion? That is an interesting question. So what's your what answer do you find?
Scott Benner 45:47
I'm looking right now because my idea is it must. Right if my blood sugar was 200. And you infused me with some blood, that sugar was an ad? Wouldn't my blood sugar go down? But would it go down that much? Does a blood transfusion or this one? Or, or change I guess impact? I mean, my guess is it's not enough for that matter. You don't I mean?
Jennifer Smith, CDE 46:17
Yeah, there's a correlation between blood transfusion and blood glucose.
Scott Benner 46:23
Yeah, blood transfusions of bank blood products are blamed as one of the causes of hyperglycemia because they are stored in
Jennifer Smith, CDE 46:31
a glucose solution probably. Or they have glucose added to them within the other additives.
Scott Benner 46:38
I mean, I could try to say these words, anticoagulant citrate phosphate dextrose, then I mean, add it. Yeah. Good job. Good. I get through that a little bit. So here's the answer. It looks like yes, it could make your blood sugar lower. It looks like
Jennifer Smith, CDE 46:53
it could make it higher heart rate.
Scott Benner 46:55
Yeah. Conclusion we conclude the blood transfusions does not cause significant changes in blood glucose levels in the study. That's from NIH. And the question was, does sugar level increase after blood transfusion?
Jennifer Smith, CDE 47:13
But not a lot? Yeah.
Scott Benner 47:16
Does blood transfusion affect your agency? The effect of blood transfusion on a one C levels might be summarized as follows. And patients with pre transfusion a one C levels of over seven, a one C tends to fall at once, even when your agency is under seven, it rises minimally or not at all. I mean, it sounds like it has an impact, but not not a great one. And if it does, it might be on the lower side. I don't know that's a lot of information. That doesn't look like it's studied that often either. No, because here's another one, the dextrose and bank blood products does not seem to affect. So here's the answer. All the answers you can think of somebody says
Jennifer Smith, CDE 48:04
yes, it can. No, it can't Yes, by just a little bit. So in general, I would draw out of this, that it could have a minimal effect. But minimal is the important piece there that you're not going to have this exorbitant rise or drop in blood sugar because of a transfusion.
Scott Benner 48:24
Yeah, that would be okay. That was interesting. Here's one looping. Oh, God, we're up on time. Are you okay? I have five minutes. All right. One more looping. Helen asks, what are the settings that most often need changing when starting to loop? And more or less aggressive? Okay, so this is, I mean, I don't know about when you're starting? Like, I don't think there's an answer to that question. Right. You gotta get your settings, right. And then once they're right there, right, but I'm gonna go from the, from the perspective of once you have good settings, what do we touch most frequently? Because Arden's a girl, and she has fluctuations from hormones. I would say that most frequently we touch insulin sensitivity. And basil. Those are mine. What do you think?
Jennifer Smith, CDE 49:17
Yeah, I would agree. I think, as you said initially, starting with settings that are optimized before enabling any algorithm driven system, including loop gives a good base for the algorithm to then work for you. And then once you have been using your current settings, and you use loop or with loop, you probably need a good week or two to compare to the previous two weeks of CGM data and see what looks a little bit different, right? More Most common, I would say honestly most common is ISF or the sensitivity factor the correction factor, which honestly gets under adjusted in manual or conventional pumping, oftentimes the correction factor, it's like this poor little like, in the middle of nowhere, but I'm not going to consider it factor. And it doesn't get adjusted, we're probably needs to much more heavy we adjust the basil and oh, we might look at the insulin to carb ratio is but your correction factor it's not even talked about. I've even talked to many people who are like, I don't even know what this does. That's the purpose of this setting and my pump, right. But when you loo, yeah, it heavily relies on how sensitive your body is to the insulin that you have present, that it can readjust. Its predicted glucose and, and the outcome from everything that it knows about what it's given you so far.
Scott Benner 51:09
Yeah, I could make it. I don't know if I how right I'd be. But I can make an argument that your sensitivity might change meal to meal can be you know, if you're varying greatly on the kinds of foods you're eating, if you went from a salad today to, you know, chicken wings and fries tomorrow, I can see where a heavier or more aggressive sensitivity would help the french fries. And it's just, it's a weird,
Jennifer Smith, CDE 51:35
maybe too aggressive when you eat the salad, or eat the broccoli. Right? Yeah. And, and the more true image of physiologic sensitivity would really be eating clean, not terribly high fat, you know, eat a nice salad with, you know, maybe a little bit of like salad dressing on top of it or something and get an idea of how if you did get a high blood sugar? How was loop working to help you with that rise? Does it cost you back down to your target? Do you settle out there, right. And if not, then looking at another meal that did work out one time of day. And the next day, you had the chicken wings and the French fries, and doesn't look like it's working at all and you're beating it down with extra, like fake entries? That's probably not really relative to your setting being wrong. It's relative to loop working against something that's so resistant. Yeah,
Scott Benner 52:36
yeah, that's the that's the mind space, you have to put yourself in like your settings are great. If you're not, you know, for general days, if you're not over taxing, suddenly, when you over tax with a a tough meal, the settings aren't going to work for it. But we can't think about that way because people can't be changing their settings constantly. So that's when you have to start saying, Okay, I see that this food falls into a different glycemic load or index scenario, and it's just going to need more insulin than on a regular day when I'm not eating something so difficult. That's where the that's where the understanding comes in. You don't have to move settings. This person is talking about what settings move. I mean, around like I said around hormonal stuff. I like Arden's basil. I mean, I try to keep Arden's basil in a place where I don't see the algorithm having to constantly take it away or constantly add more right, you know, right where the basil seems to be working. And in the moments when it doesn't work. The adjustments that the loop has available to it are such that it can stop spikes and lows. Makes sense. Yeah. Okay. All right, Jenny, I appreciate you doing this with me today.
Jennifer Smith, CDE 53:46
Always. Absolutely. Thank you. Okay, have a good day.
Scott Benner 53:57
A huge thanks to all of you for sending in these questions. And of course to Jenny. You can find Jenny at integrated diabetes.com If you would like to hire her, she does this for a living. I also want to thank I'd also like to thank the Contour Next One blood glucose meter and remind you to go learn more about it at contour next one.com forward slash juicebox. And of course, touch by type one.org find their website and check them out on Facebook and Instagram. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast don't forget to go find the private Facebook group Juicebox Podcast type one diabetes, always free 34,000 members and counting. If you're enjoying the Juicebox Podcast, please share it with someone else who you think might also enjoy it.
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#844 Would You Change Your Past
Fletcher has type 1 diabetes and discusses some deep thoughts.
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The Juicebox Podcast is a free show, but if you'd like to support the podcast directly, you can make a gift here. Recent donations were used to pay for podcast hosting fees. Thank you to all who have sent 5, 10 and 20 dollars!