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

#1023 Diabetes Pro Tip: Honeymoon

Scott Benner and Jenny Smith dive deep into the topic of honeymooning in diabetes management. They discuss the challenges faced by parents of children with type 1 diabetes as well as newly diagnosed adults. The episode serves as a valuable resource for navigating the difficulties of the honeymoon phase of diabetes.

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

Jennifer Smith, CDE 3:05
Sure. Yes, they're both good. Good topics. Yeah,

Scott Benner 3:08
details are apparently what is needed, and I am happy to deliver what is needed. And by that, I mean dig it out of your head and record it so people can hear it. Sure. Okay. Because my only experience with honeymooning that my only experience that I'm aware of personally with honeymooning because Arden had diabetes was diagnosed so long ago, and we had a little meter and some needles. I mean, I didn't really know what was happening in her. So Right. One thing that I can tell you is that I called my friend who was my children's pediatrician one day, and I I told you this before, but it fits in this this episode. So let's put it here. And I told him I preface my conversation by saying I know what I'm about to say is ridiculous. But is there any chance Arden doesn't have diabetes? And he said he sounded sad. I think sad that I asked him and he's and he said why? And I said, but she hasn't needed insulin for about a day and a half now. Right? And that lasted maybe? I don't know, 72 hours, and then it was just going yeah, anyway, that's my entire personal experience with honeymooning but I know how difficult it can be for everybody. So

Jennifer Smith, CDE 4:28
well, another good question. And that I mean, as you sort of began with I just give more insulin right? Well, a good piece of honeymoon is or coming out of honeymoon, right? When you're you've kind of moved through that lack of insulin need or really really, some people can get by on just Basal insulin. They might not need anything for their meals or their blood sugar's don't go high enough to correct or anything right. But did you notice also Oh, that after that, like three ish days that her insulin needs were higher than they were before that. Here's

Scott Benner 5:06
the here's the honest answer. I don't know. I didn't know what you don't remember. I forget that. I don't remember. I didn't know what I was doing. Right. So like, I think that feeling maybe encapsulates more honeymooning and the and the leaving of honeymooning for people more than anything like, right so somebody you or your child gets type one. It's a whirlwind. A, it's, you know, and if you're honeymooning, insulin needs are changing kind of radically sometimes. So just when you maybe get the nerve to, I don't know, Bolus two units of a basil, you know, and then the next day Your fight is 60, blood sugar all day that won't go up. And then the next day you think, well, maybe I shouldn't use the two units of basil and then you don't and then your body doesn't help that day and your blood sugar's 300. All day, that uncertainty, I think, is the main characteristic of honeymooning, don't you

Jennifer Smith, CDE 6:00
true and honeymoon is it is really different person to person, as well as the like, movement out of honeymooning is different person to person like you didn't have Arden didn't have a very long honeymoon at all. And that's not uncommon from the studies that have been done. It's not uncommon with kids under the age of five who are diagnosed to have a much more rapid rapid onset of type one very quick, very aggressive, really high blood sugars, you know, unless they've been watching for it, or they know because of previous antibody testing that it could be coming, you know, DKA, all of those kinds of things. And what that results in is causing enough of the betas to be stressed enough, and the body kind of decreasing them enough in, you know, in amount that now diabetes presents itself. So but in older kids, and especially in adults, there is often a slower progression of type one, like, you know, here it is, and all those symptoms, and that often leaves more betas in the picture. Also, what's been found is that the sooner you get containment of blood sugars after diagnosis, you give some relief to those beta cells. And because now you know, you're either injecting or you're pumping insulin. And so that's something that's helping to take care of the blood sugar levels. And your betas that do remain can actually help out. And so honeymoon then often comes in, you know, were usually somewhere between about one to four months post diagnosis is the typical, like, honeymoon, time to expect that to come into the picture. And how long it can last again is person to person. It could be a couple months, it could be three days, it could be a year or two that you continue to have this like lack of more typical insulin need.

Scott Benner 8:13
It's the consistency that you're that you're missing and and then yes people's hearts I think I'll tell you after interviewing so many people, I've heard, I believe every variation of time and distance about honeymooning from adults and children and, and crazy stories where blood sugars are suddenly super normal super out of whack. One lady I'll never forget told me like she thinks her honeymoon lasted years. And then I'm wondering like, is that? Is that honeymoon? Or is it a slow onset? Like is that like, and I guess it doesn't really matter? Right? Like, what matters is that you're using insulin now. And there's going to be this variability to how much until things, I guess you could just say settle. But obviously it's not settle. It's until your beta cells give up. Right, right completely. Do do some people just not see a honeymoon at all? Where does that happen? I'm not aware of it. In

Jennifer Smith, CDE 9:11
talking with so many people that I have, and you know, it's always something I asked about is diagnosis. If somebody wants to talk about it, you know, or if it's been very, very soon after I get to talk or you know, before I get to talk to them, it's been very close to that time period. And it seems like again, everybody is a little bit different. A little people again, very little people tend to be the ones that I hear the most. We didn't notice very much anyone, okay. Or, you know, parents are concerned because they're like, I don't know, I feel like we never had a honeymoon. I feel like we never needed just like a little bit of insulin. We just went from not using any really using insulin you know,

Scott Benner 9:55
so functionally, how do people deal with it? So we And you know, let's say I came to you and I said, Hey, here's my seven year old kid. Yesterday, this basil and this meal ratio worked perfectly. Today, it's a hot mess. And I'm saving low blood sugars all over the place. I don't know what's going to happen tomorrow. But as I look back, this is bouncing around. It's two days of this one day of that. But how do you find reasonable stability until things get normalized?

Jennifer Smith, CDE 10:30
Well, some of it again, in that early time period is, it's a bit of estimation, you can base it on Well, yesterday was a really sensitive day, if it looks like we fought low blood sugars all night, and we're entering morning time again today, with lower blood sugars yet again, that's a good visual that maybe today needs to be covered similar to yesterday, or even less aggressively than yesterday, right. So some hindsight can help. But then, you know, tomorrow morning, you wake up, hi. You didn't do anything strange overnight, and you're all of a sudden, hi, today might be one of those days that you're going to need more insulin. And so it, it's hard, because it takes us out of the picture, a lot of the things that we've done. In other we've discussed in other episodes, like testing, right, and doing things like Basal testing, in this time period, it's kind of hard, because you don't really know exactly day to day, how things are going to move overall, the general idea that kids before puberty, once remission, has kind of gone away, right? Once that honeymoon period, you're expecting it's over. Insulin needs usually are about point seven to one unit per kilogram per day of insulin,

Speaker 3 11:52
say 2.7

Jennifer Smith, CDE 11:55
to one unit, per kilogram per day of insulin. So and if you don't know pound to kilogram conversion, just take your pound weight and divide it by 2.2, then you'll have your weight in kilograms. But that's a it's a baseline, you know, if you were really, really, really low to begin with, and now you're doing a really low carb diet as well. You may not really see that insulin dosing kind of go along with what we would expect in terms of overall insulin need, right? Usually, people are considered in remission, if they're at, you know, point five or less point five units per kilogram per day or less of insulin. And then, you know, once you get to puberty, gosh, I mean, you could use anywhere between a unit to two units of insulin a day during puberty, and that's completely normal. Absolutely, and completely normal. So, if you're not so sensitive anymore, you definitely see these swings in blood sugar, you know, especially in that growth period overnight, or in the aftermath of meals, and is lasting and lasting and lasting. guarantee you're probably not in honeymoon anymore.

Scott Benner 13:09
Well, you know, you I've said it to you, I've said to everybody listening, you have to meet the need. And I don't know if I'm right or enough about that. But if one day the need is greater than meet the greater need. And if one day the the need is lesser than meet the lesser need. And, and flexibilities just it's completely key. It's what you're saying. It's like you have to sort of I don't think that I don't think that during honeymoon, you want to look real macro. Not all the time, right? You want to kind of just deal with diabetes in segments of of half days or hours or something like that. Like, here's what's happening right now. If it starts trending one way than adjust with it, if it starts trending the other way, then adjust with it. But I don't think there's a lot of value. Unless you're matching an apples to apples day and going well last Thursday. You know, she was really low. So I don't want to be aggressive six days later. You don't I mean, like, today's got nothing to know. Yeah, correlation between now and six days ago when you're in this honeymoon fluctuation. And I know that people are gonna think I'm flipping but I think you could just retitle this episode, diabetes pro tip ministration. And I don't know that we're gonna say too many different things when we get to it, which is why maybe for some people, they gloss over it when we talk about these basic ideas of like, it's not always going to be the same all the time. You can't always ask for a cut and dry answer. I mean, if you want to get through a honeymoon period, and it's, it's particularly, you know, Rocky, I think that just staying flexible, meeting the need, you know, taking a little bit of historical knowledge off of days that were similar to the one year clearancing now, I think that's really the whole thing.

Jennifer Smith, CDE 15:03
I think that's the best that you can do oftentimes, especially in honeymoon and then even, you know, coming out of honeymoon, there's, I know some people use the word like it becomes more stable. Okay. Sure. I mean, more stable in the fact that you're not like giving only one unit and that whole talk takes care of your whole day. Yes, absolutely.

Scott Benner 15:32
One day, the units necessary then the next day. It's not necessary. But there's consistency. I think they mean,

Jennifer Smith, CDE 15:37
there's more consistency is is it exactly. And I mean, in honeymoon, again, there are ups their downs, yes, you can, you can choose to use insulin from some hindsight from again, I know on a really, really busy day like this. My child needs a lot less insulin, but is running high today. Yeah. Okay. Again, it's the then meet the need in terms of where the blood sugar is right now. And thankfully, these days, I mean, you didn't have an I certainly didn't, does a kid have any visible to where my blood sugar was going at all. It was a one number, it could be rising in 10 minutes, it could be dropping in 10 minutes. And that's what it

Scott Benner 16:21
will. I wonder sometimes when I'm like, speaking to this person, now who's got a very small child who I think still their needs are, well, they're not honeymooning, they were just, they had too much basil going. So it's, you know, by using too much basil, they were getting drops, that didn't seem to make sense, right. And so it took a day or two to figure out that the basil was too high, to bring it down a little bit. But in there, while we were trying to figure it out, this person was using pens. And so they were relegated to point five units at a time. And I just said you have syringes, and she did was like just eyeball less than a half. Next time we go for this meal, and did that and fixed a lot of their problems. And so while this kind of unseen force, obviously I'm talking about basil that we needed to fix though, but you know, let the unseen force be up, you know, your pancreas working all of a sudden, was dropping her down. The limiting factor was the was the measurement on this on the pen. And like, for some reason, your brain doesn't jump over that and go, Well, this might be too much what your brain says this is all I'm able to do. Do you know what I mean? Like and so but the minute we drop, like these quarter of units, then suddenly there was far fewer spikes in the meals and then far fewer lows afterwards. And I'm just wondering like during the honeymoon period, if you are that scared of these crazy drops, do you maybe just draw back your basil a little bit? And then on days when that basil is not enough, just increase your meal insulin a little or do you really mean like, because also these these poor people are probably MDI in this moment. That remastered diabetes Pro Tip series is sponsored by assenza diabetes makers of the contour next gen blood glucose meter, and they have a unique offer just for listeners of the Juicebox Podcast. If you're new to contour, you can get a free contour next gen starter kit by visiting this special link contour next one.com forward slash juice box free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juice box free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen. It fits well in your hand and features Second Chance sampling which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash juice box free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips you can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now, through your insurance. Contour next one.com forward slash juicebox free meter go get yourself have 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 gonna see all of the terrific things that touch by type one is doing and I mean, it's a lot type one, it's school, the D box program, golfing for diabetes, dancing for diabetes, which is a terrific program, you just click on that to check that out. Both are caused their awareness campaigns and the annual conference that I've spoken at a number of years in a row. It's just amazing, just like touch by type one touched by type one.org, or find them on Facebook and Instagram. links in the show notes links at juicebox podcast.com. To touch by type one, and the other great sponsors that are supporting the remastering of the diabetes 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. G voc hypo pen is a ready to use glucagon option that can treat very low blood sugar in adults and kids with diabetes ages two and above. Find out more go to G voc glucagon.com forward slash juicebox G voc shouldn't be used in patients with pheochromocytoma or insulinoma. Visit G voc glucagon.com/risk.

Jennifer Smith, CDE 21:31
Correct most often and like you said, unless they have, you know, half half unit dosed or marked syringes in which yes, if you've got to get good eyes or you have a good magnifying glass, you can get kind of a quarter unit ish in there, whatever it might be, that I've got a good friend that does just that, and she's done it for a long time, and it works great for her. But again, you have to kind of use those microscopic doses. And on pens, it's a hard thing to definitely do, because all you can get is a half a unit. I mean, I think on pumps, honestly, in honeymoon and I know a lot of clinics often don't encourage people to start pumping until honeymoon is expected to be almost over. And I you know sometimes I agree with that sometimes I don't agree with that I think it kind of is individual in need, you have to look at what people are able to do and kind of a knowledge base of where are you already. But those doses they do, they do shift and change through honeymoon. And then you know, going out of honeymoon, you can expect the doses to definitely increase your child your teen your you know, adult that you're living with or your partner to or whatever, you're going to expect that their doses are going to increase. And while kids are growing at the same time as coming out of honeymoon, there are a lot of factors there. Another piece in the mix that often shifts things to higher insulin, and we've talked about it before we talked about illness and management is that if a child is also sick within honeymooning, and is now requiring more insulin, then by the end of the illness, they may actually either leave honeymoon sooner, or they may just be still at a higher insulin need as during the illness, the pancreatic beta cells were trying to assist, and there aren't very many of them left. So they were getting stressed out and can can leave less than

Scott Benner 23:41
that makes sense. So interesting. Yeah, I think that so I think that the next step here, I mean, besides telling people like look, it's gonna happen, you know, if it's happening, it's flexibility is key, it's going to be a little more stressful, but only if you I guess only if you're looking macro when you should be looking micro and then vice versa. Like you just talked about a lot a number of ideas where you do want to pull back and see the big picture, but not about the fluctuations day to day those you kind of got to get on like a bowl and ride them you can't step back and have an existential conversation about whether or not you should be bull riding, you know, so but but the other stuff are their illnesses is their growth, you know, activity, those things are, those are big picture items, but to now. Okay, so now you've figured out a way to ride through this honeymoon. The thing that I see from people over and over again, is that when it ends, you know, like when the honeymoons over, they can't believe it. They can't pull the trigger. They can't ramp up. Think about it any way you want to, but they get stuck in the game, and don't recognize that the game changed

Jennifer Smith, CDE 24:59
now Oh, yeah, I think the big thing there is that especially in honeymoon, the sensitivity to insulin makes people very wary. Yes, of using more, right, because you can get burned, right, by using more thinking you needed more, because yesterday, it clearly didn't work with this, you know, lunch that we provided we're giving the same lunch today. So I'm going to be more aggressive, you know, gave a quarter unit yesterday, today, I'm definitely giving a half a unit and then on the back end of the drop happens, right? The good thing to know is that in, you know, the coming out of honeymoon kind of moving out of that, that phase is that you will have again, more consistency in more need for insulin, you won't have as much potential for those drops, where you learned they typically happen even if it wasn't every day, you probably got a good idea of where things needed to be lower in dose, or, you know, that won't necessarily be the case. Once you're out of time. I

Scott Benner 26:12
feel like you I mean, when I tell people about it, I say you just kind of have to reset at that moment. That's when you go back to the setting Basal insulin pro tip, you start over again, you get the Basal straight, you reevaluate how long your Pre-Bolus time is, you reevaluate your meal insulin after you've reevaluated your Basal insulin. And you just kind of start over that. The truth is, is that I think that the transition from honeymoon to out of honeymoon is not actually much different sometimes than the transition from MDI, to pumping in that it's just the, it's the same game different players, like I don't know how to like how to think of it, it's like, you know, right church, wrong, pew, I don't know what the what the the thing is, like you're doing the same thing. But the pieces have all just sort of adjusted a little bit. And you have to just step back, take what you know about the thing you've been doing, and reapply it to the new situation. Right?

Jennifer Smith, CDE 27:08
Correct. And with pumping, you know that you've got a lot more precision that comes along with that. So if you've been doing things as precisely as possible with, let's say, Just half units, right? And basil that's given once or maybe twice a day. Now you can really address where insulin needs are heavier, and are lighter, through the course of a 24 hour day, you can meet the need more precisely, thus, the benefit of doing some Basal testing again, even if you're just doing it overnight, I mean, everybody wants to sleep. So if there's one time a day that you're gonna do it, do it overnight,

Scott Benner 27:51
part done, and you get that part time to a bunch of a one C and some just good feelings. In general, if you're if you're thinking all 24 hours or just a train wreck, like maybe you can at least get eight or nine of them straight, you know an answer. And it's a good jumping off point for figuring out the rest of the day. I think that when you were saying something a minute ago, this thought just jumped into my head, and I'm gonna put it here. And I think it fits. I think no matter the situation, maybe I'm talking about just diabetes or life in general. But do something is often the answer. People, there's a few people freeze, wondering what the something should be. But if you're watching the same thing happen over and over and over again, if you just change the variables, the stressors on the situation, you might see something new, that helps you understand a bigger picture something different. And so, you know, if blood sugars are, I mean, I don't think it's a joke, but like online, sometimes somebody will throw up a graph and be like, I don't know what's wrong with this. And I'll literally just type more insulin. Because put in some more and watch what happens and then go Oh, cause and effect. I've done this, but they

Jennifer Smith, CDE 29:05
want to know where right. Okay, they want not just more or they're like, but where should I put that more insulin?

Scott Benner 29:12
Like do something right, right. Like, if you haven't been on vacation in 15 years, take $5 a week and put it in an envelope, you know, do something, try to change the situation a little bit. And I get that it's frightening. And I used to think jetting, I used to think that all these things that I saw around diabetes, were so specific to diabetes, but I've been having some personal things going on with my mom's health recently, which Jenny knows. Probably not at all. Yeah, right away. But but the point is, is that I recognize that the confusion and the lack of knowing when to jump and feeling like you're overwhelmed and feeling like you don't understand what to do next. It's life, not diabetes, right. And maybe it's Feels a little more dire in some situations than others. You know what I mean? Like standing in the store, trying to decide between two waxes for your car might not be as crazy as I wonder if I want to add three more basil units to my kid or something like that. But the truth is, is that that inaction, that's what keeps you where you're at. So if you're somewhere you don't want to be, do something,

Jennifer Smith, CDE 30:24
right, an easier one to honestly do. Let's say you are running high, you know, all day long. And you're higher after meals, but you're still just stuck high in that scenario, and a safer thing is just add a little bit more basil. Yeah, add just a little bit more basil, right? If instead, in time periods where you're not actually eating, it doesn't look too bad. And then you've got these big excursions after you eat just about, you know, anything, even a microscopic eight grams of carb, maybe and it goes rocketing up, well, then you may be okay with basil, and maybe the next place to add more. And again, not three units more, but maybe add a half a unit or adjust your insulin to carb ratio by one gram to get a little bit more insulin around the times that you see the change that you don't want to see happening.

Scott Benner 31:22
Arden has been getting up in the morning going to school, and her blood sugar has been rising this this school year, like 30 points in the morning. And I tried to let the algorithm mess with it didn't work. I tried making just some simple basil adjustments wasn't enough. And then finally I just said, Doris, like when you leave the house from now on, we just Bolus three units, please. And she's like, what I was like, just throw in three units, get the car go to school, I was like, because whatever's happening is happening enough. I believe it's happening, I trust that what I know is going to happen is gonna happen. And she's using an algorithm. So if you make an uncovered Bolus, it removes her basil immediately. So her Basal is like 1.2 in the morning. So I figured it was about a unit and a half or so to fix the number or to get ahead of the number. And we got to cover the Basal that's gone. So I was like, just three. And then we adjusted off of that ended up being a little too much the next day, we did a little less than next day, we had a better outcome. The next day, she forgot to do it. You know, on the third day, I was like, see it happened again, like, you know, like, do this thing that made her trust that tried to do it, and it becomes a little more important to her. I just think it's another example of do something. Right, you know, I I've been saying online a lot to people lately. And you'll forgive me because I can't pronounce it. in its in its origin language. In Latin, but I've been telling people lately, Fortune favors the bold. Just try something, you know, they mean, stand up thump your chest and go, I'm gonna take a swing here. Let's see what happens. And then you get back to this stuff you hear in the earlier pro tips, you know, right, it's all well,

Jennifer Smith, CDE 33:13
and I think the bigger thing too, that you're you're bringing in is try something, right? But then analyze what that training did. Right? Don't just try it and be like, Wow, that clearly didn't work. Like, still focus on it. Well, it didn't work, your adjustment either left you too high, or like, you know, happened for you and caused it to be a little bit too low in the algorithm couldn't really save you from that extra insulin well, but now you know, so you use that for that information and you move forward and you say, Okay, tomorrow, we're going to do it this way. I mean, that goes into you know, a lot of things in terms of kind of the exiting of the honeymoon. It does it's try this it looks like consistently in the past week, he's needed more insulin. Okay, great. You're trying to add more insulin? Is it enough? Is it getting to you to the place that you want to be? Insulin needs may actually continue to climb a little bit? It's not like a night and day like yesterday, we needed one unit and tomorrow we're going to need 10 units. That's not typically the exit of honeymoon. But over time, that lack of beta cells that is that was helping you is going to show up very evidently in that you don't return to that minimal amount of insulin.

Scott Benner 34:33
Do you know what made me do this episode when Isabel told me that she thought it was necessary? It was that I had to get over that thing in my head that it's already in the podcast. Like I was like, No, it's in there already. You just have to listen to it. And then I thought, well, it's in there but it's in a different way because what we just talked about what about that? It really is the way when I'm when I was talking about God I don't even know what episode it was now. I guess maybe That's a good point. It's hard to find them all but but when I was talking about like sometimes you know, people's meal insulin meal ratio, sometimes their insulin to carb ratio can be like spot on for a number of meals, but not work for a certain meal. And I always use that silly example, if you have meatloaf and mashed potatoes and green beans, and you count the carbs and it says the carbs say, Oh, this is five units, you make your Pre-Bolus, you spike, you end up correcting later with two units, which brings you down and you don't get low. Well, the next time you have the meatloaf in the mashed potatoes or whatever, seven units, you seven units, right, like you see it happen. And then you take the leap, you stop looking back at the meal ration going no, that's not right, I counted the carbs, it's right, this is five units, very similarly to the idea of you're using a pen that only goes up to a half of unit, and you keep using it and then watching a low blood sugar happen. I go, I'm powerless, but you're not powerless. Like you just need to go get a syringe and do it a different way. And you're not at the mercy of your carb ratio just because it works five days a week, but not on Sunday when you have meatloaf like Right. So it's all kind of the same idea. Like, I know, it sounds trite. But it's all well, and that's

Jennifer Smith, CDE 36:14
I think it brings in a good a good piece too, in terms of, you know, multiple daily injections, and then we moved to pumping. And then we move to the fancy features of pumping. And then you might move to an algorithm driven pump, right? All of these things take. They take like evaluation. And a good example from somebody I worked with a while ago, who had started using one of the algorithm driven pumps. And she's like, this is fantastic. I love it. It's working so awesome. Like doesn't work on Friday night. And I was like, Okay, well, what were you doing on Friday night, that this doesn't work anymore for you. And she had this like, whole thing figured out for her dinner Friday nights that she would go out to with her husband. And on a conventional pump. She could use like, you know, a temporary basil. She could use an extended Bolus, and she had it down, Pat. I was like, just go to manual mode in your pump. And use it that way overnight and Saturday morning, turn your algorithm back on. And she's like,

Speaker 3 37:20
why didn't I think I was like, Oh, I don't know, either. But I hope that

Jennifer Smith, CDE 37:25
it helps. And it it seemed to be much better. Right. So

Scott Benner 37:31
yeah, because we went to a bar and art and got nachos with cheese steak on top of it and had French fries. And I crushed my first Bolus. I was like, I haven't been this excited about a Bolus. And while I was like I was on top of it. And then I started seeing the fat rise. And we hit it again. And I want and like I was over. And then I go upstairs to start working. And suddenly she jumps up her blood sugar jumps up and I go downstairs to my lab. And what happened? I had some gummy bears. She told me and I was like, no, no, we can't put simple sugar on top of fat and protein. I was like, are you all out of your minds? Without like significant I said art, if you were any gummy bears in this situation, the Pre-Bolus would have needed to be causing a fall before you put the bear the bears in, you know what I mean? Then that would have been okay, but she just did the like my blood sugar is great thing through and some insulin, wait a little while and ate it. And it was not nearly enough. We needed to be more drastic with it. And so I was like, so my text, my text said this, I'll bleep it out. It said that it said, open the loop Bolus for you.

Jennifer Smith, CDE 38:43
And let and let the Basal

Scott Benner 38:46
pumping for a minute and stop asking this algorithm to do something that it doesn't know how to do. You know,

Jennifer Smith, CDE 38:51
because it's not it's not a learning algorithm. Unfortunately, it doesn't, you know, it doesn't react the way that we have the experience to say, I know this is what's going to happen. Please don't fiddle with the insulin that I put in purpose

Scott Benner 39:08
is not the time to take the basil away algorithm. Cheese Steak nachos happening right now. Anyway, Jenny, you know, there was in the past, there was a moment when I, I used to worry. And I think like Well, we've already said these things. And people will find it. And now I realize that that's not how this is going to work that these continuing conversations are incredibly important. I think maybe the conversational part of this episode and many episodes is more important even than the technical aspects of what was said inside of it. Right. So like, if you listen to the Pro Tip series, and you had your brain or my brain or your experience in my experience you could derive from the Pro Tip series how to manage a honeymoon. But for people who are in that situation I think they need Get the information here. Yeah, I mean, in one spot. Yeah. And I just, I don't know if I was just like, super hopeful or lazy, I'm not sure. But I used to think like, just go listen to the protest episodes, it explains the whole thing, you know, and it really does. So I appreciate this, I think we're gonna have to, you know, like I said, I want to do one for you know, female hormones, menstruation, that kind of thing. So yeah, pick the next time we record. And then from there, I'm going to say this year, Jenny, because it'll put us both on the hook. In 2022, Jenny and I are gonna go back to certain pro tip episodes, were going to re listen to them on our time, and then incorporate questions that I'm collecting on Facebook, on how to supercharge those episodes. So they're going to kind of that's gonna get part two, kind of a situation. That's what cool that's how we will you and I will spend our time seeing each other through the winter of 2022 sequels to certain episodes, I'm thinking of them as director's cuts for oh, there you go. Older people who you remember the director's commentaries? Yes. You know, where do you mean you flip the movie on and the audio goes away, and you just hear the guy go? In this shot. What I was thinking was that if the sun came in from the left,

Jennifer Smith, CDE 41:18
we could could pan over here and listen to this music from this producer, you know, whatever.

Scott Benner 41:24
missoma Hi, X eyes are glistening. I did. I told the DP like, I don't know if you ever listen to them. They're pompous exchanges, Jenny and I will not do that. But we're gonna go back and listen to what we've said. Because I've done it a couple of times, like in Episode 500. I went back to Episode 11. That's bold with insulin. And I listened to it and like tucked over top of it like so people listening in episode, I think it's 100 Oh, my God. 105. Sorry. In Episode 100, I just basically did a director's cut of that, because I realized that when I said it, I was just saying it. Like there was and now I've lived all this time since then, and had these interactions with people that maybe there'd be more to add to that. And I think that exists for the protest series. Like and I'm excited. I'm sorry that you're going to start getting emails from me that say, please listen to this one before we talk again. But

Jennifer Smith, CDE 42:13
no, that's fine.

Unknown Speaker 42:16
You're a busy person well, and I can do it during

Jennifer Smith, CDE 42:18
my workouts. That's not usually I just, that's my mental like, my moving like mental sort of like strategizing time is my exercise time. I am not like a sit in one space and like meditate. I'm a moving meditator, but I can meditate on the episodes so we can make them better for everybody else.

Scott Benner 42:40
I have a question, then I'll let you go. How do you make out listening to your own voice? Does it freak you out?

Jennifer Smith, CDE 42:49
It's I don't know. It's I guess it's kind of weird to me, because I like I hear myself speak, you know, in your brain like, but when you hear yourself, it sounds different. I guess. I don't mind listening to myself. But yeah, I don't know. I don't think that I sound like what I sound like when I listen. No,

Scott Benner 43:12
no, no, I sound so right now we're recording, I can hear you and me and my headphones. I sound different in my headphones that I sound on the recording. And if I'm just speaking out into the world, I don't think I sound like the person on the podcast at all, but people think I do. But in my ear doesn't sound the same. Although And do you ever get on? Do you ever? Do you ever say anything and hear yourself? I go oh, Jenny, you should not have said it. You should have said it like this. You ever correct yourself?

Jennifer Smith, CDE 43:37
I do. Absolutely. And a lot of the ones that I listen to I'm like, Oh, this would have been a better explanation. Or I could have put this in as an example. And that would have been better. So maybe we Yes, I think it's great to sort of rethink them. Because then we can

Scott Benner 43:51
walk and I agree that there's there's just always going to be other stuff to say. And as we move forward into 2022 and beyond more people are going to be using algorithms. And there's going to be a whole new layer of understanding for diabetes, there's going to be things that you and I don't haven't experienced yet, that that through these experiences over and over again, abusing this technology, you're gonna come out I don't see an end to this podcast, I used to think it was finite. And now I think somebody is going to need to, you know, make up a cure for this podcast not to be necessary. So Well, that's

Jennifer Smith, CDE 44:25
what I was gonna say. I don't think until there's honestly a true like, you don't have to use any technology or anything. You just go in and get your bloodwork done and make sure your doctors like yep, you still look great. It's all perfect. I don't think you know the information that people need, especially with life changing and everything. I think it's purposeful.

Scott Benner 44:47
I appreciate you doing this with this. It's sort of the end of the year. So let me thank you for giving your time so greatly to the podcast. I want to thank assenza diabetes for sponsoring the remastered diabetes. Pro Tip series don't forget you can get a free contour next gen starter kit at contour next one.com forward slash juicebox free meter, while supplies last US residents only. If you're enjoying the remastered episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org. A huge thank you to one of today's sponsors G voc glucagon, find out more about Chivo Capo pen at GE Vogue glucagon.com forward slash juicebox you spell that GVOKEGLUC AG o n.com. Forward slash juice box. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed 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 in Episode 1025, we talked about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer, he'd really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning that Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active. Took me already from a decent 6.5 A one C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. 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. If you're living with diabetes, where are 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 If 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

#1022 Diabetes Pro Tip: Weight Loss

In this episode of the Juice Box Podcast, Scott introduces the highly requested Diabetes Pro Tip on weight loss with type 1 diabetes. He reflects on the success and growth of the Pro Tip series, which condenses tools discussed in the podcast into individual episodes.

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

+ Click for EPISODE TRANSCRIPT

Jennifer Smith, CDE 2:33
Is the variables in life that I think will always bring in something to discuss in terms of what it could be in? In diabetes? Like management? Yeah,

Scott Benner 2:44
no, I'm really happy. I'm really happy to hear from people because I think that others perspectives can make me go Oh, yeah, wow. Just because that hasn't happened here. Doesn't mean that's not happening somewhere. And then it gave gives, you know, good focus for what to do. So this is it. We're gonna talk about trying to lose weight when you have type one.

Jennifer Smith, CDE 3:03
As I mentioned, I think I did to I texted back to you. I was like, this is a big topic. It's not just like five minutes of just go out and start running. I mean, it's it's kind of like a rabbit hole. Honestly. I mean, there are many different like, little avenues to kind of talk about, and you had a lot of really good questions that came in, or like comments about, Gosh, I don't understand this, or why isn't this quite right or whatever. So, yeah. Yes. Great topic.

Scott Benner 3:33
So I'm gonna have very little to say here, probably. And I apologize for that. I guess this is the time, the time we pretend like I just came on your resume. And I'm like, Hey, how do I help? And then you just talk. But what what's the, I mean, where do you think we should start? Because to me, I think we should start at the idea that people correlate taking insulin with gaining weight. And then they don't think about calories and right, go. Hi, Jenny. Can you help me please?

Jennifer Smith, CDE 4:06
Well, maybe. I know, it's a good place to start in terms of like, one thing that everybody with diabetes specifically thinks about is that it's insulin. And I think a good place to even go with why does that start is because it's often something that a practitioner will tell people, you know, using insulin, you may be likely to gain weight. They think that was one of one or a couple of like the comments that came back about this topic. were specific to you know, why have I been told that I'm going to gain weight or why, you know, why is this going to happen? Or why did I lose weight and now I'm gaining all of this weight back like after diagnosis, right? So insulin itself whether your body makes it or you take it with an injection or with a pump, it's a storage hormone. That's its job. It's supposed to Have a certain quantity of carbs, sugar really out of your bloodstream and into places to either be used or stored, right. So in terms of management, insulin can make you gain weight. In terms of like initial diagnosis, a lot of people with type one specific have lost weight. prior to diagnosis, maybe it was very rapid. Or maybe it was like a lingering loss that people were like, well, I could just keep eating the whole cake. And gosh, I don't gain any weight, and I'm actually losing weight. And then they're like, Wait, this is wrong, this is bad, that shouldn't be happening. So they go to the doctor, right, they get a diagnosis of diabetes, they've lost weight. And in terms of that loss, it's often relative, it's usually relative to the fact that their blood sugars have been so high, that their body isn't storing those calories, right. So you're essentially paying them out, thus, DKA, and all of those things that can come about, you know, around diagnosis time, but because you're losing all those calories, and your body's not packing them in, once you have back, the piece of the puzzle that was supposed to help you use that food that you were taking in, your body is going to start storing it.

Scott Benner 6:14
And so and so. And that is the one confusion you see from newly diagnosed people is like, I don't understand I lost all this weight, and they don't understand the function of it. So explaining the function of it, I think is great. I think boiling it down into one simple idea is that you were dying. And yeah, and your body is using itself up and not storing at the same time trying to stay alive. And then all of a sudden, everything's okay. Now, the more weight listen to if I'm, if I'm talking about a school here, you just taught me but if you've lost a lot of weight, before you get to this skinny, emaciated, those are my ribs, you probably had weight to lose to begin with, right? Because it was there to lose,

Jennifer Smith, CDE 6:54
likely and especially more as the adults who are diagnosed yes, if you had weight to lose for whatever reason, you may have just thought, like I said, Oh, good, I'm actually able to take weight off. Now, I don't know why I'm still doing the same three mile walk every day. And now it seems to be working better, great. But yeah, once you get to that, like, shouldn't be able to see my lower ribs, or Gosh, my face looks really sunken in when I look at old pictures. That's not what you want. And

Scott Benner 7:24
I think that, again, it's probably sound, I don't want it to sound like distasteful, but if you had weight to lose, you were probably it's likely that you are taking in calories, that helps you stay at that weight. Meaning that when you start taking the insulin back in, there are calories there to be packed away to facilitate the weight gain again,

Jennifer Smith, CDE 7:45
and that's in any case, whether you could have lost weight, you know, and successfully, hopefully helpful, you know, left it off. But the goal was starting insulin is, in general, to maintain a healthy weight then right to get Yes, you will come back from the weight loss. But you should also with the proper insulin dosing, you should be able to get back to a stable healthy weight, you know, if you lost 40 pounds when you were diagnosed, and hey 20 of that you could have definitely lost and the other 20, you really didn't need to great, we should gain back maybe 15 to 20 pounds. And then we don't need the other kind.

Scott Benner 8:27
What is the functionality of the proper insulin dosing that makes you gain too much or not enough

Jennifer Smith, CDE 8:34
in terms of insulin dosing, that's correct. The amount of food you put in to work with it, of course, is a piece of the puzzle there. But if your insulin is being balanced along with your use of the energy that it's working with, then you should be able to gain energy back to your body that gets stored that keeps you at a healthy weight. And you shouldn't then continue to gain if the dosing is correct. And it's so it kind of goes back to, on a baseline initially make sure your insulin doses are right for you. And a lot of people wonder, you know, they I just leave it to my doctor. Yeah, it tells me how much more or less to take.

Scott Benner 9:15
And does that mean that if you're not using enough insulin that your blood sugars are left higher, so you're still having some of the action that you noticed before you were diagnosed? Right, you're, you're a little you're too high and your body's not storing the the calories correctly, the glucose clerk correctly and so you're not gaining as much weight so you could have unhealthy blood sugars, but feel like your weights good. And then you kind of come to that point. You're like, Oh, I'm good. And that really is the beginning idea of diable anemia too, right? Manipulating the insulin to keep your weight down. Okay, so yes, going the other way. If you're too low all the time. You'd have trouble putting on weight.

Jennifer Smith, CDE 9:57
If you're too low all the time. I'm one, you've, that's actually kind of an, it's an opposite of what you would think really, if you're low all the time. And that's a big reason, then when we start working with somebody we analyze insulin to begin with. And the first thing we look for, even if there are highs, high highs, we first look for lows. Because if weight management is another piece that they're really concerned about, then all of those lows that you're treating, you are feeding insulin, and you're feeding insulin, which ends up packing away the excess that you're taking in, and you maintain a weight that you don't want, or you keep gaining weight that you don't want.

Scott Benner 10:42
So this, this puts you in the position of having to look at carbohydrates as medicine, and being scared because you're low, taking away more than you need. And then suddenly, your belts back up again. And maybe you've got enough insulin in there to handle the carbs for your blood sugar. But you've taken in way more calories than you once got it. Yeah.

Jennifer Smith, CDE 11:03
Yep. So that's, that's that insulin is, it's kind of the key place to start, really. And, you know, then a lot of people ask, well, how much insulin? Should I really be on? How does this enough for me? Is that enough? For me? I know, we just talked about that kind of in depth in another episode, but really, you know, figuring out about how much insulin you need based on a weight to begin with, that's kind of a starting place that you could go to, how much total daily insulin are you using right now? What's your like current body weight, etc? Should you be using this much insulin? Is it taking this much more insulin to counter things? Or are you using like a heck of a lot more like let's call it Bolus insulin, right? But you see that your Bolus insulin is for a lot of corrections. And when you're looking at your data, you can see that the corrections are following lows. There again, more insulin than you really need. And thus your body is going to pack away by allowing the insulin to use up the food.

Scott Benner 12:10
It's funny because I wasn't 100% sure what you were going to say today. And yet I feel like we're into this situation, again, where the podcast should maybe be three minutes long. And it should say limit your variability use the right amount of insulin. And it kind of addresses so many things. I know this isn't weight loss specific. But let me just ask you one question. How many people you know what percentage of people do you think just a guess, are, are getting to reasonable outcomes by mistake. Like their bolusing too much, but they're eating on time and their Basil is too low and it works out or their Basil is too high and they eat before they get low. And they don't have to Bolus too much and it like how many people are getting there the wrong way. But it seems like it's working and then have underlying issues that they don't recognize.

Jennifer Smith, CDE 13:07
Like I wouldn't say it's, I wouldn't say it's anywhere near a majority of people. Honestly, I'd say it's a small percentage of people who have figured out insulin needs. Even though the dosing strategy that they're using might be wrong, like you said, maybe there's way too little basil, but they're offsetting it with boluses. And maybe the little amount of basil they're using is right for their overnights. And that's why it looks stable or, you know, vice versa, whatever. But I don't think that's the majority of people, I think the majority of people who are having issues with blood sugar fluctuations that they don't want, and also likely are having some issues with weight management of some type. It's, it's a start of let's look at what the initial factor could be insulin, okay. And then you move on further. And, you know, lifestyle is a big part of it, obviously. So then we look at things like calorie intake. And I think some of the some of the questions that came in were kind of, you know, around that, well, you know, I've run a calorie deficit and I've like run myself ragged going to the gym or, you know, exercising 90 hours a week. And it's still not working. But I, you know, and then you know, there's the fasting component and all of these things that people try to put into the picture. But from the standpoint of calorie, your calorie needs should meet your baseline kind of need in general. And then if you are working out on top of that, or you know, a training athlete or whatnot, then calorie needs go up. But at a minimum, there is kind of a minimum, on average that needs to be there. It's about 1000 calories a day, give or take person to person. But when you start dipping below that oftentimes what ends up happening is your body conserves. Because you're not meeting a need. And then you wonder, well, I'm at a deficit, why am I not losing? Because your

Scott Benner 15:09
body thinks you're lost on a desert island and it doesn't. It's trying to hold on to everything you put inside. Exactly. I had that problem where I've been eating more food, I've lost weight and eating less. It didn't, it didn't impact me as a fact. In fact, it sort of made me go the wrong way. So okay, so if someone asks you, is it not as simple as hey, I need to lose weight? Can you tell me where to start? Is it really person to person? Like, because what do you have to do first, like, like, think about if you were listening to this right now? And you could be any of the very people who are listening, like where do people start?

Jennifer Smith, CDE 15:48
I would definitely say with Well, first might even be an analysis of where are you? And where do you want to be? Or where have you been weight wise? Right? What's your goal to get to? And how much more are you above that than you want to be. And also, in that timeframe, it goes back to insulin analysis. If you've gained weight, as many people have in this past year. If you have gained weight, but your insulin doses haven't really shifted, there in lies a piece of the puzzle to write usually, for about a 10% change to your baseline like weight, you're probably going to expect a need to change your, your Basal and your Bolus ratios by about 10% as well, to be more aggressive and to take, you know, take into consideration that gain now when people are looking for loss. They're like, Yeah, but I don't want to use more insulin, because that's not going to

Scott Benner 16:52
work. And they think, oh insulin, put the weight on them. Correct. Okay, gotcha.

Jennifer Smith, CDE 16:56
But really, they need to first manage their blood sugars, right? And then they can start working on whittling away or whittling back and some of that comes into. Okay, let's look at the lifestyle things. Let's look at Are you exercising? Are you active enough? Does your calorie intake meet what your actual need is? You know, where can we whittle away some things so that weight comes down and along with it, then as you do lose? The same thing happens with insulin, your insulin doses should be adjusted back based on loss.

Scott Benner 17:30
You are making me think strongly about when somebody comes to me and says, Hey, I just got diabetes, and I play a sport or my kid, you know, is on the team. And we're so worried about this. And I very badly don't want to give them a band aid answer about how to get through the sport. I want to tell them let's take the time now and get your insulin right so that during the activity there really isn't any issue. And it's hard for people to believe that once they've seen it once they see cause and effect once they see I ran around and my blood sugar went down. They imagined that is going to happen no matter what all the time. And I Ardennes. I'm sure you're the same way. But Arden's insulin, so well balanced at this point, like activity doesn't make her lower or higher. Really, it's not, it doesn't really change too much.

Jennifer Smith, CDE 18:18
Yeah, it depends. I think that brings in, you know, the consistency of exercise or activity, right, the more attune your body is, let's say you go out for an hour every single single day to get some form of real exercise, right, your body gets used to that. So initially, you might see that your insulin needs drop off within the hours of the active time, right, and maybe even stretching several hours later, depending on what you did. But over time, that impact is lessened, you will usually need to be less aggressive with insulin adjustment, or maybe not at all. I mean, I can typically take my kids to the park and not really worried too much about that unless I know I'm really going to run around crazy with them. And I likely have insulin on board. Right. So then something needs to be you know, offset. But so yeah, I mean, once you get to the point of like lifestyle adjustments and a base insulin that's working, your fluxes in insulin dose then will be minimized. I think oh, sorry. Go ahead.

Scott Benner 19:23
I think people need to be certain to that. Once they start exercising their body is going to use the insulin better. The answer then is not to feed the low it's to adjust the insulin. You know maybe the first time you have to feed it but then you have to learn from there and make an adjustment so that you're not constantly battling yourself because that is what happens right? They exercise they get low they eat it adult the adult it overpowers what they meant to accomplish. Okay,

Jennifer Smith, CDE 19:49
and then they and then you end up getting frustrated too. Well, goodness. You know, I go to the gym but I have to eat like a whole sandwich and a half a banana in order to go to the gym and not have a low blood sugar. What's the purpose? stuff that when I'm trying to lose weight, and then I stopped doing it because and they stopped doing it right, or on the other side of it, you know, someone who may actually, okay, I'm going to really focus in on my diet, I'm going to clean it up, I'm going to, you know, cut my macros down and actually meet the caloric need that I'm at right now. And then what they end up with many times are lows, especially the cleaner the diet gets, and the more accurate intake of calorie value is for that person, your insulin needs will actually come down sooner. So to avoid lows and needing to treat in the time period where you're really trying to be, let's be good. Let's say, just take your insulin doses down by maybe even, it's just your Basal take it down by maybe five to 10% across the board, okay?

Scott Benner 20:49
So it's get your insulin, right. So it's understand diabetes first. And then it's the normal stuff, we all talk about it being active, getting your heart rate up. A sedentary lifestyle leads to more resistant blood sugars, which leads to more insulin, which probably leads to more lows, because you get out of balance, blood sugars, and what you just said, about clean eating. We don't really talk about it. Like we like if we were all out in a field, okay, let's just say that if it was 400 years ago, and somehow insulin existed, but we were still just farming and breakfast might be an apple you found on the ground, and maybe on Wednesday, if you're lucky. The guy up the street kills an elk. And we get a steak Right? Like if we were still eating like that, and we had manmade insulin, people would not be using nearly as much insulin as they use now, Jenny's Oh, no,

Jennifer Smith, CDE 21:46
not at all. I mean, if you were living on like, Barry berries that you picked along the trail that you were tracking the elk on and then you stopped and you ate some of the watercress to get your Vitamin C out of the like stream that floated by whatever. No, what No,

Scott Benner 22:04
you might not need as much as right now

Jennifer Smith, CDE 22:06
you wouldn't. You're also active level that I mean most like let's call them, you know, cave dwellers or whatever at that point of life, right? activity was part of your day. They didn't have a gym that they went to. Their hunt for the bison man was like, active.

Scott Benner 22:24
I bet you're running from a mountain lion burns carbs. What do you what do you think? So I guess my point is, is that while I'm not telling anybody how to eat, and I'm not certainly telling you that my daughter's counting macros or anything like that. Processed foods, right? Manmade foods, stuff that comes in bags, oils that don't belong in your body, all the stuff that we consume all the time that we're not aware of. It's making your variability greater and it's making it more difficult for you to use insulin.

Jennifer Smith, CDE 22:56
True. In fact, I've also kind of heard people and there's truth to it.

Scott Benner 23:02
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Jennifer Smith, CDE 26:18
Many people have found that if they eat a true cart, let's say they eat an apple and they Bolus for it, they end up with the ratio that they're using for that simple like very clean carb to go low. Okay, and then when they mix it up, and let's say they have potato chips or something along with the Apple or they have something, you know, more processed along with it, their carb count ends up looking clean, like okay, it comes out I don't get low later. So what gives it really is that the body processes more natural food in a better way. There's there's less leftover to kind of linger in impact. And a lot of people are basing their insulin to carb ratios, more specifically, around combination meals that are not quite as for lack of a better term clean,

Scott Benner 27:16
right. So your heavier insulin ratios work better if you have the orange with the potato chips, but if you just eat the orange, the orange doesn't need as much insulin. So the ratios you have are too heavy. Correct. I now Arden's ratios are heavier, because she doesn't she eats a diet that has processed foods mixed into it. But she'll go on a kick around this time of year about oranges, where I have to buy like 10 pound bags of oranges to keep around the house. And she's like I want an orange I want lunch. Now these are big, like softball size oranges that I'm sure to Cara, Cara oranges. Those

Jennifer Smith, CDE 27:51
are my favorite. Yeah, I

Scott Benner 27:52
think they are and they're really good, right? And but I bet you and I've never looked, but I bet you that the card count on them has got to be more like 25 or something like that. Like he could be more right. But I only give her enough insulin for like 11 carbs. And and she does a little 130 Rise and comes back again. Because I you know because I know her ratio is higher to handle other things, which is why you look at plates and go okay, tonight, I don't need as much, you know, for that. But this is not this is not going to be a satisfying, you know, people just want to hear like, please just tell me what to do. And I'll do it will work. But nobody wants to hear. I guess this I know, I don't like you know what I mean? I don't have diabetes, and I saw I'm listening. I was like, Oh, this is how I would lose weight. So you know, it's it's just do you think that we've just spent so much time as the society looking for marketable sellable ideas about how to get around? The idea of being in shape? There's no, it's, it's exercise and calories. Right.

Jennifer Smith, CDE 29:01
And I think that's the reason that there are so many I mean, if you look at around the first of the year, there, I can't remember which publication it is. But they come out with an analysis of I think, like the top most, or maybe it's the 25 top most like used column diets, right, in the past year, and what's kind of proven true to what it promotes and what really isn't, it's kind of like flimsy right. And some of the top ones are things like the Mediterranean diet. And you know, by no means am I promoting that or whatever. I'm just saying that that ends up being taught from a lot of different health parameters. And it's also a clean way of eating. Most people think Mediterranean and they think well lots of breads and lots of starchy things and that's actually not true. A lot of it is plants, especially the really good non starchy vegetables. types of plants. And then if there are grains that are the heart of your grains, right? I mean, it doesn't tell you to eat your carbs as a bag of Doritos. It tells you to go and eat some quinoa on your salad with, you know, an orange on the side. Right. But I think it brings in diets. Yeah, it's idea that there is the perfect thing out there. Right.

Scott Benner 30:23
Right. And that it's going to be doable for somebody because maybe, listen, maybe macro accounting, maybe there's a biologist somewhere that could give you the perfect diet for your body. But where am I getting that from? And where are most people getting there, I have to tell you that a couple of weeks ago, I started getting achy, right. And then I looked in the mirror, and I was like, my face looks puffy. And I went to the Costco and I bought two little roaster, chickens. And for steaks, I smoked them all, slice them up, put them in the refrigerator, and I've been eating those and salads and some of those oranges because they're around the house. for about the past eight or nine days, I'm easily 10 pounds lighter than I was. And I know that I know I'm a fluctuating person, like I know I jump around like because what will happen is at some point, someone's going to give me a piece of bread and I'm going to pick oh my god, bread Does everyone remember bread, and then then I'm going to eat a lot of bread for a week. And then I'm gonna go now my back stuff. And I feel like I gained five pounds and all that stuff. But just if I explain to you that most of my meals have been like a couple of eggs in the morning, and a couple of tiny slices off of that steak, and then at lunch, some some of the chicken and some of the steak with a salad. And I've I feel great. And I know it's true, like because I've been through it enough now now to talk my stupid childish insight into like, just continuing on that way that I don't know if I'm ever gonna get to do but I do know, it's honest. And it works for me. And I've seen it work for other people to like you take out processed food and carbs. And you're you're better off like, I don't know, it just seems obvious. But

Jennifer Smith, CDE 31:56
it's it's, you know, like you said, you're not focusing on like macros, you're not focusing on how many do I need in a day, you're what we end up finding. And I think this is the premise behind a lot of the like, the Palio kind of diet and the Keto type of diet, right, it's, if you're following the rules of those plans pretty well, they can be very clean eating plans, they can, there can also just like being vegetarian can be or vegan can be very healthy way of eating. But there are also like the complete like backside of that where you're eating a lot of processed vegan or like the Keto like kinds of things that are like the treats and whatnot, if you're focusing your intake on a lot of that kind of stuff, you're lacking in quality, and then your macros may very well without you realizing it be completely out of order. And I think that's why a lot of like plans like this end up failing, you know, I followed keto. And it was supposed to be this magic, like weight loss, and I also have diabetes, and it was really supposed to help with my blood sugar management and whatnot, well, I haven't lost any weight, well, maybe there are some things then to evaluate within it, you know, the keto diet is a way to get your body to start utilizing fat instead of carbs. So if you haven't really analyzed how you've broken that down to make sure that you are one maintaining ketosis in the right way. And that the kinds of like carbs that you're eating are really not offsetting, then it may not work well for you

Scott Benner 33:42
don't you find that you have to be in tune with what your what satisfies your body? Like, not what satisfies your brain, right? But what satisfies your body. And I've absolutely I've seen myself go either way, like where you're just eating for taste and flavor and comfort. And that's never usually good for your body. And then there's a way where you're just sort of never hungry. It's that's where I am this week. I have not been hungry this week. And if I have had any like Inkling towards a sweet, I've been specifically careful to take just like dark chocolate, like just a little bit of dark chocolate like this will this will get me through like, what I'm assuming is basically withdrawals from flour and sugar and stuff like that, you know? So I don't know like, are you telling? Are you telling me that all these questions aren't even worth looking at? Or should we ask them? No,

Jennifer Smith, CDE 34:32
I think they're very worth looking at because I think some of them may relate to what we've kind of already gotten into. And then some of them, I think are really good questions in terms of the why it wouldn't be working right? Or why it might actually work. So yeah, let's pick a favorite

Scott Benner 34:53
or should I just pick, you just pick? Well, so Jennifer's asking about her son, she says any any advice on how to balance All this high carb gluten free food for my growing always hungry 14 year old T one D with celiac. So she has a son who seems to need blending down. And at the same time, she's giving him a lot of carb heavy stuff, because it's like it's some of this. For the celiac diet, it seems like right? The gluten stuff,

Jennifer Smith, CDE 35:22
right. And that's, I mean, celiac is a hard addition, it definitely is. Because while we now have a plethora of gluten free, very tasty products on the market, most of them are made with very, very processed, very high glycemic, I mean higher glycemic than even your wheat based bread, you know type of pasta, whatever it might be. So when you start processing things like rice into a flour, or you know, potato into a flour, you have a quicker digestive component to that, and it raises the blood sugar faster, its glycemic index is just high comparatively. So when you have to do these types of things, especially if you have a teen who is growing is active, but also could maybe use some slimming down or maybe needs to gain a bit of weight. One, it's maybe sitting down honestly, with a dietitian to see what are my child's growing nutrition needs right now? Are we you know, keeping kind of a log a couple of days of what are they really in taking? And then looking at what their nutrition needs should be for the point in life where they are, you know, are they moderately active? Are they heavily active? Are they kind of couch potato video gamers? What is it? And what do they need? And then looking at the kind of food that you put into their caloric need? Again, I mean, parents are typically the purchasers of the food in the house,

Scott Benner 37:06
give or take, you don't think this 14 year olds got a credit card? Yeah, I mean,

Jennifer Smith, CDE 37:11
and my kids, gosh, I mean, if we walk down the aisles in a grocery store, and they see like, the pretty packages, and you know, like, I never go, we don't eat cereal, so I don't go down the cereal aisle, but they'll always have something on like an end cap, you know, at the grocery, especially my eight year old, like, boy, that looks really good mom, I'm like, Yeah, and it's not really good for your body.

Scott Benner 37:35
That's why they have to make the picture. So nice. There's no fun here, stop it. Well, so I

Jennifer Smith, CDE 37:44
think, you know, from from that standpoint, you have to look at what is the child in need of? Are you meeting it? Are you creating access? And then potentially from a gluten free standpoint? Yeah, finding substitutions that can be fit in to meet his tastes, because all kids and teens are different, you know, as much as you want them to eat asparagus. They might not. Yeah, so you know, right?

Scott Benner 38:09
So, so you have to be it's Listen, I know if you've been listening for a while, you know that I took me a while to diagnose my low iron thing years ago. And during that a doctor made me eat like gluten free for a month. And I gained a lot of weight because I went out and bought all these gluten free items. And somehow in my mind, I was like gluten free equals health. That's how it felt to me. So I was like, Oh, it felt like zero calorie stuff when I was going in. And man, it was just not. I think if this was me, if Jennifer was me, and I didn't know what I was doing. I think I'd introduce like, lower carb more meat friendly, like meals, like that's what would occur to me first, right? Make some chicken, make some steak, put it with a salad or a vegetable and maybe cut down on carbs. But then you got to remember like we spoke about earlier, not to dose it as harshly as you would some of this gluten free stuff or you're just gonna create a low and you're gonna then have what you did by with

Jennifer Smith, CDE 39:05
them. Right? And I think you know, when we look at, you know, going back to just that like clean eating idea. Quite honestly, you can be gluten free if you're choosing to not buy as much processed food pretty easily. Yeah, I mean, you know, things like quinoa or like a wild rice or even like a brown rice or what? That's 100% gluten free.

Scott Benner 39:32
It's the fun stuff where it causes your problem. Right? It's

Jennifer Smith, CDE 39:35
not taking it out of the diet. It's just that you know, and I know the struggle with kids I work with plenty kids and teens to know that what they get at home under mom and dad influence because this is what you're eating turns around. It changes considerably once they start to do things with their friends, you know, now gluten free in the picture. If the child is is paying attention to that and knows that they just can't have gluten, they may already then have limitations even compared to what their friends are eating because they know that they just can't do it or they're not going to feel good, right? But in that circumstance, then it kind of takes sitting down and figuring out well, what that what will possibly be there that you could have, knowing that it's still more of like a process treaty kind of thing. But also that, you know, we're not going to do this at home. But you can have it when you're out.

Scott Benner 40:34
Okay. Laura has a question. It says, Is it true that insulin on board prevents the body from breaking down fat? Meaning that in order to burn fat, you need to have stretches of time with only your Basal insulin and no insulin onboard? That's interesting. I've never heard that.

Jennifer Smith, CDE 40:50
Yeah, it is, I guess it's an interesting way to frame it. I mean, we know that in the, we know that in the overnight time period, without any food on board. And on Basal only our body does get into more of that, like fasting state, right, of actually transitioning to some fat burn, etcetera. Because you're on a low level of insulin,

Scott Benner 41:13
I see what she's saying, okay.

Jennifer Smith, CDE 41:15
But when you have insulin on board, technically, there's a reason for the insulin on board. Right? Right. You're dosing for food, so that insulin on board should be covering food that is there. So yes, your body's processing carbohydrates. And your body is not at that point, then going to be in fat burn mode, it's kind of correct in a way of stating it. Yes. I mean, the same thing for a high blood sugar that you've corrected, now you've got iob. And the high blood sugar indicates that there's excessive sugar there, and your body needs to process it. And as such, it's using the insulin to process it and break it down and get it in the right places. So again, technically, as long as there's not an insulin deficit in that high blood sugar scenario, and the insulin is working to get it down, then your body isn't also breaking down fats, either,

Scott Benner 42:16
then is that a vote for intermittent fasting for type ones?

Jennifer Smith, CDE 42:24
It could be and can intermittent fasting work, right? It can. But again, a blanket statement is to stay that any plan that you choose no long term that you can continue this, right. The problem with the diets that are out there isn't the diet itself. In fact, there's a lot of research around a lot of the diets that proves long term, these people have had this success in weight management and cardiovascular benefit, et cetera, et cetera. But they've stuck with it. Yeah, it is the Oh, I'm gonna do intermittent fasting, oh, I'm going to do the keto diet, oh, I'm going to do the, you know, cabbage soup diet for the next month. And once it starts kind of showing benefit, I'm like, I can do, I can kind of step outside of the rules, the parameters, which are often for diets, very black and white. Yes, do this, this and this, but don't do this. And as soon as you do that, don't do this. You've broken the piece of that plan. That was getting you to your goal,

Scott Benner 43:32
right. I found intermittent fasting, the easiest to stick with, because to me what it was was as long as I don't eat, like don't eat after ate, and don't eat before noon. That is basically how I did it. And I have to admit, it's very effective. Now, I realized while I was doing it, that Arden basically does that already, without the late night thing, but she's so young, I don't think it matters, right. But she gets up in the morning and is not normally hungry in the morning. And so I've had to over time thoughtfully balance out how her insulin works in the morning, right? How do I come out of sleep into feet on the floor off to school without a rise that needs a bunch of insulin so that I don't create a low because she really doesn't want to eat until she's done with school or till lunchtime, right? Sure. So basically, Arden does intermittent fast, except she doesn't do 16 Is it 16 Wait 1819 2016 Eight that was embarrassing. Oh, lot of people would edit that out but I'm not going to. She doesn't do 16 Eight and as much as she probably does, like maybe 1410 Something like that. But also she's 16 So she can you know she can like we over Bolus her meal last night for dinner. We had stuffed peppers like turkey stuffed peppers, and and a salad. And my wife, my wife like swung at it really hard and about a half hour after she ate I was like her blood sugar is like stuck at 70 I was like, This doesn't look okay to me like I think this is gonna go the wrong way, you know. And so as it started to trend away, Arden got a little lighter I and she goes Cinnamon Toast Crunch please. So she knew she had basically Pre-Bolus cereals. So she was like, let's do it. And she had some of that had my wife going, I'm gonna guess 10 or 15 carbs less on the Bolus. She hit it right on she was so close. But you know, that's a young kid. And Arden's also helped by other things that I think are worth mentioning here too. Because those of you listening have type one diabetes or love somebody who does, you really have to get your thyroid levels checked. Like you'd could be fighting against a borderline thyroid problem that's making weight loss impossible you know and if you're going to do that you really need to go back and listen to the thyroid episode with Dr. BENITO because the range that your doctor is going to say your thyroid your TSH levels okay in a real badass endocrinologist will not accept you know what I mean? They will not like if you're over a two Dr. BENITO is giving you thyroid hormone. Like then there are people right now who are listening are like oh my TSH is a five My doctor said it's okay. I'm borderline. Yeah, yeah, right. But I but my hair does fall out a little bit or I'm having trouble losing weight or I'm a little nasty sometimes or whatever the other things come. I'm just telling you if your thyroids moving the wrong way, deal with it, because it makes a lot of life easier.

Jennifer Smith, CDE 46:36
And it's a lot within this whole topic of weight management. Absolutely. If you've the Hashi Moto is which is very common autoimmune. Once you've got you know, type one, it's good to get tested thyroid levels at least once a year if not every six months, especially if you've got other family who has a thyroid disorder known already. But that's huge in terms of metabolic

Scott Benner 46:59
Yeah, but you have to you have to advocate for yourself. You can't say oh my god, Scott, you're right. I am tired all the time and I can't lose weight and blah blah, blah, and then go to the doctor and the doctor say oh your TSH is for you're fine. Your TSH just for you are not fine. That's the equivalent that to me is the thyroid equivalent of in diabetes. When somebody says your blood sugar average blood sugar is 180 You're doing great. Right? Right. You might you know you're not dying, but you you're not living at a healthy level. And that has other impacts on your life. This thyroid thing is it is crazy. It is like the equivalent you trust me at this point. I've seen everyone in my family except for me deal with it. It's like taking a long metal like paperclip and just touching it on a computer circuit board to it just mess with stuff. You know what I mean? Yeah, but and with

Jennifer Smith, CDE 47:45
with Arden's doses, have you noticed that when things get out of order, do you notice a shift in her insulin need, because that's very common right away that, you know, metabolically, she's feeling more sluggish, sluggish and fatigued. And insulin is just not working, like it was supposed to work. And if there's a timeframe in terms of adjustment, or even just starting on a thyroid medication, where you will then start to notice a shift back to normal insulin dosing. See, again, that insulin manipulation in terms of the weight management piece with thyroid in the picture have to be very kind of eyes on right to make sure that you're adjusting than where you had bumped everything up in terms of insulin need, you're going to need to start bumping down. And if there's weight loss in the picture at the same time, definite need to bump down or you're going to just run lows Yeah,

Scott Benner 48:41
I there's some times I think I should even have a flowchart for myself like if this then that kind of chart because you're right, if the thyroid level starts to get away, then her insulin needs go up. And then we adjusted it doesn't happen right away and our insulin knees start coming back down again, the same thing with she had to start a birth control pill to regulate her periods. Hall. I lost three months of my life to figuring that out. Like it was just first they gave her a pill with not enough estrogen. And so it was basically just two wasted months. She was exhausted all the time because she was bleeding constantly. So I had to get her through those pills. Those aren't the right pills put her on the right pill that started working the bleeding regulated. Yay. Now she's lost so much blood I had to go get her an iron infusion. Got her the iron infusion. Now we're waiting for that to come back up when the iron infusion comes on board her insulin needs are going to change again. Yeah, vitamin D levels seem to impact insulin knee Yes. I just

Jennifer Smith, CDE 49:44
in fact many people for vitamin D that you bring it up that's another like peace and I think in terms of like, like, again going down the rabbit hole of discussion and weight management the we're kind of on the track of like medications and medications in terms of thyroid as well. less things like iron, but vitamin D, you know, your lab will tell you optimal is between or standard is 30 to 100. Optimal according to the female specific physician that I'd worked with years ago, before I had my first son, she was like, you know, optimal range is really 50 to 70. For vitamin D, she's like, and if it is not in there, you need to be being supplemented, because otherwise, especially with diabetes, vitamin D works on the cellular level. And it allows insulin to be seen correctly, it for lack of a better term, by the cells. And so it lets insulin actually work the way that it's meant to have one of the many things that can, so if your vitamin D level is off, supplement, I mean, in general, someone with type one, adult wise, should be supplementing at least 2000, I use a day. And if your levels are not optimized at least 4000 a day. And if they're really on the low end, you need to be doing like the hyper significant doses of vitamin D for a short period of time, if you like. And then

Scott Benner 51:10
for 50,000, I use and you take one once a week, or something like once a

Jennifer Smith, CDE 51:14
week, or I've even seen some doctors do like 110 1000 iu a day for you know, a couple of weeks and then retest. But vitamin D is huge. And

Scott Benner 51:23
I'm not a doctor, but there's something about vitamin D deficiency and autoimmune that go hand in hand. So just look at the studies out of Finland, right? I tell you, I listen, I take 5000 a day, and I take 5000 A day of vitamin D, I take a zinc tablet, I taken a sorbic acid with iron, and a B 12. And that's that's what I do every day. And that's what you know, my kids do and and everyone here is doing because when the D levels drop, again, problems with insulin, I'll tell you right now too, because Jenny mentioned ranges that you need to be in versus what lab values will tell you, Dr. BENITO back on the thyroid thing said, if you were a woman of childbearing years, anything under 70 for your ferritin is too low. And they're not going to tell you you're low till 20. So she's like, if you are having a period, you gotta be above 70. So there's a lot of things. And then all of these things also impact your body's ability to work correctly, which is in part and parcel of losing weight or

Jennifer Smith, CDE 52:29
losing weight, right. There was one in here that does go along with medications that I think is a really important question. This woman has a son on a medication that is more for like attention. And it's specific to using it versus not using it school year versus spring date break or summer time and what ends up happening in terms of insulin needs. And I think it's an important one, because I've seen a lot of kids who are using Add ADHD kinds of meds. And a very, very common thing with those is that it decreases appetite. Okay. And if they're using it in their school day, and they're also the brain uses carbs, and so the more thinking that's going on, and the potential that they're really not hungry, they may not even finish the lunch that you packed for them, they may pick at the lunch that comes from the school lunch, because their brain is just saying, I'm not hungry enough to eat, okay, you may end up having to have two types of Basal profiles, maybe one for like a spring break time off another one for school days. And again, as kids get more into the teen years, that becomes really beneficial in terms of growth and the potential for weight gain in the wrong direction. Because if you're constantly feeding loads again, or constantly adjusting insulin up and down, but it's kind of willy nilly and not quite right on with need. It's a medication adjustment kind of thing that goes along with adjusting insulin again.

Scott Benner 54:11
We're right up on it. But there's enough questions in here that all circle around menopause. Do you have any feelings about what happens at that time and Chinese? Yeah,

Jennifer Smith, CDE 54:20
that's a fun one. For myself. In general menopause in and of itself. I mean, perimenopause really is the start of kind of that time period in a woman's life where your cycles might start to get less evenly spaced. Right. Let's say you were the typical like 29 days and you was right on spot and now like, huh, now it's like 26 days and next month, it might be 32 days and then maybe 29 days and, you know, periods can get a little bit more aggressive, or kind of look more spotty, but that perimenopause kind of leading into menopause, which is really A woman has not had a cycle in a 12 month time period, right? So insulin needs can look very jumpy, you might even find that, again, as we get older. And these things come into the picture from a female perspective, our metabolism does slow down, we oftentimes start to need a little bit more insulin, or it takes a little bit more activity to maintain or burn off what we were able to do when we were 30. That doesn't work anymore when you're 45 or 50. So I mean, menopause, perimenopause, it brings in a whole circle of hormone impact, right, that may more aggressively change your insulin needs, especially around your cycle times.

Scott Benner 55:50
So not unlike, well, I guess, more aggressive but not unlike having your period and seeing right hormone fluctuations throughout the month,

Jennifer Smith, CDE 55:58
right. And then once you're in menopause, oftentimes, you know, outwards of a year or two post no longer having a cycle. Many times, then insulin levels should get more stable, because you don't have that hormone flux. And as we age men and women have less and less and less growth hormone cycling anyway. And so we end up especially women passed about the age of 65, or people passed about the age of 65. Oftentimes, their baseline Basal needs definitely go down. Okay. And the reason they are is because their hormone Cycling has kind of started dropping off.

Scott Benner 56:39
Okay. All right. Did we do this justice in an hour? Because I feel like we did, but I don't know much.

Jennifer Smith, CDE 56:45
I think that we did as much as we could get it in an hour. I mean, if we really wanted to focus in again, dig really deep into that information hole. There's a whole bunch of out meds that are very specific to like weight loss, and, you know, things like the GLP ones, and things like the SDLT twos, and what, despite them being type two meds, they are getting a lot more. They're kind of climbing on the ladder of benefit for those with type one and who are just insulin users. And they do have promise in terms of weight management, if use the correct way. Okay. So

Scott Benner 57:32
do you feel comfortable talking about that? Because maybe say here that if you liked this episode, look for that one coming in? Yeah. Okay. Great. Thank you. Yeah, Jenny, you got to do all the talking. I was at some points. Uncomfortable. Not for because you I was like, huh, there's not a lot for me to do here. I was just checking. I was just saving files and checking rates and looking at questions I was like,

Jennifer Smith, CDE 57:58
so like, I should have just gone and gotten an extra cup of tea. Kind of nice.

Scott Benner 58:01
I should have just said, Jenny, tell me about weight loss. I'll be back.

Jennifer Smith, CDE 58:05
It really is. I was looking at all the questions. I mean, there are a lot of really good questions, but I think a lot of them honestly. Go back to insulin. dosing it the right way for what you're kind of taking in. And then also, secondly, looking at what are you taking in,

Scott Benner 58:25
right? And obviously, in my mind, these questions all are, they're similar, they're tied together, whether it's vitamins, or your thyroid level, or your calories or, or whatever it ends up being is there is a balance that optimizes your body, it's not going to be the same for everybody. Some people's vitamin D level can be crashy load to the floor, and they'll never notice it, and it won't matter to them. But for some people it does. And when you get those things in the right balance, then you feel better and feeling better. To me. It's like you feel stronger, you're more rested, like all this stuff happens. You're clear in your mind. But how but some of these things nobody would even know to look into. No, you know, even vitamin D like I can remember 10 years ago, my Ardennes nurse practitioner gone. We're gonna start checking vitamin D was almost like a mandate came down from a mountain. You know what I mean?

Jennifer Smith, CDE 59:15
Yeah, actually, I don't even know when that would have been. But if it wasn't, I remember when I was working in DC, and the endo practice I worked with within the, our director was very, like high up within the whole, like diabetes management like realm of information. And his he was like, we're testing vitamin D levels for every person with diabetes. And at that point, it was really just, if the thought was it was relevant more to type two. But as we started testing, then I went to my own Endo. And I was like, you know, I run I'm outside all the time. I have like, you know, like brown skin from being outside. Like, I don't take my eye like I'm sure it's fine. In fact, I didn't mean the level came back and my doctor himself called me not as nurse. He was like, This is really weird. But he's like, I want you to go and get it tested again. He's like, This can't be right. And my level was 18. Yeah. 18. And so when I got it tested again, nope, it was 18. Again, he was like he did he that was the one time a week, the 50,000. I use, I came back in eight weeks, it had moved to 21. And he was like, huh, so I he sent me to see like a naturopath, who was also a physician who knew a little bit more in that realm. And she actually had me started, she started me on oral drops, okay. And the drops get absorbed through your oral mucosa rather than having to go through your gut. And because we know there's a lot in terms of gut and absorption in autoimmune disorders, she's like, I guarantee your body's not absorbing it. She said, that's the problem. And is it within about I think it was 10 weeks after that, I got it retested and was already up in the high 40s. Yeah,

Scott Benner 1:01:04
you know, I have to, I thought I was gonna have to live getting iron infusions my whole life, because I couldn't absorb it through my gut. And I do probably have some, like, weird stuff going on down there. And instead, I mix it. So first of all, I use a really pure, like, supplement from a company that, you know, you can do your own research and find one that you like for yourself. But I researched out found a really pure supplement, and I have to take the iron within his sorbic acid at the same time. I do that it absorbs great if I take just the iron tablet without the sorbic acid, we won't work. Yeah, that's it. There's a over the counter when called vite Tron or vitamin D or something like that. It's it's iron that comes with its C, vitamin C, together that helps that too. But yeah, these are the kinds of things no one's going to tell you about or they're just gonna blurt out. We're testing for vitamin D now, then you come back, quote, unquote, in range, and they don't give me one anyway. And you're like, Well, this was a lot of fun. So anyway, everybody balanced your body, balance your insulin. Things should get better. That makes sense. All right. Thank you, Jenny. Yeah, you're welcome. Absolutely. I want to thank assenza diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free contour next gen starter kit at contour next one.com forward slash juice box for E meter, while supplies last US residents only. If you're enjoying the remastered episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org. A huge thank you to one of today's sponsors G voc glucagon, find out more about Chivo Capo pen at G voc glucagon.com. Ford slash juice box, 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 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 talk 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, weightloss 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 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 insolence 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 and 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.

#1021 Diabetes Pro Tip: Postpartum

Scott is joined by Jennifer Smith, a registered dietitian and certified diabetes educator, who shares her insights on Postpartum and 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 remaster diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one, see all of the good work they're doing for people living with type one diabetes at touched by type one.org. And on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries G voc hypo Penn Find out more at G voc glucagon.com. Forward slash juicebox. At the end of this episode, which by the way, if you're a person who's like, Oh, I'm never gonna have a baby or I'm a boy, or whatever it is, you're thinking right now postpartum doesn't apply to me. These diabetes pro tip episodes are, I think terrific. And I think they all go together. There's a lot to learn from listening to this episode, because at its essence, it's dealing with huge variables, which is what you'll find after you've had a baby. So it doesn't apply. But it does. You'll see, at the end of this episode, I'll tell you where you can find Jenny, I'll tell you where the rest of the pro tip episodes are and what the topics are. And anyway, I think you should listen to this one, whether you're going to have a baby or not. Alright, well, that took three minutes, which is probably two minutes longer than it took mostly to get pregnant. So here's Jenny, but a bump. As time passes, I'm becoming more and more aware of a lot of pregnant women or women who want to get pregnant who have type one diabetes who are listening to the show, and who are enjoying like there's a series back in the show with Samantha where I interviewed her every three months, like during her pregnancy. Yeah, I remember you mentioned her and that apparently, is making the rounds on the on the internet and the way people listen to things. And I just get a number of emails and I'm sure you do as well that are either that start off with like, I can't, I'm never going to be able to get pregnant because I can't get myself together. And then they go I can't believe I did it or I'm doing it you know, like that kind of a thing. But then there's that. The rest of it that I guess we stopped thinking about because the baby's out. And I don't know that's that's weird. So a person in my mind, being a person who's never been pregnant and doesn't have type one. That journey seems painfully taxing to me from going from not thinking you'll be ever, ever be able to have a baby to figuring it out to then doing it having these insanely great a onesies while you're pregnant. And I don't know it just feels like it would be super simple to just not abandon it but lose sight of it after you have the baby because of all the things that happen after that.

Jennifer Smith, CDE 4:46
And I don't think it's that. I don't think it's that the good majority of women really think that they're just going to just give it all like all the work that I've put in over the past, you know nine to maybe 12 Once if they really did a lot of really good preconception management to kind of get there, and managed, it could have been a long haul of, you know, nine to 18 months, let's call it of trying to really strategically nail things down. But I don't think that if you've done that, or even if you've come into pregnancy, maybe not where you wanted, but you really did an awesome job of mastering things and getting things taken care of through the pregnancy. By the end of pregnancy, most women aren't like, Oh, I'm just gonna, like throw it all in the basket, everything I learned how to do. But there is a big piece postpartum that, especially as a first time Mother, is completely 100%. New. Yeah, it's I mean, it is it's like being thrown into like, a new job. In a country where you don't speak the language, they're like, here you go, it's all yours to like, figure it out.

Scott Benner 5:54
And by the way, that job will die. If you drop it or leave it,

Jennifer Smith, CDE 5:58
you're gonna kill a million people, if you don't do it exactly the right way.

Scott Benner 6:01
That's how it feels, isn't it?

Jennifer Smith, CDE 6:03
That's kind of what it is postpartum. I think a lot of the a lot of the up, down comes in, because you're trying to manage something 100% new, or the hormones that shift and change after you deliver can be a roller coaster of effect. And for me, I usually say in a general sense, the first three months post delivery, is going to be kind of a rollercoaster up and down. Mainly because especially if you're nursing or pumping to feed your child, the shift in hormones, and the shift in how much your nursing how much you're pumping, can drive things, the opposite way that you would think that they might, which makes it very difficult to establish, I would have usually like over Bolus for this, or I would have usually been really aggressive to nail down this now climbing blood sugar, but oh, I'm going to nurse in the next 15 minutes. So I really can't do this strategy, because otherwise I'm going to tank. So there's a lot that changes postpartum.

Scott Benner 7:23
Okay, so not only. So there are some people who enter a pregnancy and already have that a onesie that they need. But But despite that, whether you're a person who had to get there, or you were there already, once you're pregnant, your insulin needs, they drastically changed. I know it's not like trimester to trimester Exactly. Right. But there are times when you don't need as much as you think and times and you need so much more that it's hard to imagine how much more you need. Right? Right. So now you have that in your head, you've been pregnant, you're having breakfast that prior to pregnancy, took three units during pregnancy took 12 units, and now you've you're holding the baby, you're thinking is this 12 units? Is it three units? Why does the weight of the world feel like it's on my shoulders? Like, you know, am I nursing? All this stuff comes together? And how do you do that? So you started by saying the hormones, and I only want to spend a second on this, but you know, I'm older. And growing up, it doesn't happen much anymore, like society has really shifted, you know, in the way people are towards each other. And that might be harder for like somebody in their mid 20s to believe but when 30 years ago, you know, stuff that you think of as a joke now is actually how people would think about women sometimes like, oh, you know, she gets upset, or you know what time of the month it is, or that kind of thing, not giving any, like, credence to the idea that when your hormones are jumping around is really difficult to deal with. And you're right, and that women are in a particularly vulnerable situation because of that. So how you feel from a hormonal shift could be physically, it also could mean your your clarity. And I think what you said is just really important to remember, especially for first time mothers, when you have a baby and they give it to you, it does genuinely feel like someone just told you that the fate of the world rests in your hands, and you don't understand what to do. But if you mess it up for certain the universe won't exist anymore. It really feels like that.

Jennifer Smith, CDE 9:33
And some people have really awesome babies that are like the easiest. They just they sleep when you'd expect that they nursed beautifully. They sleep again, like they don't have any like major poop problems. You know, you just have this like, what you would call like, I have no trouble with my perfect baby. And then there are women who just don't like some kids are just one that type of an infant as a newborn, and I think when you have diabetes to then it brings in management again of something that's completely new. I don't know, should I do this? Should I try this is the doctor right? You know, am I going to do this wrong to my child, bla bla bla. And then there's diabetes in the picture, and the timing of insulin, and the timing of adjusting and remembering to change your pump site or to actually take your Basal insulin injection. I mean, there's a world of scheduling difference that comes into the picture postpartum.

Scott Benner 10:35
And I would imagine to and this is just me imagining but if you live for nine months with an A one C, and like, the low fives, there's got to be a part of you as a type one is just like, wow, I want this for the rest of my life to write. And now you feel like if it's going away, now, it's another failure on top of, I don't understand why this baby throws up all the time. Or, you know, like, I I'm sure people are like, oh, yeah, like I've everyone's heard the joke about like, the baby peed on me one time. Yeah, that's fine. My son couldn't hold down food for months, until we figured out what to give him. And, and the combination of it was, quite honestly, Kelly holding him at her grandfather's funeral. When basically it felt like somebody took a half a gallon of spoiled milk and dumped it on Kelly, because it just came out of him like that at a funeral. And she had only been a mom for a little time. And it's hard. And so it's fun to talk about like, oh, the baby peed on me. Right throws up all the time. But sometimes it throws up at a funeral and your hormonal and your grandfather's bed.

Jennifer Smith, CDE 11:41
Your CGM is going off because your blood sugar is skyrocketing. Because you're stressed out about said incident.

Scott Benner 11:47
Yep. And so I was gonna say my wife didn't have type one diabetes. So then all that other stuff that goes on top of it. So what do you so is it similar? Like, could you sit down and make a flowchart? Is it similar for people at at least at some core level? Or is it going to be different for every woman?

Jennifer Smith, CDE 12:06
There are similarities as you know, we talk about in our in my pregnancy book that I co wrote, it's, there's enough similarity, just like in pregnancy, I mean, everybody's going to have some shifts and changes that are a little bit different, very specific to just like diabetes is very specific person to person, but postpartum Yes, I mean, the transition typically, as soon as you have delivered and the placenta has been delivered, as well. It's, it's like the placenta, which is the major like functional hormonal unit. Once that's gone, and baby is out, the hormone shift. It's like a drop off a cliff. It's like, it's gone fast, which is the reason that we usually say, based on where you were, at this point in pregnancy, just before delivery in terms of insulin use, if you didn't know where you were pre pregnancy, so you could see how much things shifted up by the end of pregnancy, than we usually recommend adjusting Basal rates down by about 50%. Wow, okay, that's the that's expected, it could be a little less, it could be a little bit more person to person, again, may differ. But that's a baseline adjustment. So if you've never been told what to do, and nobody's directing very well expect that postpartum you should cut your bezels by 50%. Another really good idea is to most women know when their due date is. If you're using an insulin pump, especially set up a profile that's called postpartum, because as soon as you deliver, all you have to enable do is enable that.

Speaker 1 13:40
Wow, that's that was gonna be my question. Like you're saying, like, placenta comes out, you take a deep breath and go, I need my pump right now. And that's it. 50% Less 50% Less. Yeah, so that placenta is

Scott Benner 13:54
please forgive me if this is ham fisted, but it's the it's the equivalent of a giant sausage cheese pizza sitting in your stomach that somebody just reaches in and takes out all the sudden and now you don't have that impact anymore. Correct. Wow. Okay. Yeah, I don't know if anybody's ever seen a placenta but it is very close to a cheese pizza. When you look at it.

Jennifer Smith, CDE 14:13
They're very interesting. organs. I mean, they're and the cool thing is that your body creates it for one purpose. And then it's gone. It's not like your heart which is like you know, it's always there for your whole entire life. It's like your body makes this thing just like it makes the baby and then it's all done it's only got this like nine month life

Speaker 1 14:37
I was just thinking this i It's funny you said that because I was just thinking the same thing like why can't we just tell our body to make another heart? Yeah, like I mean if it can do that, it could at least you know, vacuum or something, you know,

Jennifer Smith, CDE 14:48
at least also make another pancreas man if

Scott Benner 14:52
I mean, why not? I'm not a doctor, but somebody should get on that.

Jennifer Smith, CDE 14:57
I entirely agree.

Scott Benner 15:01
Imagine if you just had a panel on your back and you flip the switch and that nine months later your body just spit out an organ. Had a little slot on your side. I don't know why this is impossible, probably because of science but never. Okay, so baby comes out. We're all like, who went and on taking those weird bloody pictures that people take in the beginning and everything and then I changed my Basal rate. What am I going to see next my budget does the body begin making milk at birth or does it even start prior to that? That remastered diabetes Pro Tip series is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have a unique offer just for listeners of the Juicebox Podcast. If you're new to contour, you can get a free contour next gen starter kit by visiting this special link contour next one.com forward slash juice box free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juice box free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen, it fits well 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 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 for 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 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. 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.

Jennifer Smith, CDE 18:50
The way that it should happen again, everybody's a little different in what happens. But what should happen is a first milk is created it's called colostrum. And essentially that's very short lived in production before milk comes in. It could be a short lived, you know, few days, it could be 24 hours before your milk comes in. But that milk is a very like it's very simple form of nutrition for the baby. It's kind of what the baby is in need of right here and now. And there's not much of it. So it's not like if you were to pump it you're gonna get like six ounces of it. That's just not what you would get right. So, but in that simple form and with the loss of the pregnancy hormones. Now you have this sensitized system that was resistant, leading up to this point. And so there and also why some mental shift the shift of you know, nearing the end of pregnancy coming you know, pre Bolus is in 15 minutes, it's sometimes 45 minutes by the end of pregnancy, in order to have good flat after meal blood sugar as well. Now you have to completely flip that switch, and it's back to maybe I need 10 minutes, maybe I need no Pre-Bolus in the early couple of weeks post delivery. So not only is it that your Basal shifts, but it's also that your ratios shift your insulin to carb, your correction factor your Pre-Bolus time. So there's, there's a major transition,

Scott Benner 20:32
right? You just become a completely different person with type one diabetes, just like that. And, and so is it similar to, but more drastic to have getting your period like being that, like, there's that, you know what I mean, I don't know if it works for everybody. But Arden's three sometime now that she's on birth control, she's more like two different people during the month. But and, and it can be it's drastic for us, you know, she can go from a unit an hour to two units an hour, basil, depending on what time of the month it is, and that he doesn't flip like a switch. It's not like, but I can see it happen, happens over hours and maybe a day, but it doesn't happen. It's not like at three o'clock. She's like, I just got my period and everything changes immediately. What is it that just blown up? Much more? Because I mean, what are you really talking about? So for people who don't know, like, I go into pregnancy, I just said, I go into print, let's just say I'm pregnant. Alright, I'm pregnant. I

Jennifer Smith, CDE 21:35
have type one diabetes, you're a lady with long curly hair. I'm

Scott Benner 21:38
a lady. I have type one diabetes, I get pregnant, my Basal rate is 1.5 an hour in the first trimester, is it? How much does it go up? A lot in the

Jennifer Smith, CDE 21:50
early weeks. Typically, we a good round estimate is if you know the percent of increase you've had in the days before your cycle starts. If you've taken enough notice, and you have a rise and you offset it by a percent of Temp Basal or an extra Basal dose or whatnot, you can expect those early weeks of pregnancy, typically up to about 678 weeks that you're going to have an increase in insulin need. That's pretty similar. It might be more dramatic than that it may be less, but you're going to have a ramp as your body is increasing. Its production of now pregnancy hormones to sustain the pregnancy in furthering along.

Scott Benner 22:32
Okay, so I should have said my my Bolus was ones that we could keep track, right? It say I'm one usually when I get my period, I'm too. So then we're gonna say in the first six to eight weeks of pregnancy, I'm probably going to be more like two more like I have my period, correct exam there. Right. And then from there it goes, it goes up again.

Jennifer Smith, CDE 22:52
So end of first trimester, most women notice either a plateau, okay? Or they notice a bit of a dip off in their insulin needs. For just that end of the first trimester, usually, we say on average, it's about it starts at about eight weeks, goes through about 12, maybe even 1414 weeks, which is that fertile, very early second trimester start time period of sensitivity, you may have needed to back off of your Pre-Bolus time again a little bit, you may have gone down slightly in your baseline basil needs just more sensitivity around meal boluses. And kind of almost feeling like things have sort of stabilized like you have a little bit more wiggle room like I can eat three chips in between and not actually Bolus for it because it doesn't seem to do anything to me, or right. And then second trimester again, a little bit of a nudge up potentially an early second trimester. But a little bit more stability up until about 18 weeks 18 to 20 weeks. We kind of refer to it as the the slow roller coaster climb. So if you imagine you're at the bottom of the roller coaster to begin with, and now around 18 to 20 weeks, you start that slow like click click click up the roller coaster Hill. And that kind of progresses you increase in resistance along the way all the way up until about 3536

Scott Benner 24:20
ish weeks the steady climb.

Jennifer Smith, CDE 24:23
It's a steady climb. And initially in the second trimester, it's on average expect to make some tweaks to things about every two weeks give or take in basil as well as insulin to carb ratio as well as the Pre-Bolus time continues to lengthen. Your correction factor may need to get more aggressive. But usually by the beginning of the third trimester, that's the most resistant time okay, and often through like 34 to 36 weeks

Scott Benner 24:52
as you're talking I'm literally I have a piece of paper in front of me and I'm just kind of moving a pen. As you're talking I tried to make a graph of what to understand Especially now it's gonna grow up every two weeks. So I know this isn't mathematical. And I'm not telling anybody that if you started with one unit the day before you got pregnant, but where can somebody end up who started at one unit an hour, where could they end up at 35 weeks.

Jennifer Smith, CDE 25:14
So insulin needs, on average, double or triple from pre pregnancy to the end of pregnancy, or what we would consider just pre delivery time, which is about by 36 weeks, by 36 weeks, we reach again, this sort of like plateau place, where again, some sensitivity can start to come back, some women's Basal needs start to dip off just slightly shouldn't be aggressive or heavy. In fact, it's a time period that if you are having aggressive changes in your insulin in terms of like drops in need, it's a time to check in with your provider. Some of it can be relevant to placental failure. And so it's a time again, if things change drastically that you would check in. But otherwise, it's expected a little bit of a nudge down a little bit of increase in sensitivity kind of creep back in before you actually deliver. But on average, you know, how much to adjust. Like I said, most women either double or triple their needs from pre to about that 36 week point. And so

Scott Benner 26:19
I now you have the baby. And you could be going from this mindset on three units an hour. Back to why Yeah, back to one all the sudden, exactly. And on top of that, all the sensitivity around meals has changed. And and you're telling me nursing is going to drop the blood sugar

Jennifer Smith, CDE 26:38
nursing for most women who have good milk supply, and are able to, you know, pump or nurse completely without you know, most women experience especially in the early weeks, usually about the first eight to 12 ish weeks posted delivery, notice some shifts down in glucose. After nursing, during or after, if your child nurses for a lengthy period of time, you could notice it during the nursing session itself. Some women notice it only at certain times of day, versus the whole day, you know, having to consistently pay attention every nursing session, they're eating, you know, like to glucose tablets, or having half a juice box or something like that. I mean, our recommendations are once you once you're a few weeks out from delivery, kind of baby by that point has some typical sleep wake poop kind of patterns, you're probably still nursing about every three ish hours, maybe a little lengthier overnight, as long as your baby's nursing Well, during the day, are feeding well during the day. But you know, most often if you're going to nurse in the aftermath of a meal, a good recommendation is to take the Bolus dose down or count carbs, but underdose by you know 25%.

Scott Benner 28:01
So it's dramatic enough that if I eat, I keep saying I if the lady eats before nursing, that meal won't need as much insulin because you're gonna need some of that meal. So that means if you're not planning on eating, and you're going to nurse, you need to eat something going into the nursing,

Jennifer Smith, CDE 28:17
typically going into nursing or during the nursing session to prevent a low. Yes, and it could be anywhere, it could be simple, it could be five grams of carb, it could be as much as 15 grams of carbs. It just depends. And that's where, you know, looking at things like insulin on board, yeah, you might not be bolusing in nursing directly after but if it's still like within two or three hours after you bolused You still have some active insulin from that Bolus,

Scott Benner 28:44
and we tell people I at least I say and I know I feel like you agree with having active insulin while you're exercising is a pretty sure way to make yourself low. But so I'd want to avoid active insulin during nursing as well or plan for it. And the other thing is there too. If you can go negative insulin and get through exercise without dropping you can't do that with nursing this a nursing is more taxing on your body than some forms of exercise. Is that fair? Like is there a correlation to think about it in there are no

Jennifer Smith, CDE 29:21
I guess there's some relation to think about it. I think like I was thinking of overnight, right? Where for the most part. Mom, moms dads, they're tired at night with a newborn many people are and if that's the case, you're likely going to bed at like nine o'clock like you nurse your child and you're like, Okay, go into sleep because I'm going to be up again at like midnight, one o'clock to do this all over again. You may have eaten dinner at like seven o'clock. You're going to bed well you're well into Basal insulin by let's call it 11pm Right. So any time you're going to nurse after that And you're only on basil. And I experienced this myself for both my kids, Basil overnight, if I even if I had it at all. And my basil is, while I was nursing kids overnight in those early months, it was like near nothing. My basil was like, point 2.25 overnight, it was already down to almost nothing. And if I nursed and didn't still have something minimal, like I actually made these, what are called like lactation cookies. They're made with like oats and flax and peanut butter and stuff that helps with lactation, blah, blah, blah, but I made them so they were each about five grams of carb. But they were nice, because I could eat it, it had some stability to it, it wasn't just pure glucose. So it had some stability. And so I've usually eat it as soon as I started nursing, or something like trail mix some nuts and seeds with a little bit of like dried fruit in it, something that was no more than about five or 10 grams of carb. And that helped with the stability component with rather than

Scott Benner 31:00
the backhoe was die well, and so this is another time you know, where the food choices you make are going to make things easier for you to get you care. And, you know, so there's gonna, you're gonna have a different scenario going into nursing, if you're like, Hey, I know what to do. I'll have a handful of this and a little bit of that, and that's gonna work out perfectly. But on Thursday, when you're like, you know what I'm gonna do, I'm gonna have ice cream before I nursed there's going to be all everything about ice cream still exist there and your diabetes. Okay, in fact,

Jennifer Smith, CDE 31:29
those kinds of things, you know, as we know, ice cream, typically should cause a bit of a rise possibly later fat, depending on how much have you ate, you know, to spoonfuls probably not, but like the whole kind of it, probably,

Scott Benner 31:43
you're telling me that there's a way that I can get I can have ice cream far enough out in the future ahead of my nursing where I could balance that fat rise against the nursing. You know, there are some lunatics that listen to this podcast are gonna try that I saw somebody online this morning, who's trying to stay 100% in range till they get to their endosome appointment and they're doing it. That's awesome. Oh, my God.

Unknown Speaker 32:06
A lot of

Scott Benner 32:08
Yeah, I don't know. I don't do that. So I for Arden, I think they just got a little like, I just wanted to see if that's what I want to tell people to I know it sounds difficult in the beginning to have a baby. But if you want to know how good you will get at it at some point. Here's a great example. About two minutes ago, there was a bang in Jenny's house that was so loud. I thought the world was coming to an end. She didn't flinch. She didn't stop talking. It was that's what happens. Eventually, you just become a steely eyed missile man. She just did not move. She's just because there

Jennifer Smith, CDE 32:48
are beings all day in my house. I mean, when you work, you know from your own home office, and you have children in your home. I'm sure there will be more beings. I don't know what they're doing upstairs. But they are having fun.

Scott Benner 32:58
It was so it was just a great example of how you do become really great at parenting after you've had kids for I swear to you, you resilience. I don't think it's almost like you didn't hear it.

Jennifer Smith, CDE 33:10
Don't pay attention. Sometimes. Oh, yep. Sometimes, like, felt like I have a big sign that my husband made for me. It's outside my office door. And one side says quiet zone mommy is working. And the other side is Mommy is done. You may enter and be loud is what it says. Well, you know, when I'm working, it's still always in the quiet zone. Well, you know, with an eight and a four year old. They know what the sign says. But that doesn't always still click into place. So yeah,

Scott Benner 33:43
it does not overwhelm what they want in their hearts at that moment. That's for sure. Now, listen, artists funny artists going to be 17 in a couple of months. Wow. Isn't that crazy? And I saw her go into where my wife was working the other day. She looked at me like she was six like Hey, watch this. slides into Kelly's chair sits on top of ringers. Mom, can you wrap my head? Kelly's like, you know, reaching around for the keyboard and everything. So we will it will you won't always feel overwhelmed. How many people do you? I don't I'm not gonna say how many people but I mean,

Speaker 1 34:16
do you see women generally able to stick to their diabetes goals after pregnancy? Or should they expect it's gonna get out of whack? And they're gonna have to do some work to get it back like how does that usually go?

Jennifer Smith, CDE 34:32
i I see that. You should expect that there's going to be fluctuation that you will have to learn to adjust to. I myself, I had to learn to adjust because, you know as much as I know clinically and professionally, the experience itself speaks volumes about what you need to transition through. And so I think every woman postpartum should expect that things are going to be a little bit wonky here for a bit of time. I mean, some things that I think, helped me transition where I prepped some meals and froze them prior to baby coming, you know, and whether we have diabetes or not, that can be really, really helpful. You know, some of those kinds of things I also had snacks planned I had. Meanwhile, you end up sometimes nursing your child wherever is comfortable, you know, planned places, you know, in the baby's room in your bedroom and a comfy chair in the living room, just some things that were like easily reachable, that I didn't have to like, Call to somebody to bring me and I just had glucose tablets, and some juice boxes, some like trail mix, and that kind of stuff sort of set multiple places around. So I mean, there's some planning that you can do ahead of time. But the diabetes management piece of it, it kind of learned as you go, I mean, I'd say that about the women that I worked with, through pregnancy, if I had to estimate, I'd say about 50% of them end up sort of sticking with me a little bit longer postpartum, just because especially than the new moms, you know, ones that already have one or two kids. They're like, Yeah, I think I got this, you know?

Scott Benner 36:23
So does being pregnant with type one, give you an advanced. So what do I want to say here? There are so many times when I'm making this podcast, that it occurs to me that success with diabetes hinges, a good deal on your desire to be successful, and your ability to feed that desire with effort. Does that make sense? Yeah, absolutely. And so you, you get pregnant. And then it becomes like this thing we were talking about in the beginning like this, this feeling that you are in charge of the universe all of a sudden, and I will tell you too, and I mentioned it sometimes, when I talked to adults who didn't have particularly well managed, like teen years or whatever, a lot of them have a through line, they started to care more about themselves, where they started caring more about another person, like they want it. And then they wanted to be healthier, because they wanted to be in this relationship or because they wanted to go to do something or, and the baby falls in that category to me, like I want to, I'm going to do this so that the baby can be healthy. And that the number of women that I've talked to who were living really unmanaged lives with type one diabetes, and then are all the sudden 4.8 A one sees, you know what I mean, an eating like a lot because they're growing a baby, it happens. I just see it a lot. And so I always kind of think personally, as a person who's never going to have a baby and hopefully never have type one diabetes. There's something about that motivation in there. That I guess the fight in postpartum is to not, I don't know if it's something you can stop, but for all these things that are going to happen to you postpartum to try to still wiggle out a little bit of your energy or effort to devote to your blood sugar.

Jennifer Smith, CDE 38:19
Absolutely. And I think a good reason there too, in terms of diabetes postpartum is glucose management still translates into that time period for the sake of the child even though they're no longer growing in you. And your blood sugars aren't as direct of an impact postpartum, if you are nursing and you are not managing your glucose as optimally as you know would be helpful. Those higher glucose levels are going to impair your ability to make enough milk okay, if left high, your ability will be decreased. You will also be more dehydrated as you nurse it takes fluid out of you if you're not putting it back and glucose levels are also trending high that in and of itself is also going to make your glucose management more difficult

Scott Benner 39:17
does it change the milk itself?

Jennifer Smith, CDE 39:19
To a degree I mean years ago we don't we don't talk about this really much anymore. Although I have heard some women who've asked me should I just you know pump when I'm really really high and then dump it because I've been told that that I sugar milk is really bad for my baby. I mean, overall increment of right now my blood sugar is high because I ate something and didn't really have the right carb count and I'm knocking it down Should I not feed my hungry child right now? Absolutely not. Go ahead and feed your child nurse your child pump, whatever. Don't get rid of the milk. Your body works really hard to make that milk don't get rid of. But the goal is To have more sustained levels that are still in target to so you're able to continue to make milk and that the amount of milk sugar that's in that, that breast milk is stable, right? That it's stable and at the level that it's supposed to be protein fact, carb content of milk changes as the milk as the baby's kind of needs change through the growth cycle. So you want that amount of natural carbon there to be appropriate. If you're sustaining blood sugars, you know, well above 180, you can guarantee that your milk is richer in carb, not by like loads and gallons. But overall, you're supplying your child with bits more carb, and in a tiny growing body, a little bit can be a

Scott Benner 40:49
lot, okay, that's it just occurred to me, like we talked about undiagnosed people can, their urine can smell sweet, or their breath can smell sweet. I was like, I wonder if it could happen to the milk too. That makes sense. So much like most of this about diabetes, sustaining low variability is always just very important. No bouncing around, you know, that kind of thing. But if you just threw, like, say you were a person who had the baby, just like, boom, I'm going back to my nine a one see that milk would be tainted in some way? Not Yes. Yeah. It's not perfect as what we're saying.

Jennifer Smith, CDE 41:25
Not perfect. Right. I mean, you know, is enabled perfect. I don't know. But I mean, if you're sustained if you're sustaining these really elevated glucose levels, that's not a benefit. And you're going to I mean, for the most part, you're going to have difficulty maintaining

Scott Benner 41:42
milk production. You are, it made me wonder when you were talking about long term? What about people who I know sometimes you see people like nursing a two year old? So it for people who do that? Should they expect that? That hit like your body never gets used to that, right? Like, you're gonna get that? Yeah, that blood sugar head is gonna come forever, if you? No, not really,

Jennifer Smith, CDE 42:01
no, actually, no. In fact, after about three to four months postpartum, there's a stable enough nature to the milk supply, and to what your body or your baby is demanding. And that for the most part, things stabilize a lot easier after about three to four months. In fact, I nursed my kids while after they were a year old. And in fact, I think they were both almost two. I mean, it wasn't all day, it was like for bedtime, and for naptime by the end. So it wasn't really that they were probably even getting very much, but usually post a year, you're typically not going to see that hit. And the big reason, especially after about six months to a year is because now your baby is starting to eat. While milk supply is still considered the main nutrient up to a year of age. Some kids start eating really, really well, after 678 months. And so you may see a decrease in the amount of nursing that goes on as the baby becomes more interested in food and takes in less, especially the overnight many women, you know, might have a really great child who just sleeps all night. And so they might only nurse once or twice maybe, or eat, you know, some women nurse on need during the day. But those, those sessions are not typically going to cause the drop in blood sugar that the early three months will cause

Scott Benner 43:29
I want to make sure I didn't misunderstand something. So there is it a balance between you might not be using as much and your body's becoming very good at making it or is the like at first I thought you were saying like the same lady's body that can make an Oregon knows that can figure out how to make milk without it being like a tax on the system. Like is there some of that and some of the not being?

Jennifer Smith, CDE 43:51
I think it's Yeah, honestly, because for the most part, like I said about that three to four month mark, I would say the women that I get to work with well past the immediate postpartum time period, they find a lot more stability in their glucose even though they continue to nurse beyond that point, then the lactation or the nursing sessions don't have the hit that they do initially.

Scott Benner 44:16
Okay, thank you. It's a quick little parable, why are Vali asked you to think of there's anything that we haven't talked about. Let me tell you that I was interviewing somebody recently who said that they were listening to I interview this person I was talking to them doesn't matter. I was conversing with the person who said that they're pregnant now. They're listening to episodes of the podcast about pregnancy with you in them while reading the book that you wrote, and did not connect that you were the person from the podcast. They didn't realize the person that wrote in the book was the person talking on the podcast and all of a sudden it hit them one day. And she was like, Oh my gosh, it's the same Jenny. That's awesome. It was really cute. I want to tell you about that, I almost just texted me and I'm like, I'm going to tell her that while we're recording the postpartum episodes, that, that's awesome. That was really cool. Anything we didn't say that we should have, oh, I'm

Jennifer Smith, CDE 45:10
trying to think, um, you know, the only other thing that we didn't really touch on, while it should be considered is, depending on how you're feeling postpartum. I mean, most women have like this, I give you restrictions up until about six weeks post delivery, when you're going to have your check in with your OB and blah, blah, blah, and make sure everything's healing well, and you're okay. And then they kind of like, check you off. And you can drive again, or, you know, if you've had a C section, or you can get out and start running again, or whatever. And I think that's a piece to consider in the mix with diabetes, because, you know, we know what exercise. So now you not only have exercise coming into the mix, but you've also got nursing coming into the mix, and all these insulin changes that you're trying to make. So one of the big things that sort of fits here is if you have maternity time, not all women do. But if you do have maternity time, use your maternity time to try to establish sort of a route, like a routine or a schedule. And some of that's going to be dictated by the baby, obviously. But even regular for you trying to get your nutrition in timely through the course of the day. You know, once nursing is a little bit more regular, the baby's waking nursing times are more you can fit it in or around the meals and exercise is a big one of that. If you're going to start exercising, try it at a similar time of the day to kind of get a feel for how does this work? You know, what can I get away with? What's too much? What's too little? Because I think that just brings in the whole, like, I feel good enough to go and you know, take a three mile run. But what's this going to do? Oh, no, let's try.

Scott Benner 46:57
I hear you. So it's not dissimilar to it is interesting, as you're talking about it, it really feels like postpartum is a lot like just being diagnosed but having way more information about diabetes, right? Like Like, what if, what if somehow magically, I knew the things I knew, but never had to put it into practice. And then all of a sudden, there was a newly diagnosed person here, I'd be able to roll with the variables much better because I have better tools. And so you're going to go from having diabetes, maybe not doing it as well, learning how to do it really well, or already knowing how to do it well, and then it's going to feel like you're diagnosed again, and you're taking care of a baby at the same time. And all your variables changed again, I'll tell you, I'll tell you this is giving me a different feeling for first episode of season seven 2021 was with a woman named Jill, who was diagnosed as she got pregnant. So she was pregnant for the first time and had type one diabetes the first time and I am now talking to you thinking I had a lot of empathy for I might not have had enough like, like hearing about all this.

Jennifer Smith, CDE 48:11
That's a whirlwind of change. Not only is she pregnant, but now she's pregnant with something she has no background to managing. And she's got to learn how to manage it through the variables of pregnancy as they shift and change. I would imagine that postpartum was probably a lot more difficult for her than pregnancy was.

Scott Benner 48:31
I wonder? She's She's active on the Facebook page. She looks like she's doing terrific. She actually also was misdiagnosed type two diagnosed type one. It's a fascinating story. If you have to go listen to it. If you haven't heard it. Let me know which episode is it. I'm actually going to look right now because I don't know. I've I think I'm at the point now where this I've done so many of these.

Jennifer Smith, CDE 48:56
I know you're like I don't know what else.

Scott Benner 48:59
Let me look real quick. It is called Wait a minute. That was January 2021. I'm looking Why do I not see it? It'd be helpful if I knew what year it was. Now that I know what year it is. I'm getting down. It's called wine beans, babies and cue. It's episode to come up with these names. It's episode 425. Well, she was misdiagnosed as type two. So you know, she still went on a wind vacation with their friends. Beans, I forget babies because she was pregnant. Because she was told she could go she could she was told she could get pregnant by a person who told her she had type two diabetes. And then she got pregnant as she found out she had type one diabetes and a doctor with the last initial of Q set her straight. That's where all that comes from. And you just I can't remember what the beans were Damn it is a good episode. She's really lovely. Yeah, but I know her because she reached out right in that moment. Like she found the podcast and she's like, I don't know what to do. I just found out I'm pregnant. I have a baby coming in. I have type one. So I was like, well, after you figure this all out and have that baby, you got to come on the podcast. Yes. Tell the story. Anyway, she's terrific. And, and so are you. We've covered this pretty well. I like this a lot. We did a little like personal chatting at the beginning. So we didn't get to do one of the things I wanted to do, but I'll just put that on my list. Okay. I thank you very much. I somehow find it delightful that your kids were much noisier than normal. While we were talking about having

Jennifer Smith, CDE 50:41
this was one child. Oh, really? That was just just the four year old the other ones at school?

Scott Benner 50:47
Oh,

Jennifer Smith, CDE 50:49
I can imagine he is. So my mom came my mom came this past weekend to visit for my birthday. And she bought them a ring toss game, which has, like it's like a wooden base. And then it's got you know, the things to like, throw the rings over. And I'm expecting that either the whole thing was lifted up and dropped on the floor, or the ring toss was being thrown from a larger distance and maybe all the rings at one time were being thrown? How much

Scott Benner 51:18
of this do you think is the part of the country you live in as your mother prepping them for beer pong later is Do you think that what this could be I swear to you, it felt like two adults lifted up your dining room table and dropped it from about eight inches.

Jennifer Smith, CDE 51:32
And the funny thing is, it was like, like you said I didn't flinch. Because it was like a background like I don't it's just a background noise.

Scott Benner 51:41
I thought off the bleep myself out because here was the thought in my head. I thought did she not hear that? Cuz you didn't blink. It was fascinating. Anyway, ladies, have a baby get through all this and one day you'll either be as good at this as Jenny or is not Miss Jenny as I'm not sure how to put it. Yes. 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. Je Vogue glucagon, find out more about Chivo Capo pen at G Vogue glucagon.com forward slash juicebox you spell that GVOKEGLUC AG g o n.com. Forward slash juice box. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bumping nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low Beegees in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two in Episode 1008 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025 We talk about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny Presented everything, even the scary stuff that reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning 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 show 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.