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

#1014 Diabetes Pro Tip: Glucagon and Low BGs

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

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

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

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

Unknown Speaker 6:13
has changed

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

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

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

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

Scott Benner 10:03
is just one of those things

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Scott Benner 30:47
Try some other stuff first.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Scott Benner 48:11
Yeah, you might be maybe

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

#1013 Diabetes Pro Tip: Illness, Injury and Surgery

Scott and Jennifer discuss getting ready for a hospital stay with type 1 diabetes.

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

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:04
Hello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CD and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisit double. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. While you're listening please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have an amazing offer for you. Right now at my link only contour next one.com forward slash juicebox free meter you can get an absolutely free contour next gen starter kit that's contour next.com forward slash juice box free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries G voc hypo pen. Find out more at G voc glucagon.com. Forward slash juicebox. J Let's do a big Sick Day episode. And so I'd like to try if we can to get through sort of a regular sick day like you know, little beyond the sniffles the the flu a stomach virus, an injury like a broken bone or something I might have to take, you know, steroid for and then an actual surgery and have you where do I want to start? You've had a surgery pretty recently, haven't you?

Jennifer Smith, CDE 2:50
I've had multiple surgeries. I've had a week surgeries I've had I've been out surgeries. I don't like surgeries. But I've had them. Yes.

Scott Benner 2:59
So let's start there a because you got good information about it and be because Arden is going to have a cyst removed in a couple of weeks. So I'd like to hear about this. So let's start with something you were awake for. I guess also, like dental procedures would probably fall in this category a little bit maybe, maybe not,

Jennifer Smith, CDE 3:20
they could they would be a little bit different only because like a dental surgery if you're going to be awake for it like just a tooth removal or something like that. Usually, the awake component to it means that you don't really have to go in fasting or without any food in your system, you know, those kinds of things. If it were going to be a no now, they usually try to take all the wisdom teeth at once if they're going to do that. And oftentimes now I've heard a lot more people being completely put under my son was for wisdom tooth, you know, extraction, I didn't I my dentist said Your mouth is not big enough. You need to have your teeth come out, but there's nothing wrong with them as they come in, we're going to take them out. So as my teeth kind of came out and honestly my wisdom teeth didn't completely come through until I was well into my 20s and so they just took them out in office.

Scott Benner 4:25
I mean, I'm gonna make a note here to myself, because it has nothing to do with this. But my wisdom teeth extraction story is absolutely insane. And I will tell it at the end. So why don't we just made a note to myself. So okay, so if I'm just going to the dentist to have a cavity down or something like that. Not a lot for me to do probably handle things the way I normally do. You know, I guess

Jennifer Smith, CDE 4:49
your big thing to make sure is especially if you're new to having it done is and you've never had any like pain medication. No, you may experience a little bit of a higher blood sugar, potentially a stress component from having like the Novocaine. I mean, that needle is, it's scary, it's a scary looking needle that they're shoving in your mouth, right. And it doesn't feel very nice either, as they inject it several times. So for those of you know, those people who have never had this done, I, it's not very fun. And if you ever do have to have it fun, done, it's not a fun thing. But it could cause a rise in blood sugar because of a pain component, because you're just in a setting that's completely not under your control. So, but other than that, yeah, you shouldn't, you shouldn't have to go there fasting, or make any true adjustments to anything. You know, in the future, if you had a second surgery, or a tooth extraction or tooth work, and you knew what happened the first time, you could potentially look back, and maybe make adjustments like setting a Temp Basal increase, or taking a small amount of Bolus ahead of time to offset arise if you don't want it, or just correct after if you're not quite sure what's going to happen.

Scott Benner 6:07
Yeah, especially I'm thinking if, you know, if you're trying to, I'm not usually up for like, run high to avoid a low kind of situation. But if it's an hour, an hour and a half, and the dentist office, and it makes you comfortable, you know, let your blood sugar be a little higher for that. And then and then get at it. And because I guess too, if you're numb, taking in juicer gel or something like that could end up so you don't want to be in that situation be harder.

Jennifer Smith, CDE 6:29
Exactly. Yeah. So it's it mean, in some things like that, it sure it's a little bit safer to potentially be a little higher, if it does end up rising. I mean, obviously, don't go in at a blood sugar of 250, just because you're scared. But if it rises up, you know, higher than you'd love it to be, again, an hour hour and a half of being too high, you can correct it after without worrying that things are going to drop too much. And you can't chew anything, then that's okay.

Scott Benner 6:56
So this is so funny, I'm going to ask you, when I say leave it a little higher, I have a number in my head, what's your number?

Jennifer Smith, CDE 7:03
Let's say a little higher would be like 180 ish. Yeah,

Scott Benner 7:06
I might be insane. Actually. It's like, I was like, he could comfortably be 35 ish in there, I don't want to get crazy, that thing starts drifting to 160, I got a fight with it, then you know. But the point is, is wherever you feel like you can keep the control. And if you're real stable, that could just mean like dialing your Basal back a little bit to just let your blood sugar kind of come up a little bit, you might not have to eat something to make it happen. Okay, so that's simple. Now, moving on to the kind of the next step of it. Wisdom teeth knocked out cold. Now, I do know this from my son, if you get a good doctor, you're only under a very short time. But when you come back, you are not in any shape to make decisions. drink, eat, my kids said some crazy stuff on the way home from that doctor. And then even once his head cleared out, which I have to admit, didn't take too long. He's bleeding, his his mouth is packed with gauze and everything. So I guess we're in are we in that situation, now we're better high than low,

Jennifer Smith, CDE 8:12
it would be better than to be I mean, again, in that case, you know, if you went into that surgery to be put out and your blood sugar was nice and stable, let's say 120 even, it should for the short amount of time of that type of a procedure, it should remain stable, or it might climb again, from the stress on the body. In the aftermath of that, though, again, it would definitely be better to be a little bit higher than you're typically running. And again, I'm not saying like 180 200 High, obviously, you could correct to bring that down safely. But if you're running like 140 Leave it i that there is no detriment there whatsoever at 140 You know, as long until you can take something in or start to eat, or, you know, whatever the dentist told you for when you could start to eat again. I mean, even with my wisdom teeth being taken out one at a time, I think there was I think I had two taken out the first time it was a bottom and it was a top wisdom tooth. And I remember a couple of days of like just soft it was you know where the chewing component just was not pleasant. So having a plan of action to just like any other sick day kind of thing, having some things ready to go especially if you're an adult and you're taking care of yourself. You know having some soup or some broth or some jello or yogurt or popsicles or even ice cream or whatever it is that you can tolerate soft enough don't have to chew it that you can get something in.

Scott Benner 9:46
I think that I think that my as I'm thinking about this happening for Arden next year, probably my plan would likely be higher, not so high that it could get away from you higher but control And then if it tries to move, just kind of keep tamping it back down a little bit like so that you're in the power position, right? It's not out of control high. So that you're, you're going, Oh, geez, I have used a lot of insulin here. And it's not low, just you know what it tries to come up, push it back down, like, play, play that game for a little bit. So you've got the level you're looking for, but you're still reasonably in control of what's happening. I put yourself in a power position there, I think that's happened to handle it.

Jennifer Smith, CDE 10:25
That's correct. Considering the fact that as we've said before, the littler incremental adjustments sooner mean less insulin sitting there to potentially dump you down to low later. And then a setting where you can't actually take anything in, whether it's a mouth surgery, or this might even move in to kind of like stomach bugs or those kinds of things where you may not be able to take anything in or not quite sure when you can take anything in. It's it's certainly better to nudge little by little rather than take this big walk being adjustment and then you can't eat anything to offset.

Scott Benner 11:01
Yeah, I think bumping is the nudging is the way to go. That's i So as I'm considering it right now, for the first time talking to you. And when artists wisdom teeth come up, I think that's definitely what I'm gonna do. I'm gonna shoot for 140 in that range, take your advice over my advice, maybe more like 141 50. And then just keep knocking it down. If it's if it tries to run away, basically, just kind of keep tripping it as much as it tries to get up, I don't know.

Jennifer Smith, CDE 11:29
And find out ahead of time what her favorite soft or cold things are, so you can have them ready.

Scott Benner 11:34
Well, yeah, the pre like, you're gonna have to prepare, right? Like you're gonna hate. This is not something you're gonna want to think about after the surgery is over, you're gonna want this stuff

Jennifer Smith, CDE 11:41
like parking lot of the grocery store while you run in and be like, What did you want to get in her mouth is full of gauze. And she's like,

Scott Benner 11:49
I can't get her to pick food when she's not sick or injured. Like we were at the grocery store yesterday. I'm like, you just grab a couple snacks for lunch, whatever you're looking for. I don't know, you decide. And I said, How about those? She goes, No. And I went, Well, how are you going to tell me the side? And then I say something? He told me? No. I was like, what if I grabbed something that cheers if you show it to me, I'm gonna say no, if you bring it home, I'll eat it. And I went, Oh, that's a reasonable understanding of your psyche. I was like, Okay, great. So I did anesthesia impact at all.

Jennifer Smith, CDE 12:19
So some people, myself being one of them, not only do I have experience with surgery I've experienced with anesthesia, not my body doesn't like it. So again, if you're going into something where you've never had any anesthesia whatsoever before, just be aware that it can cause some like, post operative nausea. Many people get a little bit like woozy headed, I myself just don't tolerate it at all. I talked to the anesthesiologist ahead of time, I say, you need to load me up with whatever tools you have. Because I will probably throw up on the nurses when you get me awake. And there's only literally been one time that I had a I had a hernia surgery and umbilical hernia. And, man, if I could carry that anesthesiologist around in my pocket, if I ever needed surgery again, and his little toolkit of medications, he used post surgery, I was golden. I didn't feel horrible. I mean, you know, normal, but not like nauseous, whatever. So anesthesia can cause some nausea. So just be aware of that. If you know that's an issue, again, talk to the doctor about it ahead of time, there are many different kinds of medications they can use to stop that. And it depends, you know, on post surgery, sometimes they'll try to get you to nibble or drink a little bit of something in the post op when you're you know, recovering waking up. You can also be really really woozy, like in and out of like waking up and then getting really drowsy again and that it takes for everybody it takes a little bit of time to wear off. Usually in a post op setting. They'll probably have you in recovery for at least an hour. It could be longer than that, depending on how you seem to be doing. So it's I've always brought somebody along who knows how to look at my pump, how to potentially do a finger stick for me even though the nurses there could definitely do that for you. So my mom has come to a couple of my surgeries. My husband was there obviously for both C sections that I had. So it's really really really advantageous if you've got a go to person to be there after

Scott Benner 14:43
so funny. I alluded to this while we were recording recently, but you I have a question that's on the tip of my tongue. And if you would have paused I would have asked what you said. I'm like, one of us doesn't need to be here. I'm afraid it's me. So I was gonna say Did you wear your pump? And yes, you know, how did you take control of it? What did you do? So, as long as you were coherent, you were doing it?

Jennifer Smith, CDE 15:09
Correct. As long as I was coherent I was doing it's also really an ahead of time for any type of surgery. I mean, again, like a dental all kinds of things. Dentists could probably really care last as long as things are okay and controlled when you come in. They may if they know you have diabetes, they're definitely going to ask when you come in are your sugars, okay? Are they control? Are you feeling well, you know, whatever, they're not going to know anything about telling you to do or dial back or dial up or anything that's a dentist, people, doctors, though, will be more involved will be more involved. And they think it's really important thing to talk ahead of time,

Scott Benner 15:49
right? Because they're as a default, gonna just err on the side of I'd rather see your blood sugar be 300 for the next couple of hours, they're always going to feel that way. They don't really want to be managing your blood sugar. I really don't. Yeah, I've seen this now in multiple people in my life type two type one, you know, all the way down to my my friend Mike, who was in a, you know, in a coma at the end of his life. And they nobody would nobody? Gosh, I don't want to say they care. They didn't care. But it was a problem. They they weren't prioritizing, I guess, you know, it was a

Jennifer Smith, CDE 16:24
secondary issue. Yeah.

Scott Benner 16:26
They think of it that way.

Jennifer Smith, CDE 16:29
They're they're concerned. I mean, from the medical standpoint, in fact, if you don't address the fact of staying on your pump, and keeping your CGM on and whatnot, as long as you can keep them on, there are some medical procedures that include machines in the operating room that could potentially require you to be off of your products, just from a machine. I guess, interference standpoint, there may definitely be some things, there may also be length time of a procedure or a surgical procedure that determines you need to be on an insulin drip versus being left on your pump. So you know, those kinds of things, there is a definite difference. But for shorter lived surgeries. If you go in with your team, and you talk to them, and you say hey, you know, you know that I'm on an insulin pump. If you've got backing of your Endo, you can have your endo write a letter of approval for you to remain on your pump and your continuous monitor through the surgical procedure. Your doctor may even include in it, you know, glucose levels, we've, we've discussed, she or he will come in with a glucose level here to here, she or he will have a temporary Basal adjustment set, many doctors are a lot more conservative than you need to be for surgery. Many doctors will say dial the basil back by 50%

Scott Benner 17:52
just seems like a lot, again, which is a lot.

Jennifer Smith, CDE 17:55
And for most people again, there are the rare people who have a drop in blood sugar from that stress impact and whatnot. But it's not common. It's more common for stress to cause a rise in blood sugar. So, you know, dialing basil back kind of goes back to some of our other episodes about like testing things. If you're going into surgery, first thing, they will usually have somebody with diabetes on insulin, have surgery first thing in the morning, they will not push it into the later afternoon or the evening, mainly because they'll want you to come in in a fasting state. And it's easiest to get that in the morning for somebody with diabetes. They're in lies, do you know that your Maysles are doing what they're supposed to do? If you've got time?

Scott Benner 18:45
Well, yeah. Can you imagine to you're going to need to be fasting for a procedure at 8am and you wake up and your blood sugar's 45. What are you going to do? You know, you're gonna have to do something. And now you're gonna have to show up at the hospital and say, I drank juice this morning, and then they're gonna Bucha back out again and you have to reschedule. So, alright, that makes sense to so conversations ahead of time with doctors. I'd like to control my own insulin pump, I can do it when I'm on, you know, when I'm not capable. I've got a person here to help me. Here's a letter from my endocrinologist outlining you know, some of my goals for my blood sugar's that they'd like me to be able to stay on my devices. If I'm MDI, I don't want to be on a, you know, on an insulin drip, I want to, I want to inject my slow acting, you know, the way I always do, and probably having a little bit of, I don't know if charting is the word or records to be able to show the doctor like, look, here's what I do. Normally, I feel confident I can come in and accomplish this correctly is probably important

Jennifer Smith, CDE 19:45
because it eases their ability to also chart and say, you know, this is the plan of action. This is where you know this patient's glucose levels, they're controlled, the insulin doses are here. The glucose levels are huge. Willie here, this is where they came in the morning of the surgery, even showing them. I mean, every surgery I've gone into they've all the nurses have been fascinated with the continuous monitor. They've been fascinated with it. What happened

Scott Benner 20:14
to art and when she went into the emergency room for that belly pain, and you and I talked that they actually, yeah, and the other nurse who was way in charge, super confident and competent. And she, when she saw that thing, she's like, This is amazing. And I was like, Yeah, right. And she's like, alright, well, you know, what do you want to do? And I was like, I, you know, it was that moment. And I said, Listen, I'm not trying to be like, I'm not, you know, I'm not blowing a horn here or anything like that. I'm like, but my daughter is a once he is incredibly stable. On the lower side, her blood sugars. And I showed her like, this is her blood sugar for the last 24 hours. And like, I am completely confident that I can keep her blood sugar here. And if I can't, could we just do it? She's got an IV and right, you could hear you could hit her with, you know, yeah, with glucose. dextrose. Right. And so that actually happened, we were there for so long that they did have to run dextrose. And it was really interesting to watch, because it took forever to hit, and then it jacked her up. But if you gave her any insulin at all, it went right away in two seconds is very, very interesting to watch how it works. But when going into that scenario, right away, I mean, after we were settled, like I didn't run in the door yelling, she has type one diabetes, and we're gonna take care of it. Like, you know, after we were settled, you know, we were there for a little while. I'm like, Hey, listen, here's the situation. We'd love to stay like this. And that, to be honest, she seemed thrilled to let us do it. It almost felt like, well, then I won't have to do this. So perfect. You know, it was a little bit of that. And okay,

Jennifer Smith, CDE 21:44
that's actually for the most part, what I've actually what I've experienced, there's almost like you, you can't physically see it, but you can see it because with diabetes, we've become very intuitive to other people's like, what you can see them thinking you can like hear their gears going right. And every time I've come in for a surgery, I can almost like see the nurse let go. Their shoulders like relieved. They're like somebody has control of this. And we don't have to worry about I mean, they will, they will ask where your glucose is, if you do a finger stick or look at your CGM. Report it to them make sure that they know and are aware of where things are going. If you didn't at all make an adjustment to your insulin doses or take anything, make sure to note it to them so that they can chart it. Because it becomes part of the medical record then. But yeah, I mean, my, the my first child when he was born, we knew it was going to be a C section. And so we came in planned everything. And the nurse anesthetist who was there during the C section. She actually at that point in time, I had the receiver yet for my Dexcom. Right, I was still using it. And I she was holding it because my husband was like, you know, with me, obviously. And she was amazed by it. She kept like, she's like you changed again. He's like, that was 81. Like, yeah, it'll give you a new number every five minutes, right? Yeah. But she was like she was so just enjoying watching. She's like, this is a really steady line. And I was like, Yeah, that's what happens when your insulin is dialed in the right way.

Scott Benner 23:32
So you know, to your point, I'm recalling a conversation I had with a nurse in a hospital setting. And we talked about this. And she told me that one of the things she dreads the most is running up on somebody who really, you know, doesn't have a firm idea of what they're doing. And she's like, but that but it's, they feel like it's working for them. Yeah. And then you feel like you're in the position of explaining to them like, Oh, this isn't okay, this should be more like this or more like that. She's like, No, that's not my job. And you know, and they don't take it well, and they're already under stress over a lot of other things. And now here you are in the corner of the room going, Oh, by the way, you don't do a very good job of taking care of your diabetes, here's what you should be doing. She's like, it's not the right time.

Jennifer Smith, CDE 24:16
No, not at all. In fact, I when we went in for my second son's birth, you know, management had already been established endocrine and my MFM team had already written Jenny will manage, if she's unable her husband is here, he can help her manage, she will remain on her pump, et cetera, et cetera. And the nurses were really really surprised by that because they had had a woman the week prior, come in on a pump. And they thought she knew just like, you know what everything I was saying. They said, Okay, we need you to dial back, you know your rates by this much blah, blah blah because she didn't come in with a plan of action herself and This woman, unfortunately, literally didn't even know how to button push on her pump. So I don't I don't know the whole story other than the fact that the nurses and the doctors were like, well, we you can't safely we cannot allow you to stay on your phone. And so she was so excited. She's like, so glad you know what you're doing. Like this was the scenario we had.

Scott Benner 25:19
I hope hopefully, that'll this will give the confidence to other people to make these kind of like pre planning decisions to. Okay, so let's, you know, injury. And I only have one example. But Arden got hit really hard in the kneecap with a softball bat at softball ones. And her blood sugar began to rise almost immediately after the pain hit her and stayed up for the better part of 18 or 24 hours, she needed a lot more insulin now. You know, I don't think there's a lot to say to this other than there was an impact coming from her body that required more insulin, and I gave her more insulin. But that's Is that is that a hard and fast rule that paying put your blood sugar up in constant pain can hold it up? Or is that that's person to person? I would imagine to? For the

Jennifer Smith, CDE 26:05
most part, yes. I mean, as as kind of just a blanket statement. Yeah. For the if you're in pain, and it's considerable pain, blood sugar's will be higher. If the pain ebbs and flows, you may find a little bit of kind of a drop down as things feel much better. And if it starts up again, maybe between pain medication or whatnot, it may start to escalate again. So So yes, pain, pain is a horrible thing. You know. And that's actually one of the things that I in having had two births. The management of pain, post delivery, was, most women's insulin needs fall dramatically, after they deliver child and placenta and everything, and all those pregnancy hormones are gone. But after a surgical delivery, like a C section, or a more traumatic delivery, potentially, you may actually see that the stress of that, and the pain that you're in, could leave those glucose levels higher requiring more insulin, despite the pregnancy hormones being gone. So that's kind of a similar example. You're swapping

Scott Benner 27:17
the hormones for the pain. Right? Right. And I did see with Ardens needed when pain issues only taking Advil, but when it worked for she needed less insulin. And then at the end of that Advil if I if I didn't overlap it correctly, then she'd start to go up again. Okay, well, I just wanted to hit that. But now we're gonna, we're gonna jump into the like, the illnesses, you know,

Jennifer Smith, CDE 27:38
yeah. What Can I Can I comment on one thing, of course, prior to illnesses, as we've been talking about, like, planning for surgery, and all of those kinds of things, if you do have a plan of action, and you know, you'll be going into the hospital. The other things to definitively know is your length of stay for that, okay, because you do have to plan ahead for how much may you need to bring along as far as supplies, right, especially if you're on a pump. If you're on a CGM, you want to make sure that you have enough that you don't have to either send somebody home, the hospital will not have anything to help you out with your pump supplies,

Scott Benner 28:18
they're not going to offer you an omni pod, if you know,

Jennifer Smith, CDE 28:20
they're not going to they you know, I mean, certainly they've got glucose glucometers in the hospital, they've obviously got insulin, if you're really stuck on your type of rapid acting insulin for another example, and you've got something planned coming up, make sure to bring your insulin to the hospital with you, you may have to give it to the nursing staff, they may have to hold it in in the medical area with your name and label on it. But otherwise, you're kind of going to be at liberty of whatever's on formulary at the hospital and it could be the kind of rapid insulin either you've never used, or maybe it just doesn't work as well for you.

Scott Benner 28:56
Do you ever? Have you ever had an experience yourself or spoken with somebody who's had the experience where they go into the hospital, the hospital wants to leave their blood sugar higher. The people say I don't want that. But the hospital resists. And then the person sort of Mission Impossible style gets insulin to themselves because I've heard that from a lot of people. Like I had to I had to hide my pen from the nurse like that kind of stuff. Now that

Jennifer Smith, CDE 29:25
I'm sure she wouldn't mind me answering it because ginger who I wrote my book on type one with Yeah, you know, she is she is an MDI. She takes multiple daily injections. She doesn't use an insulin pump. And her first delivery. That's what she had to do because the nurses were like, We don't want to I don't know what they told her to take her insulin dose down or up by so much that ginger was like, that's gonna kill me. She's like, you can't do that. And so yeah, she had her like insulin pens in her room with her and When the nurses weren't in the room, she just dosed herself. Now, am I advocating for that as a health care professional? No, I'm advocating that you talk to somebody. But you know, what if in the case of the question that you asked if they're just leaving it, like so much higher, detrimentally higher than would be healthy for healing. I would advocate for bringing in like, a patient advocate asking the hospital to bring somebody into the room to talk with because there has to be a safe work around that. You're being safe in the hospital staff knows what you're doing, but that you're doing what you know is better for you.

Scott Benner 30:42
You know how this always happens. Because it happens in so many different walks of life in and around diabetes and separate over to, especially at school, by the way with, like how people take care of their children at school. There's this idea institutionally, this is how we do it. And when you come in and say, hey, that's really cool. I'm glad that works for people. I would like to do it like this. No, no, no, this is how we do it. But no one remembers why this is how we do it. Right. Like and it really is. It's the meatloaf story. You know, it's it's that I ever told you the meatloaf story. I've said on the podcast, it's here I'll do an abridged version of it. Mother and a young girl it's a pot roast actually mother and a young girl and making a pot roast. Mother gets out the pan cuts the ends off the pot roast, puts it in the pan sticks it in the oven. The daughter says Why did you cut the ends off the pot roast? Mom thinks for a second says I'm not really sure that's how my mom made pot roast. So they find the grandmother asked her grandmother says I don't know. You're gonna have to you know next time you're at the old age home, find my mom and ask her why. So they visit the old age home they find the mom she's 100 years old and all curled up in a ball. Great Mom, do you remember why we cut the ends off the pot roasts? You know, when we make them? And the old lady thinks and thinks and she goes? Oh yeah, I had a really short pan. Right? You know? Exactly. So. So you don't know why the hospital's saying what they're saying. You don't know why the school is saying what they're saying. And sometimes you just have to be reasonable, like you said, and talk and say, I get this is what you normally do. But hey, this is what we do. And look how well it works. Couldn't we? Couldn't we find a middle ground here? Correct. The problem is sometimes that communication breaks down because of I mean, I know on my end, when I would break down for me in the past, it's always emotion, like, you know, you're very emotional and you feel like oh, you're gonna, you're gonna ruin my kid's life or something like that, or you know, you're gonna hurt somebody and you feel and then you start wrong. And then before you know it, you're arguing. And so you have to really, you gotta come at it from a real calm place. But But that's, yeah, I'm not advocating anybody doing that either. I'm just saying that the number of people I know who have done that is more than I can count on my fingers. So something that kind

Jennifer Smith, CDE 32:50
of goes along with that, too, would be sort of an emergent type of setting where you come to the hospital unplanned, like an emergency room, right? Really important thing is that you if you can, if you're awake with it, or somebody who's with you can advocate for you. It's not odd for them to want to disconnect a pump, right? Do not let them disconnect your pump. Say that like more forcefully or whatnot. I mean, if you are with it enough, do not let them take your pump, right? Because they don't You don't know. I mean, emergency department personnel. They're, they're great clinicians, but they see a host of things like trauma problems, issues, whatnot, they are not schooled in insulin pump management, they're not. So that's a really, really important one.

Scott Benner 33:49
And these are emergencies that aren't the top end of the emergency, like if you're really injured. You know what, these people are going to try to keep you alive. You stopped thinking about your insulin pump now, but like that, that kind of stuff. But yeah, in moments where you're cognizant, it's, it's a weird thing. Like, why would you give over the control of your insulin pump to somebody just because you broke your toe and you're in the emergency room now? Correct? This doesn't make any sense.

Jennifer Smith, CDE 34:12
Okay, that's also the benefit of having a

Scott Benner 34:15
medical alert. Look at Jenny is wearing her bracelet, don't you? Oh, it's

Jennifer Smith, CDE 34:19
always on. I think actually, I glued it closed. Because I've lost it. It comes from American medical ID by the way, it's they do a great job. But my clasp had come like it unsnapped twice already. And I've had to reorder the same bracelet. So now it's glued closed. Like they would literally have to cut it off of me to get it off.

Scott Benner 34:42
I was gonna joke that Jenny is making side money by mentioning American medical bracelets on the podcast, and then she said it broke twice and I thought well, that's probably not what they want people to hear.

Jennifer Smith, CDE 34:52
Class I'm quite sure that it was, you know, my fault of catching it, whatever. It's just Yeah, it's so See, it's funny, because when I went into the hospital the last time for my kidney stone, it was not fun. It was a whole bunch of extra visits and whatnot after, but I told them I was like you. They wanted like all jewelry and like everything removed, and I was like, well, you're gonna have to cut it off then because it's glued together. And the doctor was like, Okay, well, we'll just put some, whatever it's called, like, coal ban, or KBN or whatever around it, and he's like, you're fine. We'll be

Scott Benner 35:29
fine. Oh, there you go. There's Jenny's had diabetes for 30 years, and she's wearing her bracelet now. Don't you all feel bad for not wearing yours? I don't even think Arden has one. So I'm feeling particularly bad in the moment. Oh, I'm sorry. You know, it's funny. It's when she gets older. Like, then I think of it like right now she's with somebody constantly. Who knows she has diabetes. It's you know, but it's those other moments. I guess it's the ones you can't plan for, you know,

Jennifer Smith, CDE 35:58
I've got a lot of friends who have gotten tattoos actually, you know, type one wrist tattoos. I've actually got a good friend in Michigan who she even talked to some EMTs. And she asked specifically about her design so that she could know from a medical perspective, would this be visible enough? Would this be recognized as a medical ID and whatnot. So there are some beautiful designs that are out there? I just have never one day gone that route. I have a tattoo but I just don't have a tattoo on my wrist.

Scott Benner 36:34
are we sharing where your tattoo is? Or no,

Jennifer Smith, CDE 36:36
it's on my leg. Okay.

Scott Benner 36:38
I have a couple of tattoos. I have one at the top of the crack and right now I'm just kidding. It's on my shoulder and one of my shoulder and one of my mine aren't that cool though. Maybe they are I don't know. I've had them for so long. That sometimes I look in the mirror and I see it and it startles me the one on my shoulder happens with on sometimes like what is on me. And then I realize that 25 years ago I got a tattoo and I don't I don't see it because it's behind me. Anyway, okay, so So let's start with the easiest version of a sick day right like a cold sniffles a cough like something that doesn't you know morph into something worse, just something that is you're under the weather. How does that does that always present with your blood sugar the same way it for you personally. The remastered diabetes Pro Tip series is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have a unique offer just for listeners of the Juicebox Podcast. If you're new to contour, you can get a free contour next gen starter kit by visiting this special link contour next one.com forward slash juice box free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips 10 lancets, a lancing device control solution and to carry case but most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen, it fits well on your hand, and features Second Chance sampling, which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash juice box free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips, you can use my link and save time and money buying your contour next products from the convenience of your home, it's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now, through your insurance. Contour next one.com forward slash juice box free meter go get yourself a free starter kit. while supplies last US residents only touched by type one has a wide array of resources and programs for people living with type one diabetes. When you visit touched by type one.org Go up to the top of the page where it says programs there you're going to see all of the terrific things that touched by type one is doing and I mean it's a lot type one it's school, the D box program golfing for diabetes dancing for diabetes, which is a terrific program. You just click on that to check that out. Both are caused their awareness campaigns and the annual conference that I've spoken at a number of years in a row. It's just amazing. Just like touch by type one touched by type one.org or find them on Facebook and Instagram links in the shownotes links at juicebox podcast.com. To touch by type one and the other great sponsors that are supporting the remastering of the diabetes Pro Tip series touched by type one.org. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. GE voc hypo pen is a ready to use glucagon option that can treat very low blood sugar in adults and kids with diabetes ages two and above. Find out more go to G voc glucagon.com. Forward slash juicebox G voc shouldn't be used in patients with pheochromocytoma or insulinoma visit G voc glucagon.com/risk.

Jennifer Smith, CDE 40:45
For me personally it does, I've found that just the typical sniffles I'm not really feeling bad, I'm just feeling kinda like stuffed up or something. Typically, I don't see any change in my blood sugars whatsoever, I don't see any change in my insulin needs whatsoever. It's not really until I start feeling sick, where I might feel a little more fatigued, tired kind of rundown, like I could go to bed like at 8pm instead of 1030. You know kind of thing that I like a good thing for me to know that I really don't feel good is that I just don't want to work out because I typically do something every single day for a workout. And if I really would rather like skip the gym, I know that I'm really not feeling great. But blood sugar wise, I've already I already know that I'm not doing great because I'll see an incremental creep excuse me, I usually need about 20 25% more insulin with something that's got me kind of just not feeling the best at all

Scott Benner 41:49
right so with Arden when she has the regular just sick day sickness she needs her blood sugar's are so easy to control those days. I don't like it not, not like I'm coughing and My chest hurts, or there's, you know, snot flying out of my nose or something like that. Just when she's a little under the weather. Her blood sugar's easier. Now maybe if I really delve into that maybe she doesn't eat as much during those days. But like there could be another reason that I'm wrong about. But I have heard people say, you know both ways I need more, I need less. And so for this right? Hydration really is got to be step one, in probably all of these right? You have to stay hydrated, keep food in, you know, as best you can. So you don't get into one of those deficits where you've got a bunch of insulin going and there's nothing inside of you and you drop quickly, is kind of morphing that from just a regular sick day to a slightly more sick day where you're under the weather, maybe have a bit of a fever is the biggest fear. What if I need to eat and I can't or what if I get sick to my stomach and my stomach empties like what do you think of the biggest fear around being sick as being

Jennifer Smith, CDE 43:00
I would say it's more the it's not like the congestion, the nasal the bronchitis, the ear infection, that's usually not, it's more the bugs that hit the digestive system that are the fear for most people, high blood sugars. Most people will realize that they need more insulin, whether they're just throwing insulin and correcting because they're staying high or they actually intuitively are like, oh, I need to bump my basil up. I'll use a Temp Basal here because I obviously I'm just running across the board. Hi, that's not so much the worry, it's more the Gosh, I really don't feel very good things could be coming out one or both ends and nothing really seems to be sitting well or you have consistent enough nausea that you can't really do more than a sip every hour. Yeah, those are more of the bugs that worry people. So I mean, there are there are some kind of hard and fast rules, you know, if your blood sugar is on the lower end declining or dropping, and you can catch it ahead of get being too low. You can if you're using an insulin pump, set a Temp Basal decrease about 80% for about two hours. So if you're really nauseous to the point that you can't take anything into stop that drop off, you can decrease basil enough again before you actually are too low to stop the drop and sort of curve you off until you could get a little bit of something usually extreme nausea doesn't last like nine hours at a pop. It kind of ebbs and flows through a stomach bug. So you know, at some point you can get in something even in the case of honey, you can put put honey in the gum and sort of just massage it in. You don't even have to swallow it but some of it does start to get absorbed in You know, through the mouth. So it's funny.

Scott Benner 45:02
So you just described exactly how I help Arden sleep in really long. So on a Saturday if she you know, she goes to bed late and or she's been really exhausted all week or something like that this Saturday is going to be one of those, like, she's got a lot going on this week, and I know she's gonna sleep in. There's a moment, like in the in the beginning of the day, the six o'clock 789 o'clock hour, it's like a 50% decrease in her insulin. And that keeps her at 90, right. But if she starts power, sleeping into that 10 o'clock, 11 o'clock, 12 o'clock, I sometimes have to go down to like an 80% decrease, just because everything in her body that could possibly keep her blood sugar up, is gone. Now it's just, it's really gone. She's been asleep for 12 hours, you know, 10 hours, it's really gone. So I've learned that I can't take all the insulin away. Because if I do that, she's going to jump up or be really high two hours after she wakes up or something like that. So you have to leave some in, but almost not enough for it to impact the moment at all, just for to help overall. And then from there. It's great. I mean, the idea of the honey in the cheek, something that doesn't make it to your stomach, because the lining your mouth is really absorbent for things. So your cheeks under your tongue, right? Yep, that kind of stuff. So you can get sugar in there without actually swallowing? I'll tell you, I'll tell you two in a panic situation, if you don't have anything even table sugar, you know, you can dissolve sort of in the saliva of your mouth and leave it there. Yep, yeah, there's a lot of ways you bet, you're going to have to get creative unless you're planning to head right, and you have sports drinks that you can take these kind of micro steps off of throughout the day, you know, but all we're talking about here is, is maintaining that balance with the extra variable of your stomach maybe being sour or incapable of holding the feet, right?

Jennifer Smith, CDE 47:04
When it comes to also prepping similar to other illnesses and whatnot, kind of, you know, like the discussion about mouth surgery, just prepping and making sure you've got some things on the shelf in your house, kind of, if it's popsicles that you always keep in the back of the freezer that have a sticker on that say, don't touch unless, you know, sick days, Sick Day stash, or whatever it is, there's actually a really good electrolyte. It's not pre mixed, it comes in like one of those little two, not tubes, but like packets, kind of like Crystal Light, almost. It's called Drip Drop. That one works really nice. I think each packet, if you'd consume the whole thing, it's only about like nine or 10 grams of carb. But the nice thing is that it's got the electrical light component to it too, for replacing what might be coming out. Yeah. So just some options.

Scott Benner 47:54
It's very dense with what you need to and I know about it for completely different reasons. But when Cole was recruiting for college, he got stuck at this three day event in August. And it was like 115 degrees. And he was playing baseball for three days in a row trying to you know, it's like, look at me, someone take me on their damn team, you know, but he was downing Pedialyte throughout the day to stay in that. So it is really impactful.

Jennifer Smith, CDE 48:22
The other component to stomach bugs and adjustments would be if you are able to take in a little bit usually because of stomach bug means that you're not absorbing well. Digestive leave, we really expect that you're probably absorbing only about 50, maybe 60% of the carb amount that you might be taking in one don't Bolus until you know that it's going to stay down. So in this circumstance, you're not doing Pre-Bolus thing at all. You take the food in, you make sure it's going to sit there, it's going to stay you Bolus only for about 50% of what you actually consume. This is a survival situation, right? It's a survival. And again, if you see it coming up sure that's where that like little bump nudge, kind of with a little bit more, maybe a little bit more whatnot, but be conservative to begin with. Because stomach bugs don't last long. They're not like the common cold five to seven days, maybe even 10 days. Usually stomach Bugs Are Gone within about a 72 hour time period, you may still have decreased absorption for days after you're feeling better. So don't don't think it's odd that you might be dropping a little bit low when you're back to eating what you consider normal food after meals. It might just be that your digestion is just not up to par yet. So

Scott Benner 49:37
if you're a person or a parent of someone who is prone to stomach issues, is having a prescription on hand for So Fran or something like that. Is that a good idea? Like something like an anti nausea medication? Yep. We'll talk about that.

Jennifer Smith, CDE 49:52
There's another one that's over the counter. It's called Emma trawl. e m e t r o l I think it comes in a lot. Little white bottle has got a rainbow on it. That was something that the, my second, my second wisdom tooth extraction, the dentist actually recommended for me for nausea, so and it seemed to work really well. So.

Scott Benner 50:17
So if I'm on MDI and I have this illness coming up, how do I cut back my, my slow acting insulin? Is it a percentage do you think? Or where do I start

Jennifer Smith, CDE 50:28
to, you know, it again, in the circumstance that you wake up in the morning throwing up or you know, just not feeling the greatest and you're taking your Basal dose in the morning, you can adjust it absolutely. And you can take it back by 10 20% as a starter. If it's really considerable nausea, and you're not really sure that you're going to take anything, and you may cut it back even a little bit more than that, and then just cover with boluses of your rapid insulin, if you are riding higher through the course of the rest of the day. But don't take an additional dose of your long acting insulin from what you missed. From the initial dose to make up don't just wait the next time you need

Scott Benner 51:12
to know. So you know, when you're talking about taking care of kids. I mean, anybody who's a parent who's had a child is sick, you realize, you know, for sure, like everything in your life stops, right? It worked doesn't matter. You know, the television show you really want to watch tonight disappears out of your life, you know, the weather doesn't you're you're keeping your kid alive. But But what if I'm an adult, and I'm alone, right? I'm living by myself and I have type one diabetes. I'm sick, and I'm exhausted. And I know I am going to fall asleep and stay asleep. Like, what what do I do before I fall asleep because that kind of illness you see people sometimes 10 hours, they're out like a light, right? And it's the kind of illness in the in the stress on your body. You might not wake up if you have a problem. And you don't want to be in that scenario. You don't even want to wake up with an extremely low blood sugar. I can imagine having a 40 on top of a stomach virus, right? It's gotta be horrible. I'm guessing. So do you do you ever? I mean, how long have you been married? You ever lived alone? Like, what would you do in that scenario? Would you?

Jennifer Smith, CDE 52:17
I've personally never lived alone. I either I went from my parents to having college roommates, to having off campus college roommates, too, then I think I lived alone for about a month between my college roommates moving out graduating and then getting married to my husband, your husband

Scott Benner 52:36
should take a lot of comfort in the fact that your face did not go Oh, geez, I do have to get divorced. Isn't that what Scott saying? No, no. Jenny has to fly. You look very comfortable.

Jennifer Smith, CDE 52:50
I've traveled alone. Right? You know. So in that circumstance, too. There are always like safety pieces. You know, when I when I travel alone, I actually set my CGM alert for a little bit higher over in the overnight time period, just because I want to know sooner than if my husband was sleeping next to me, because he's usually the one that hears it before I do.

Scott Benner 53:14
I got hit the shoulder last night. Don't you hear that? And I'm like, no, because I'm sleeping. She's like, it's beeping I was like,

Jennifer Smith, CDE 53:22
but for those living alone, I think some some strategies. Again, this would be a staying safe, by being potentially a little bit higher is actually better. So if you know that you are just like Dawn and you are out and you are gonna go to bed and you may not be up for the next 1012 hours. Just set a Temp Basal decrease. Or again, if you're going to bed at night, and you know that wake up in the morning at six o'clock is probably not going to be until 10 o'clock because how horrible you feel. Maybe you take your Basal insulin injection dose down a little bit. You know, I mean, there's safety things. Yeah, you may wake up higher than you want to be. But it's in this scenario of being alone. That would be the safer case. I mean, I'm not advocating obviously for waking up at 200 or 300, or whatever. But yeah, you wake up at 180 instead of waking up at 100. You know what, at least safe?

Scott Benner 54:19
Well, I mean, the idea is to get through this unconscious time period and back to back to conscious safely. That's what you're shooting for.

Jennifer Smith, CDE 54:27
The other component too could be you know, setting alarms on your phone, or setting an alarm clock in that time period just to wait I mean as much as you want to sleep in need the rest because you don't feel good. If you really are worried because you already took your Basal insulin and you can't adjust it now or you're getting to that point of just needing to lay down and you just had a meal and you're not quite sure what that Bolus is going to do for you. Set an alarm,

Scott Benner 54:55
right? Yeah, I mean, everybody should have an old $8 windup alarm clock they can pull out of a drawer right and send across the room so that you can't just reach over and touch snooze on your phone. Yeah. And, and get out of it that quickly. Okay. Well, that's, that's really, I think we're finding a lot of good ideas here. So real quick medications around illness, cough medicine, you know, they make some without sugar I guess or I could Bolus for like

Jennifer Smith, CDE 55:21
they do. It's called diabetic tossin. Diabetic tussen. That's what it's called.

Scott Benner 55:27
They really should just call it diet Tostan. But all right, I mean, I'm not a PR department over there.

Jennifer Smith, CDE 55:33
It's cough syrup that doesn't have any sugar added to it whatsoever does the same job but doesn't have any, you know, glucose raising component to it.

Scott Benner 55:43
Chris Rock in his stand up, it was like, rub some testing on it was that my mom used to say, Rob, so it was that? I don't remember figure out I'll figure that out. Okay, so diabetic Causton. What about is there? I mean, steroids. Steroids are going to push my blood sugar up the entire time they're in the body, right?

Jennifer Smith, CDE 56:04
Correct. Yes. And the increase can be considerable, depending on the dose. So injected, injected steroids, like a cortisone injection into a joint or something like that, those will cause considerable increase in blood sugar, definitely within the 12 hours after, you're going to need an increase at least 50%. Many times people see 100% increase. And then that that increase will last for a couple of days until the dose from an injection sort of starts to dissipate. I mean, the impact of it stays within the body, but the impact of the actual let's call it you know, cortisone, or whatever else has been injected on what other kind of prednisone or whatever it might be, it's going to dissipate enough that you're going to see the need for that increase in in Basal dose come back down. I, you know, it's, it's not odd to see 100% More 150% More Basal dose, especially, many people who are also paying close enough attention will often also need an adjustment down in their insulin to carb ratios, their correction factors. A, as far as oral steroids, depending on the dose, and again, on a potential hard stop or a taper of the dose. Most often, those are people who have like a bronchial illness, and they have like a background like asthma or some other type of lung condition that the doctor really wants to attack the illness to prevent pneumonia or something else, you know, progressing. Those types will usually again, increase the need significantly, and the insulin to carb and the sensitivity factor will need to be adjusted.

Scott Benner 57:59
Okay. And to medications that may have a side effect of nausea, you should be careful about if they want you to take them with food, give yourself a chance to not show up, you know, not make yourself nauseous when you when you might need to hold something down. I want to double back a second to the idea of an alone adult or even a kid whose parents, you know, might feel like it's slipping away. Like, when do I it's so funny to ask this question, because we spent some time talking about the fact that hospitals don't seem to particularly you know, value, like your blood sugar that much. But that wins the moment when you wave the white flag and go to the hospital. Like Like when am I like, you know, not that you should be running every time you're sick. And by the way, I feel terrible. Because some people get sick more frequently than others. I can count I can count on two hands. The times both of my children have been ill. Arden doesn't get sick much at all. Which by the way, too, for those of you who do, what a horrible joke that is from nature, right? Your immune system was strong enough to beat the crap out of your pancreas. Can't make bronchitis go away. Right? Yeah, like whoa, come on, man. But But So when do I like what's the Mendoza line for when I think I better get the professional help. And why do I want to do that? Like what is it I'm avoiding?

Jennifer Smith, CDE 59:18
That kind of comes in and I know we had a whole discussion, an episode all about ketones and how to look at that and whatnot. But that kind of brings that into the picture as far as blood sugars and or hydration. And if you are ill and you're really not feeling good check ketones. You know, because in the case of moderate to high ketones, those often especially if you are not feeling well and you can't get enough hydration and fluids in you may very well need to go to the emergency room. In that case, it's just and your blood sugar's may not look like high enough To say, Well, gosh, I This is really bad I have to go to, you know, to the emergency room or the hospital. But if your ketones are at that moderate high level, you definitely need some help clearing those or you're going to be in trouble and IV would help with that, right? Is that IV would help with that, because they're not gonna make you down a whole bucket of water via your mouth, because I have could put an IV in and they're going to push it in through your vein, because if

Scott Benner 1:00:27
you could, you would, too. And and I know I know that because and I think I've told this here before, but Arden woke up one time with should have bent cannula, one bent cannula, and like 14 years is amazing. But she will come it's pretty. She woke up with a higher blood sugar. She was nauseous. I tested her ketones. They were high. And I said to her, I'm like, Look, here's your options. Now she wasn't sick. Like, you know, I mean, shouldn't have a stomach vise. I said, you pound this water down. I crush you with insulin. And you promise me that you can eat something to stop the fall. Right? Like and or we're going to the hospital. And and she's like, and she took a bottle of water for me and Arden is I've mentioned this here before she's a princess slipper. When she drinks water. It's like, Oh, little bit a little bit. She took that bottle of water. And she pounded it all down. And she was like, is that good? And I went yeah, you can sit with the next one, you know, and we got like three bottles of water in or over two hours. We made a big Bolus. She, her blood sugar broke, and her ketones began to fall. And we caught it with a little bit. We caught it with something. And that was it. It took us three hours to not go to the hospital. But she was willing to do it. And it was hard. She told me later that drinking that water was incredibly difficult because of the pain she had from the elevated ketones. Yeah, she was she felt very nauseous from it. Obviously, she wasn't sick. But yeah, at some point, there's going to be a safety issue, please don't get to the point where you're calling an ambulance, you know what I mean? Like, like, you might have to give up at some point. Right?

Jennifer Smith, CDE 1:02:06
This kind of, it kind of brings into it. A component of like nausea in pregnancy can be a very considerable thing for some women, especially in early pregnancy. So if you have significant enough nausea, and you're not literally able to take things in, or you've gotten to the point of actually vomiting, because of the significant nausea, it's always better to try to go and get at least IV hydration so that you don't run into an issue of ketones. Even though blood sugar levels may not be elevated in that circumstance. You could develop ketones mainly because you're just not keeping anything in. And that's very, very, very bad in pregnancy.

Scott Benner 1:02:57
Can I ask you a question? And I don't usually put you on the spot for this because it's a question about how to do the podcast. When I put this episode out, I was thinking to put the ketone, defining ketones right with it. You see them as compact these are companions to each other. Okay, absolutely.

Jennifer Smith, CDE 1:03:12
That's a great idea.

Scott Benner 1:03:13
We'll definitely do that then. This is usually the time where I say Is there anything I didn't say that I should have said

Jennifer Smith, CDE 1:03:20
the only thing I would say is for all of this the biggest thing comes from like my years with Girl Scouts be prepared. Okay, great to be prepared. And one of the best things I can recommend doing is having you never know when you're going to have to run out the door to like an emergency like situation right or even in the case of I know this is an illness specific but this is like just being prepared like you have to run out of the house because I don't know your stove is on fire. I mean, if you have a diabetes emergency bag packed get a backpack or red backpack cheap go to Target or wherever get one put in it. All of the things you could potentially have to take with you quickly out of the house. It'll be a lot easier in a an illness emergency especially especially somebody has to take you out of the house right? If you got stuff packed to go at least you know you've got you know, a set change and extra test strips and batteries and whatever they're all in.

Scott Benner 1:04:29
So a Jumanji situation when giant vines and lions are going through your living room and you really need to get out. You want to be able to grab this bag. Correct and at least have it packed somewhere and no, it doesn't have to be hanging by the back door chasing you through the kitchen. We're very mean in that movie. Hey. I know Robin Williams and now now people are like Robin Williams wasn't in that movie. That was the rock. How did you confuse those things? And who is Robin Williams but there's been two Jumanji movies so young people please leave me alone. I want to close As by saying that as we were talking, I was proudly struck by how much of what is normally spoken about on the podcast translates very well to this idea of sick days. That, you know, obviously, there's heightened scenarios, but that the tools you use really aren't much different. You might use different ones in different times than normal, but, but it's not like. And the reason I say this is because when people are trying to figure things like this out, I oftentimes see them believing that there's some extra special knowledge that they don't have about diabetes that applies only to the day you're sick. And I still think that one of your greatest diabetes tools is common sense. And so I think that, you know, we obviously broke things down a lot more granularly here, but it's still the tools. It's the Pro Tip series, you know, applied slightly differently. So right, um, I thought this was really terrific. I appreciate you doing this. And we talked so long that I can't ask you to define Lada so I'll do that next time. Okay, so that you can go I will say thank you. You're welcome. I want to thank assenza diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free contour next gen starter kit at contour next one.com forward slash juicebox free meter, while supplies last US residents only. If you're enjoying the remastered episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org. A huge thank you to one of today's sponsors, G voc glucagon, find out more about Chivo Capo pen at G Vogue glucagon.com Ford slash juicebox. you spell that GVOKEGLUC AG o n.com. Forward slash juicebox. If you're living with diabetes, or the caregiver of someone who is and you're looking for an online community of supportive people who understand, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, there are over 41,000 active members and we add 300 new members every week. There is a conversation happening right now that would interest you, inform you or give you the opportunity to share something that you've learned Juicebox Podcast, type one diabetes on Facebook, and it's not just for type ones, any kind of diabetes, any way you're connected to it. You are invited to join this absolutely free and welcoming community. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low Beegees in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two in Episode 1008 teen pregnancy 1009 teen explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025 We talked about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son on how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning that Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active, took me already from a decent 6.5 A one C down to a 5.6. In the past eight months, I've never met Scott. But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link.

#1012 Diabetes Pro Tip: Fat and Protein

In this episode of the Juicebox Podcast, Scott interviews Jenny Smith about how to bolus for fat and protein. They discuss the misconception that these macronutrients don't require insulin and provide valuable insights into the timing of bolusing for them. Additionally, Scott introduces a special bonus episode with Vicky, who shares her experience with bolusing for a keto diet. Whether you're eating keto or not, these episodes offer valuable information on managing insulin for fat and protein.

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

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:04
Hello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right, you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CD and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisit double. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. While you're listening please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have an amazing offer for you. Right now at my link only contour next one.com forward slash juice box free meter you can get an absolutely free contour next gen starter kit that's contour next.com forward slash juice box free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries G voc hypo pen, find out more at G voc glucagon.com forward slash juicebox a half an hour before you and I started recording this someone sent me a message on Instagram and said how do I deal with fat and protein overnight because I was bawling all night with my kid. So I texted them back and I said hey, great timing. Can you see my recording calendar from where you're at? And hold tight? Because the answers coming? This is another one that Jenny proposed that I'm really interested in. And I don't know how much help I'm gonna make. Why don't we start with what I know? Because it's so little. So forever seriously. So for everyone who listens to the podcast and knows that I'm just sort of fluid with insulin Right? Like more. More need equals more insulin. And so because of that, I don't usually stop and think about whether that means it's protein or fat or what it is just if Arden's blood sugar seems to require insulin, I give it more. I'm assuming I'm been handling fat and protein rises for ever.

Jennifer Smith, CDE 3:17
You're not dissecting her meals, you're just saying I see the need. I'm giving more insulin. That's kind of what you do. Yeah,

Scott Benner 3:24
I see diabetes as a forest fire and I fly over it with a giant plane full of water and just drop all the water on top of it. Then I go oh, look, we got most of it. And and

Jennifer Smith, CDE 3:35
look at that's where the fire started. There it is right that comes in and looks at and Scott's like, I didn't really care where it started. I just want to take care of

Scott Benner 3:43
meaningless to me, I'll go get another plane full of insulin and drop it back on again. So So I never really think about stuff like that I do a little more obviously, as you and I have been speaking as the years go past, but I find it to be it's another level. Like sometimes I joke about things being like like ninja level, like, I think that you don't really need to know about fat and protein if you're doing what I do. But you do need to know if you want to start understanding things in a bigger way. So I'm really excited to do this. Now. The only thing I know about protein is that I do indiscriminately Bolus for protein. I don't know why I do it. But I do it. So where some people might look at a plate and go, oh, there's potatoes. Well, that's, you know, this many carbs. But then there's a you know, a cheeseburger well that's meat. I don't do that. And here's a roll that rolls 25 carbs and you know, and we're gonna have broccoli and I don't know, broccoli probably has five or six carbs or like, so I look at it. I look at I look at a plate I go broccoli, and six, the roll. Let's call it 30 Then I look at the potatoes and add another 35 And then I look at the burger and I go. Let's call it 10 and we'll extend it for a little bit. it. And so that's me looking at a cheeseburger with mashed potatoes and broccoli, right? I don't know why I do that with the other than I know, people who eat incredibly low carb, who tell me that they Bolus for their protein but farther out from when they actually ingest it. Is any of that right? If visiting, dancing for diabetes is wrong, I don't want to be right about this, I want to be right about the fat and protein thing. But I would not want to be right about visiting dancing for diabetes being wrong. If it was wrong, which it's not, I think you should definitely do it. Dancing, the number four diabetes.com. You know, studies show that if ads are incredibly confusing, they work so much better. Check out dancing for diabetes on Instagram and Facebook, throw them all like it's a really great organization, dancing the number four diabetes.com Even if you're not interested, could you go like 30 pages because they paid for this. And now I'm listening back to it. And I didn't do a very good job. So let's at least give them their money's worth. Is any of that right? Because,

Jennifer Smith, CDE 6:09
yes. And again, I from the standpoint of looking, you're not doing this in a blind way, you have, you have the method that you've developed for analyzing looking at Arden's control and her management and what happens here and what happens there. And you remember it, you've got like this, like library of like, times of this has happened, you can like pick from them, Scott, and you're like, I know this happened last time. So let's time this time for the burger and broccoli, we're gonna give 10 for the the burger, because I know what happened last time and something was off. And the carb count for everything else was right, right. In context, though, for everybody who's listening, and why would you need to Bolus for protein. It's really typically two points that you'd need to Bolus for protein one, you brought up the low carb eaters, or those who are eating lower carb at times, if you've got a meal that's typically less than about 15 to 20 grams of carb and a normal amount of protein, not like this big 16 ounce steak, but a typical, you know, five ounce chicken four or five ounce chicken breasts, let's say you're usually going to need about 4050, sometimes even 60% of the amount of protein in the aftermath of that meal in order to accommodate for your body's own digestion of protein in a low carb environment, because remember, carb is the body's natural first fuel, right? Okay, if there's not enough of that first fuel there, your body looks to another source, like protein digests it down, and you get a usable amount of glucose out of protein. Even if it's not a huge amount of protein eaten in a lower carb environment. The opposite of that would be let's say, she has a high carb meal, or anybody has a high carb meal that's like the meat lovers pizza, okay, and which is not only a huge amount of carbs, as well as a huge amount of fat, but you've got this large amount of protein, let's say instead of your standard, like 25 gram portion of protein, which is like about the size of the palm of a woman's hand, that's about 20 to 25 grams of protein, that's pretty normal amount, okay, if you've got this huge amount of protein that you're taking in, even in a normal amount of carb or a high amount of carbs, you're still going to need Bolus for about, let's say, 50% of that protein, but it's going to be a drawn out type of insulin need. So both of those scenarios would require you to take, you're doing like a dual Bolus, you're extending some of it, assuming you're meeting that protein kind of need for a while. Protein Bolus typically is a good idea is at the end of the meal, to set an extended Bolus with 0% delivered upfront and 100% extended out over about a three hour time period. And that's just for aware proteins impact usually starts impacting about two two ish hours after a meal. And then by about three hours, you're too high and you might sit high and correct to try to get it back down. When in effect had you use what you use to correct to actually Bolus for the protein you wouldn't have had the rise to correct to begin with.

Scott Benner 9:36
Yeah, I got it. It's parallel to the idea of over Bolus and like when you can't Pre-Bolus And you throw in a ton of extra to handle the rise before the rise happens. Okay, so i i Bolus the meal normally. Then I finish eating and I put in this amount for the protein in an extended Bolus 0% up front the rest of it out over maybe three hours. Correct. So So Basically, I'm creating a heavier blanket of insulin over the timeframe where the food's going to have impact where the

Jennifer Smith, CDE 10:07
protein is going to have the impact or where you're assuming from previous experience with meals like that, that impact is going to kind of fall in and fat is even longer. But as we've kind of talked about before fat can have impact up to 10 to 12 hours after eating high fat.

Scott Benner 10:21
How does that technically happen? So these are where my questions exist. And by the way, I just everyone listening, I just stared at Jenny while she said that and thought, Oh, I'm in a Master's class about diabetes. And so, so fat as an example, when How does fat does it slow down? Digestion? Like why does fat hold up blood sugar I don't understand, I guess. The remastered diabetes Pro Tip series is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have a unique offer just for listeners of the Juicebox Podcast. If you're new to contour, you can get a free contour next gen starter kit by visiting this special link contour next one.com forward slash juice box free meter will you use my link you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juice box free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen, it fits well in your hand, and features Second Chance sampling, which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash juicebox free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips, you can use my link and save time and money buying your contour next products from the convenience of your home, it's completely possible that you will pay less out of pocket in cash for your contour strips, then you're paying now through your insurance, contour next.com forward slash juice box for a meter go get yourself a free starter kit. while supplies last US residents only touched by type one has a wide array of resources and programs for people living with type one diabetes. When you visit touched by type one.org. Go up to the top of the page where it says programs there you're going to see all of the terrific things that touched by type one is doing and I mean, it's a lot type one, it's school, the D box program golfing for diabetes, dancing for diabetes, which is a terrific program, just click on that to check that out. Both are caused their awareness campaigns and the annual conference that I've spoken at a number of years in a row. It's just amazing, just like touched by type one touched by type one.org. Or find them on Facebook and Instagram links in the show notes links at juicebox podcast.com. To touch by type one, and the other great sponsors that are supporting the remastering of the diabetes Pro Tip series touched by type one.org.

Jennifer Smith, CDE 13:36
Yes, so one it's also usually the reason as you just said fat does slow digestion a bit. It's a it's a tough nutrient for your body to break down and make use of. So even if there's a ton of carb with it, it's often the the reason that somebody eats a pizza and they're like, Wow, I must have nailed that carb count because my blood sugar is like beautiful rock steady flat, no rise at all. And then all of a sudden later, they get this like creep and the creep happens and it happens and then you ride high and you're like throwing insulin at it and dumping the plane worth of insulin. The problem here you know, it's it's it's annoying, right especially for people who may not realize where it's coming from because they've never been told what it potentially could be. So it's not a miss missed amount of carbs but it is the reason that you had that nice flat look in the aftermath of eating that let's call it pizza. Otherwise if you just ate the pizza crust, I guarantee that pizza crust is going to give you a rise without the fat being there right even if you did, right right right right right bread or potatoes or whatever it is. Now fat The other reason it impacts blood sugar is because as it gets to the system A creates a rise in triglycerides in the bloodstream, which is a stress on the system. So we know what stress does to blood sugar, right but as stressor, if it impacts insulin use as if, as if it's reducing it by about 50%. So let's say your Basal overnight is running at 1.0 units an hour, and it works beautiful, you've tested it, you know that it does what it's supposed to do. But in the effect of pizza, or anything, high fat, nachos and cheese or whatever it, you know, the whole bucket of chocolate, whatever, you essentially have a Basal now that's functioning almost like point five instead of one. And so you are not getting the impact of all the Basal uniate, your blood sugar climbs because of the fat, and it stays high, because of the fat and it can be long duration. So I mean, you know, we typically recommend people accommodate for a high fat meal or something, you know, high fat in nature, like the whole hog, and does Sunday by her whatever, 50% increase in Basal at the end of the meal, okay, and you extend it out over eight hours,

Scott Benner 16:02
wow. 50% Basal increase over eight hours for a ton of fat. See, that's ton of fat, that's where it's at Jenny. So there's a couple things in there. But the one thing she just said was how the the impact of the food sort of gives the the appearance that your Basal is only at half power. Because Because now your body needs so much more insulin. It's funny, because that stuff we say I've been saying for years, but I never thought of it that way. Right? I never considered it the way you just said it. I always say the buyer, like you know, in high carb situations, you need more basil, that just makes sense. If you know, if one unit keeps you stable, when you're not, you know, when you're not putting the body through through the paces, then when you're when you're attacking it with ice cream, or pizza or something like that, it stands to reason that you would need more in that situation. Right to meet the need. But it's interesting the way you put it. I hope that maybe that I'll find a strike other people maybe at the core of their thinking, because that's a neat idea. Like when when you're using that kind of food, it's as if you don't have enough basil by half correct. So they have they have something to like measure with even the idea of eight hours. I think the genius behind the extended, you know, the Temp Basal increase over that much time is that if you do start to trend down at some point, you can just make the decision, hey, the foods out of my system. Now I can shut it off. Maybe I'll have to reconnect this a tiny bit to you know, but that's it. Right. Right.

Jennifer Smith, CDE 17:27
And or maybe you got enough temping increase for quite a while. And now it's going to navigate down as you turn it off, and you may not necessarily get 100% back to target, but you're certainly going to navigate down to a much lower number than you would have been had you not done that at all.

Scott Benner 17:42
Yeah, yeah. I mean, you have to know by now, if you've been listening this long that you would rather stop a lower falling blood sugar than a fight with a high one. That's it. You know, it's simple. How much truth is in the way my brain thinks about, like, more dense Carvey stuff like a soft pretzel or pizza or something like that, in that it sits in my stomach, and it breaks down slower, so that it has more opportunity to so my blood sugar is being impacted by over a longer period of time, sometimes past when the impact of my Bolus is there. Do I think about that correctly? Or is that just the cartoon way that works?

Jennifer Smith, CDE 18:21
No, it's a it's a great way to kind of think about it and also plan to Bolus for it. And some of that also takes experience, right? It takes experience seeing, well, gosh, whenever I eat this soft pretzel, it's all carb. And unless you're like dipping it in the cheese sauce, or something high fat that kind of comes along with it, the vat of butter, if you're just eating the soft pretzel, it's all carb, but the dense nature of it may be what requires a little bit more drawn out. Because you don't necessarily need that quick impact all up front, you may need some but then you're going to need it for a little bit longer in the aftermath. The same is true for some of those, like more whole grain hearty types of starchy foods, things like wild rice or quinoa, or you know, those kinds of things. They've got better fiber complex to them, they've not been processed, they're going to break down slower, and they're going to have a lower glycemic impact. So you may need to draw out the Bolus a little bit in order to prevent having a low before it kind of impacts or hits you later.

Scott Benner 19:29
Right. You have to stop thinking about the food goes in and my blood sugar tries to go up right away so I'll get it That's not That's why your timings messed up. Like you have to understand a little bit how the food makes its way through your system with high carb, low carb high fat, low fat, you know and in between there the the you know, I used to tell people like try to imagine an overlay machine like but then that got like an old idea. You know, like when you're in school when they do the you know, the somebody would write on a piece of plastic and it would they'd shine it up on the board, right? Yeah, yeah, they used to say take two pieces of plastic instead and make one, like a line of the impact where your insolence hitting and want a line of where the food's hitting the goal is you have to slide those, those pieces of plastic left and right, me till they match up. Yeah, you absolutely can't. You can't just throw in all the insulin now and just hope it hits because you hear people say all the time, like, oh, I Bolus and I got low. And then I got high later. None of this makes sense, diabetes. And I'm like, No, you're so close to you. It's interesting. Jenny earlier, you said that I look at a plate. And I just know from experience and everything. And I also think I just know, I don't know why I know. And that's important to understand. Like, I can't quantify it for you. Sometimes I can just look at a plate and go, that's this much insulin, I know it. And it is obviously from something but at the same time, I have privately for the one person who call me an egomaniac in a recent review. This is not me being egotistical. I'm just telling a story. But I, I fixed two kids Basal rates this week, remotely. And they sent me a graph. And as soon as I looked at the graph, I thought, I know what's wrong with this. But I couldn't explain it to you. Like, you know what I mean? Like I couldn't write a manual about why this graph right points to what it points to, but I knew as soon as I saw it, and I think everybody can get to that, because I know who I am. I know what I got in school is for grades. I can't possibly be that smart. Right? So you so seriously, like I think time just teaches but and Please, Dad, this is not an invitation for everyone to send me their thing. But I, but I am by the way, it did make me think, Jenny, I think there's gotta be a way to start a service where you take people's graphs and make basil recommendations back from the graphs, because once you get people moving in the right direction with their basil, they start to see it, and then they can die, then they can dial it in on there. And then they don't need you this this person, this lovely person has texted me. You have to let me send you something cuz I'm going to be bugging you for the rest of my life. And I laughed and I said, Hey, you can't send me anything. And I don't, please, I don't want anything. And but but be you're not going to need me for like, ever, like three days from now, this is going to just make all the kinds of sense in the world to you. It just starts to you start to see it. You know, when you have diabetes and use insulin, low blood sugar can happen when you don't expect it. G Bo Capo pen is a ready to use glucagon option that can treat very low blood sugar in adults and kids with diabetes ages two and above. Find out more go to G voc glucagon.com forward slash juicebox G voc shouldn't be used in patients with pheochromocytoma or insulinoma. Visit G voc glucagon.com/risk. Right, I wish the matrix wasn't a 20 year old movie because it's such a great reference. But things start to slow down, you know, they

Jennifer Smith, CDE 23:08
do and they start to they start to come together in a way like like Neo sort of all of a sudden, all of those images that are flooding the screen in the matrix, like you said, That's a great movie to bring up in context here. Because it just it comes together and his brain is like, I can see it all it's clear. And I mean, diabetes, life with diabetes changes, variables come up. And there are always going to be new avenues to explore and figure out but the intuition of the day to day management, the intuition gets easier. And I think that that's what you kind of you manage off of a lot of really good built in intuition of It's this. It's this feeling and you can't you can't often I think other people would agree, you can't often put that down in writing. You can't say, I know how I know how this is wrong. I can't tell you why. But I know this is how to fix it. I know this needs to be adjusted here. You need something else here or whatever. Now. Some of it can be you know, some of that intuition can be simplified. If you do do some, you know, we're talking all about like food and the impact carbs and fats and proteins and some of that if you know, I've gotten a little bit into the science of why there's impact there from these foods that we don't really ever talk about fats and proteins are kind of like swept under the table when diabetes education comes, you know, comes up. It's usually all carbs, right? We focus on carbs, we learn how to carb count. And I mean, the basics of carb counting are pretty easy with a label. You look at the label for the serving size, you look down the label for the total carb amount. Next down, you might look at fiber if there's enough of it, you might do you know, deduct a little bit of it, but that's what we're taught. And then you're given this little ratio of It's like, oh, for every 10 grams that you count from a label, you need this much insulin to take with it, right. So it's a very mathematical figure. But if we take it sort of one step farther than that very simple carb counting, as you mentioned before, not all carbs are created equal, you know, you could have 10 grams of counted, you know, celery versus 10 grams of counted watermelon, there's going to be a different impact blood sugar wise from those carbs, even though the carb count is exactly the same. And so that it kind of brings in, can you be precise in carb counting to a degree, you can look at labels, you can measure, you can use weighted scales and all of that kind of thing, you can get precise. But from the standpoint of then understanding why blood sugar did this versus did this, you know, up swings, stable flat dropped down, that actually it takes it a step further into glycemic index, and the nature of that food and glycemic index also, in it encompasses the components of a meal to not just the carb at the meal. But like I said, before, with the pizza, you could have just the flat old pizza crust and Bolus for that with just all the carb that's there, you're aftermath blood sugar is gonna look very different than when you eat it as like a meat lover, or an all over cheese pizza. There are different components, they're impacting how those carbs are going to change your blood sugar.

Scott Benner 26:36
And when those variables are invisible to you, it causes you to say, oh, that's just diabetes, I can't do anything about that. That's just diabetes. But there is like I've, I've been saying forever Jenny's just put it into specific words, which is beautiful. But I've been saying forever. If your blood sugar is getting really high or really low, you're not using the insulin correctly. I know that doesn't help you figure out how to use in somebody, it should help you to know that there's still an answer. And just because you don't see it in the moment doesn't mean it doesn't exist. It would be no different than if I sat down and looked at multivariable calculus. And then I said, and then I said you there's no answer to this. Well, a person who understands Multivariable Calculus would say, of course there is you just don't you just don't understand calculus. And so the trick is with diabetes, how do you find the ideas that help you get through this stuff without everything turning into a calculus problem? Right? Like, how does it just become day to day super simple and easy. And the reason you need to listen to Jenny is not only because she, you know, teaches this stuff and Integrated diabetes, not just because she's been living with type one diabetes for a very long time, not just because she's the CD, or nutritions, blah, blah, blah, all that stuff, but she lives in a part of the country where food literally tries to kill people. So I mean, that wow, like my brother and Jenny live reasonably near each other and the things my brother describes as food. When he got there, I was like, Brian, that's not food, don't eat that. Like,

Jennifer Smith, CDE 28:08
I would have to say Madison is sort of a little bit of an island in the state of Wisconsin. So Madison is a little bit a little we're a little beyond what the typical Wisconsinite but yes,

Scott Benner 28:20
well, I'm just saying if you're rolling into a moment with you know, bratwurst on a roll with a beer with some popcorn, so can caramel. Yeah. And cheese curds deep fried like you, boy, you you need to know what you're doing, you know?

Jennifer Smith, CDE 28:32
Right? Absolutely. And that's, you know, that's where understanding and learning things like, hey, fat, and protein and all of these factors, they can have an impact for you. It's not all cut and dry. Count the carbs, take the insulin and you've got it made it it's not and I I hate saying that because it sounds like, Well, gosh, I'm never gonna get a handle on this if I have to start being a mathematician and you know, figuring it, all

Scott Benner 28:58
right, but you will if you just if you think beyond what you were told. So somebody tells you like Jenny said, they'll flip the box over a half a cup of this is 10 carbs, you know, you get sick, you know, you get a unit for every 10 carbs. So that's a unit like that. But then once that doesn't work, you know, you guys have heard me say it a million times. It's insane to go back the next day recount the same 10 carbs and go okay, unit, because that's what the math The doctor told me. No, no, I used the unit, my blood sugar went up, it took me three quarters of the unit to correct it next time. Let's try a unit and a half for a unit. Like try more because more it took more. You know, you just have to like, you have to be able to walk past it. Yeah, you have to I'm telling you for the people that I speak to over and over and over again. There's a moment where you just have to trust your gut. Like you have to trust that what you're seeing is actually happening, which is why I made one of the tenants of the podcast, you know, trust that what you know is going to happen is going to happen. You know, and that's just that's simple. Like it's not I say all the time, like it's not stalking if you need it. And somebody I got a private message of the day it said that sentence unlocked my world just, you know, changed my life. And I thought, I'm glad I randomly said it because I didn't think of it ahead of time. i You guys have been listening for a long time you realize there's no notes in front of me. I've planned none of this. As a matter of fact, Jenny and I started recording, I go, Hey, we're gonna do like the fat and protein today. Okay, and she goes, okay. It's about unlocking your mind from what, you know, the confines that you are giving at diagnosis. And it's really it's, it's energizing to see it happen to people early in their diagnosis, because then you know, they're not going to live their whole life like this, but it's rewarding to see someone who's live with diabetes for a long time. Have like the light turned back on for them. Yeah, I mean, some of the messages you guys send her you guys want me tissues, you know what I mean? So it's really something Okay, so I did we do we did carb counting basics. I like flipped the box over, take a look go by weight

Jennifer Smith, CDE 31:04
box over? Yeah, I mean, if you wanted to go beyond the carb counting basics and get more into a little bit, I mean, taking it beyond would really be looking at the glycemic index, but then one beyond would be glycemic load. You know what that is?

Scott Benner 31:18
Those are going to be defining diabetes things we're going to do after we stop recording this journey. Okay, awesome. All right. We're gonna we did well with this, I think, yeah, I want to thank assenza diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free contour next gen starter kit at contour next one.com forward slash juicebox free meter, while supplies last US residents only. If you're enjoying the remastered episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org. A huge thank you to one of today's sponsors G voc glucagon, find out more about Chivo Capo pen at G Vogue glucagon.com Ford slash juicebox you spell that GVOKEGLUC AG o n.com. Forward slash juicebox. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bumping nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and lo Beegees. In episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two in Episode 1008 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025 We talk about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with this and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics. Scott brings useful information and presents it in digestible ways. Learning that Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so it is active as the carbs become active. Took me already From a decent 6.5 A one seat down to a 5.6. In the past eight months, I've never met Scott. But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Jennie Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link.