Full Transcripts

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 CDE 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 revisitable. 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 Ascensia 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 Juicebox free meter while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke HypoPen Find out more at Gvoke glucagon.com forward slash juicebox. And now I'm proud to present the episode that started the diabetes Pro Tip series. What was originally episode 210 diabetes pro tip newly diagnosed we're starting over Welcome to the Juicebox Podcast. I'm your host Scott Benner. I first interview Jenny Smith, the CDE from Integrated diabetes back in season one on episode 37. At that point, Jenny and I were just talking about different management ideas. But it was then that I realized how much we agreed about type one diabetes, and the management of the disease. I brought Jenny back on and episode 105. And we really drilled down about A1Cs what they were and what they weren't. After that second interview with Jenny, I decided that one day I would have her back on to discuss all of the diabetes management ideas that come up on the show, I wanted to break them down into small categories, something that was easily digestible, where we'd stay focused on just one idea. I wanted to create something that you could come back to hopefully learn from and if you found useful share with others simply. And so with that in mind, I give you the first in this 10 part series, diabetes pro tip for the newly diagnosed or for those wanting to start over with Jenny Smith CDE. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And to Always consult a physician before becoming bold with insulin or making any changes to your medical plan. If you're a newly diagnosed person with type one diabetes, or the parent of someone who has been newly diagnosed, what do you think the first things to understand are?

The first things to understand beyond the glucose values are what does insulin do? How does it work? I think that's it's a huge one that is it's under, it's under emphasized, I guess is the best way to put it. Many people, especially adults who are diagnosed are kind of given a this is your insulin. This is the dose to take and kind of go experiment at home. I feel like that's kind of the way that it is and I think insulin is a first most important thing to really understand. How does it work? What's What's the purpose of it? How is it supposed to kind of finish working? And what is the effect for you?

Okay, and so what are some, like bare bones ways to come up with those understanding. So I think, obviously, if you have a CGM, it becomes different, right? If you have a CGM, you can get yourself at a stable spot where you haven't had insulin or food for a while. And just give yourself an amount of insulin and see how it moves you. Let's talk for a second about like old school, do you still teach people that they need to do Basal testing?

In a general way? Yes, I think especially for pumping is helpful in the beginning, because it does in that basal only time period, it does give you a general idea of how things are being kept with the rate that's at play. I do think that basal testing needs to be more explained, let's say, when we are talking about pumping insulin, though, because there are as you know, a lot of variables that could be at play in that basal testing time period, especially like from, from a woman's standpoint, it could very much be that it's not the right time of the month to be Basal testing. Right? Right, right. So all of these various are a kid or a teen who is a kid or a teen who is really athletic. Right, and there is consistent effect of activity level. And it may be different on different days, but there could be overlap from a day ago that you had for our practice or a tournament. So Basal testing. As a general idea, yeah, it can be a really good place to start, especially if you think things are really off in a certain place of the day. But is it the end all be all of knowing where your insulin should be? Not 100% of the time

and so, so what I ended up telling people when I speak with them, is that, you know, if you're having an issue, and that issue could be anything like you're spiking at a meal, or you're drifting high all the time, or you're incredibly high all the time, you know, any of those things, you have to first look at your Basal insulin. It's it's absolutely far and away the first thing and I have to apologize to your audience texting me and I believe she's trying to tell me, it's lunch. That's okay. Hold on. So lunch question mark. So Arden has been sick the last couple of days and pretty, pretty kind of resistant like this to her insulin a little bit. But we are ahead of it now. So she's 106 and stable now. But to give you an idea, she woke up at 110. By the time she was getting dressed, she was 120. Then there was this diagonal up, I Bolus a unit and doubled her Basal for an hour. And 30 minutes later had to Bolus two more units to get her back to this 106. And what she never got over about 150. But she sees that rise every morning like that, that little bit of a rise. But this morning, I used I'm going to save three units more than I would normally use. Yeah. And it's just because she's not feeling quite well.

Again, another reason that basal testing. This is not it's not purposeful. In fact, I think, you know, a lot of people try to overcome that morning time rise with a Basal adjustment. But what happens then when you wake up at a different time of the day, right? Or you have a variable schedule, so a lot of times I actually tell people, you know what, let's look at what the rise is. Don't correct it. Let's let's watch the rise. Let's figure out how much of a rise Are you consistently having, you know what, we can offset it with it with a dose of it of Bolus. Sometimes that actually hits the mark better than trying to incrementally adjust a basal behind the scene that could actually change day to day.

Right, right. Okay, so now this is um, this is really interesting. To the way like, tell you what just happened. So this is kind of hilarious, but my wife is here I'm gonna have to walk away for a second and back. Arden's pump only has 10 units left at it, and her and just add her lunchtime Bolus is going to be 12 units. So I just had her do a smaller Bolus as a Pre-Bolus still, and I'm going to send my wife over to like swap. I'll be back. Let me go explain this to my wife. I'll be touched by type one has a wide array of resources and programs for people living with type one diabetes. When you visit touched by type one.org Go up to the top of the page where it says programs there you're going to see all of the terrific things that touched by type one is doing and I mean, it's a lot type one it's school, the D box program, golfing for diabetes, dancing for diabetes, which is a terrific program. Just click on that to check that out. Both are caused their awareness campaigns and The annual conference that I've spoken at a number of years in a row. It's just amazing, just like 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.

So all is okay. Yeah,

my wife's it's across the street. Yeah, my wife's gonna run over. She's working from home today. And it really does just go to show, I guess, the fluidity that you have to keep around diabetes because, okay, I'm lucky my wife's here today. If she wasn't, I would have to tell you, Hey, I gotta go. But in the end, there's no panic here. Arden's blood sugar's 107. I wanted, I wanted to do a Temp Basal increase of 50% for an hour and a half. And an extended 12 unit Bolus for lunch. But she only has 10 units. So instead, I had her set the Temp Basal still and do an eight unit extended Bolus. So she's still going to have four units going when my wife gets there, they're going to swap that pump real quick. And then she's going to head off to lunch and be okay. Right? She'll be fine. She's got early lunch. Yeah, on every other day to 1030. And then on the 30, like,

what does she get up at five o'clock, the breakfast? Really that

she eats? 1030 every other day and the opposite day? She eats at 1130? And she's out of school by two. Oh, wow. Okay, it's all kind of very quick. I don't know if she's learning anything. But so so I Yeah. So anyway, what I wanted to say about Basal is that, I'm sure just like you, I meet people who are having trouble, right, they're either on the roller coaster, and they're going to 400. And they're going to 60 and up and down or, you know, somewhere in that problem. They're high constantly, they're always 180, you know, they can't really seem to do anything about it. And when they get to you, they have all of these theories about why their blood sugar is too high. Right? And I tell them, your blood sugar is too high, because you don't have enough insulin, and it's not timed correctly. And we're going to start with your basal. And they'll inevitably say, Well, what about my insulin department, that doesn't matter? I'm like, you can have a perfect insulin to carb ratio. If your Basal insulin is not right, none of this matters, right?

That's right. That's why we call Basal insulin, the foundation of your management, it really is we, we actually tell people, it's like the foundation of a house. If you have a sound structure that you're building on top of everything you put on top of it will work. Even if the insulin, the carbon, the correction factor, and things are a little bit off. If the basal is off, those are going to also look like they're not working well.

And it becomes impossible to diagnose what's happening, right. And so what I ended up saying is that you try to imagine we use round numbers for examples, but try to imagine your basal is a unit an hour. That's what that's what it should be. But you have it at point five. And then you have you look at some food and you say, Oh, well that food is two units. So you and let's say you're right about that. Let's say you're 100%, right, that the food takes two units, you put your two units in, all you've done is now replaced the basal that you needed, right? You're so you're resistant, you're high, now you're replacing your basal, it's possible those two units will only go towards impacting the problems your Basal insulin has, right. And then your blood sugar shoots up and you go, I don't understand, I put in the right amount of insulin, I counted

my carbs, right, I counted my carbs. I looked at the label and I did everything

the doctor told me why didn't this work. And in the end, and you know, through this series that you and I are going to do together I'm going to repeat a couple of things over and over that I've found to be incredibly helpful. But in the end, if your blood sugar is high or low, you've mis timed miscalculated, or a combination of those ideas. And that's pretty much it, you know that I find that to be the core of it. It's not the first step to me. Not being afraid of insulin is the first step. But we're going to talk about that in a different episode. But I think that it's it's timing and amount. And I think there's a million other things that can impact your life with diabetes. But that's the seed of the tree, right? And you could throw away all the leaves and all the branches and everything that comes off of that seed if you'd have that seed timing and amount you're well ahead of the game. Right?

Right. Absolutely. And I I would say the that those two pieces actually go very well together as far as not fearing insulin, you know, not being afraid of using it because i i certainly work with many people who that is a major problem it is I just want to eat 200 Because I'm afraid to give the amount my pump is telling me to give or the amount that the doctor told me to give you You know, and I think understanding Insulin is the base of that, understanding it and understanding the timing. And the action of the insulin and how it also individually works for you, helps to dissipate that fear, right?

I think that I think that if you can keep your blood sugar stable at 200, then you can keep it stable at 180. And if you can do it at 180, you can do it at 140. And believe it or not, if you can do it at 120, then you can do it at 75. And, you know, and so, because the, the tools that you use to, to achieve that stability aren't different depending on what level your blood sugar is at. It's all the same. It's all the same stuff. Okay, so that's, that is that's excellent. So we'll talk about fear in an upcoming episode as well. I'm newly diagnosed, I go into my doctor's office. Now you are uniquely qualified to tell me this. What do people get told a diagnosis and why do they only get told what is shared with them. The remastered diabetes Pro Tip series is sponsored by Ascensia diabetes makers of the contour next gen blood glucose meter, and they have a unique offer just for listeners of the Juicebox Podcast. If you're new to contour, you can get a free contour next gen starter kit by visiting this special link contour next.com forward slash Juicebox free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash Juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and to carry case, but most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen, it fits well on your hand, and features Second Chance sampling, which can help you to avoid wasting strips, every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash juicebox free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips, you can use my link and save time and money buying your contour next products from the convenience of your home, it's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now, through your insurance. Contour next one.com forward slash Juicebox for a meter go get yourself a free starter kit. while supplies last US residents only.

I think it there's a wide range of what people are told, I certainly think that the younger the diagnosis, especially for type one, the younger the diagnosis, the more education there is, the more information is provided. adults that are diagnosed I think, unfortunately, get the least amount of education again, and it differs system to system and provider to provider. But in the beginning, you know they're taught how to use a glucometer. They're taught how to give an injection they're taught or you're going to be taught essentially the basics of that insulin action. And you're going to be taught carb counting, right. I mean, that is pretty much the gist of what you're going to be taught.

Anyone who's been listening to this podcast for any amount of time will know that I call that do not die advice. That's the that's the advice you get so that you don't die. It doesn't keep you healthy. It doesn't help you understand anything. It just keeps you from going home and falling over.

Well, and I think another piece of that too is it's very, very soon in that beginning is how to avoid hypoglycemia, how to avoid a low blood sugar because insulin causes low blood sugar. And unfortunately, that's where the fear starts.

Exactly. And so that's where it starts where the fear starts, but try to understand it from the clinicians point of view. You are frazzled I say this all the time being diagnosed with a disease that you cannot cure. It feels like someone just walked up to you with a shovel and smacked you square in the face with it and then started yelling, Basal insulin Bolus glucometer. This is a test trip and you're like, wait, wait, why? And so the doctor sees that on your face and can't in I guess in their minds, they don't want to overload you. But the unintended problem is just what you said that you start with fear then everything starts with fear. It would be a simple sentence. It would be it would be Listen, we're going to teach this to you slowly. I know that seems counterproductive but it's not But there's no reason to be afraid. And that's what we're going to learn. Now the question is, do doctors not teach that because they don't have the time, or they don't have the knowledge? Like what like, because there are everyone's going to walk into a different endos office, you're gonna get an 80 year old guy who's been doing this, since people have been boiling their urine. And he and he's just gonna think that if you count your carbs, and inject and go to 300, and come back to 100, that's amazing. And that's that, right, right. And then you're gonna get a guy who's in his 50s, who's just starting to hear about like, this CGM stuff, and you're gonna get different advice from them, you're gonna get different advice from, you know, a woman who's been out of medical school for three years and has diabetes. How do you as the patient know what advice you're getting? When you don't know anything about diabetes?

That's a very good question. Absolutely. And I think, you know, with today's technology, honestly, I personally, as people have come to, to work with me, or to work with us that integrated, you know, it's people come because very soon, they realize they're not getting what they need. That's not quite, they're not sure what they're missing. But they know from researching and looking and Googling it, that the information that they've gotten is so just literally the tip of the iceberg, that they're missing so much more beyond and that, you know, that the doctor is saying, Well, you have to be in good control for a year to be able to start on a pump. And most parents or even adults are saying, that's not the case. Right? Does that make sense? That's that's not doesn't make sense. I want to know what I should be doing. I want to know, what is the best for my child or for myself? I want to know, and I think those are some of the things that as a as a newly diagnosed, asking more questions of your provider, even though you may not know exactly what you're asking, when you've Googled it, and you've researched and done some of your home's searching, and even asked, you know, some people I think more and more people are, they're kind of they have acquaintances or whatnot, who might have diabetes. And so they, they will ask them, they'll say, Well, they're doing this, you know, maybe I should ask about this. And I tell all the people that I work with, you know, what, if your providers not able to meet you or can't answer, even those basic questions in the beginning, it's, it's time unfortunately, to find a new provider. It really is.

And based off of that idea, I want to say, I want to say the same thing to two different segments. So if you're a clinician, and you're listening to this, or if you're a person who has diabetes, or is trying to care for someone who does, there's a space that a lot of people get into, they're not given enough information up front. And they're, they're paying attention, right, they want to do well, they're paying attention, and they see inconsistencies with what's been taught to them in the doctor's office. But because you're the doctor, or because you're looking at a doctrine, you were raised to listen to a police officer, your teachers and a doctor, you're raised to believe that a person in a white coat is infinitely more intelligent than you are, there's no reason to question them. And so when they give you these concrete laws of diabetes, you go home, put these laws into practice, and they don't give you decent results. This is for the doctors, it puts people into such a psychological bad place. It just wrenches their gut, they feel like they're killing themselves or their children. And they don't understand why. And even when common sense things about their diabetes show up. They can't bring themselves to make the leap, because you've told them or not told them anything about that idea. And I will give you a great example. And it's a very simple example.

Or kind of before your example. You know, it's kind of a cut and dry too. As you know, kind of going with what the doctor said, the doctor said to do this, the doctor said I should take my my insulin and eat right away. Well, if that's not working, and you don't, if you don't know that and clinically, clinicians, I think, really do need more information about what really is the real life of diabetes. What's the real life use of insulin and mastering its action and all of that because clinical book does not mean it meets what happens at home. And when your clients come to you and your patients with or people with diabetes come to you and they say, This isn't working. I'm following all of your rules. It's not working. Instead of saying well, you must be doing something wrong because that that happens often whether as a clinician you want that expression to come out or not. It does you make them feel like they're not doing something right. Right. And you don't give him a way to to help you don't explore with them. Say, Okay, I hear what you're saying, I hear that you've tried everything I thought would, excuse me would work. And it's not let's, let's see why it's not working, maybe something is variable for you.

And let's have more of a conversation and explain what's happening. So that so that the doctor can glean more from what's going on. I'm at the point now, and I'm sure you're there, too. I can look at a 24 hour graph, and make changes in five minutes that improve somebody's life. immeasurably in 24 hours. I don't know why a doctor can't do that. So I mean, I figured some can

Yeah, some are, some are awesome, but some are not gonna know me

well enough. Now to know that, you know, I'm not the greatest person in the world. And I can look at it and go, Okay, this is this like this. My example of, of how powerful the doctor suggestion or non suggestion can be to people is that I was speaking with a woman in her 40s, who had diabetes for 25 years. I looked at her graph, she was distraught. And I said, you just need more insulin? And she said, Well, no, no, because in the oceans, like I said, all these reasons why it that wasn't the case. And I said, No, that doesn't make sense. And in a brief 32nd, Explanation, over a telephone call, I could literally hear the light bulb turned on in her head, and she went, Oh, my God, I just need more insulin. And I was like, right? That's it? I mean, can we go now or, you know, but but think about, think about that. A well intended, intelligent, educated person who goes to her doctor's visits, and in 20 years, can't figure out why their blood sugars are the way they are, and no one's ever helped her. Right. So what I'm saying to people who are newly diagnosed, or people who have gotten to that point and want to start over, you have to sort of think different, you have to, you know, if you're, if you're in a situation where you're newly diagnosed, and you've gotten some real, like what I call like old timey information, you need to think differently. And if you've had diabetes for a long time, or have been caring for someone forever, and it's not going the way you want, that's the first thing you have to do. You have to say to yourself, I must not be thinking like flip it upside down, look at it all the time, I have a friend who every decision they make is wrong. And I once said to them, How come when you have a reaction to something, you just don't wonder what's completely opposite of that, and then just do that. I was like, I was like, You're right, you're always wrong, you know, so like, and, and that's what happens every day, you get up and you do this thing with this insulin and this pump and all this stuff, and it always goes wrong, but yet, there you are the next day,

doing it over and over and over again, which is a another reason that I you know, working especially with the women through pregnancy that I work with, that's a piece of the variability that I try to encourage them to sort of work on prior to pregnancy. Okay, you know, because if you can figure out, it's why many people with diabetes, eat some of the same things over and over and over again, they have a standard breakfast, I know that it works, I know that I need this much insulin, I knew they need to use a temporary basal for this much or for you know, whatever extended Bolus, and it works for me, it's, that's the reason because once you figure it out, you're like, great, I like little magic, this magic piece right here and I'm not gonna screw it up. Now

I'm just gonna have this half a piece of wheat toast two eggs over easy and two tablespoons of avocado for the rest of my life.

Right? Exactly. Every morning, if that's

happening to you, if you're listening, and that's happening to you, I say this proudly, the there are some low carb people who will get upset and I want to tell them right now you can eat low carb your whole life. I don't care. I'm just saying that if you ended up there because you couldn't figure out insulin. You know, if you're if you're eating something you don't want to be eating, there might be a way to manage this. But I tell people very proudly, that at this point, my daughter is 14 years old when I'm recording this. She has had type one diabetes since she was two. And for the last five years, her agency has been between five two and six two, with absolutely no diet restrictions whatsoever. Anything you can think of Arden eats and eat frequently.

And I bet her more important within that I think we talked about this in the A1C discussion and podcast. But more important than even the A1C is per standard deviation the variability which I would estimate without even seeing her information, I would estimate that her standard deviation is very nice meaning she's got these juicy little gentle rolls through the course of the day rather than this major roller coaster because you can have an A1C of a 5.4 Yes, but you can have wrong major, you know, standard deviation,

and we will talk about that in coming episodes. You can't run around with your six A1C but be at 300 Half the day and 50 the other half of the day. That's you've just tricked the A1C test, right,

Doctor? Yeah, because again, that goes back to clinicians. A1C is is certainly it's a starting place. It is not the end all be all there is more in depth that needs to be looked at with that A1C. Yeah,

we try very hard. Well, you know, as you go on and listen to these episodes, you'll realize I'm not trying that hard anymore. I figured it out to the point where it doesn't really take that much involvement from us. But Arden's low alarm on her Dexcom is set at 70. On my follow app, it's 120. For the high alarm on hers, it's 130. And so we'll talk about like bumping and nudging later on, but that's my concept is that smaller amounts of insulin as you try to leave a tight range, get you back into that range more quickly. And cause far fewer lows later. Yes. Give me one second here, we'll take a pause. Okay. I'm gonna text art and she's now wearing a new pump. I need to know how much insulin delivered from the last Bolus. And then because it's a new pump, and she's literally going to walk right into lunch. Excuse me, I'm going to double her basal for I was only gonna do 50%. Now I'm just going to double it for an hour and a half. And that way, if there's any slow start with that site absorbing and having action I'm just going to do, I'm going to do something that at some point during these you'll hear me talk about where I call it over bolusing like I just I imagined not just what her needs are now, but the momentum and higher number that I know is coming. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. Gvoke 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 Gvoke glucagon.com forward slash juicebox Gvoke shouldn't be used in patients with pheochromocytoma or insulinoma. Visit Gvoke glucagon.com/risk. Yep, so

that's hard change was one thing that I was always in in. In the beginning, I was very thankful that I had noticed a difference with my Animas pump change that I needed that site to just be like, just saturated with insulin to get absorption sooner. So and I was glad because when I started Omnipod in 2006, I started doing the same thing that I did with my other pump sites, you know, just Temp Basal going up by almost 100%. For about it was usually about an hour to two hours depending on kind of where I was at that point. And if it was if I was having to change that pod, especially if it was before a meal, and I was going to need insulin for that meal with the new pod. I actually instead of doing it through the pod, I gave an injection, because I just found that a Bolus with that new pod site. It never went well. Whereas if I did a Temp Basal increase, I took a Bolus via injection for that food that I was going to eat and let the pod get settled in. I didn't have any blood sugar issues. Okay.

Yeah, it's everybody's strategy is different, right? But I'll tell you what it what it what that tells me is, again, this is going to be another sentence you hear over and over again, you have to trust that what you know is going to happen is going to happen. Yeah, so if you make a pod change and your blood sugar's 90, you still need to do that. Right? Right. It's okay, hold on, since you got 5.6 units, so I'm gonna do a Temp Basal increase 95% for an hour, and Bolus seven units. All now go eat as soon as possible. So she's got 5.6 units in from 20 minutes ago or so she's still 102. And so I'm not scared of those seven units. She's going to be eating in five minutes. And look, the 5.6 units didn't do anything over the last 20 minutes. So I'm good. My goal here on this Bolus is 75. Diagonal down while she's about halfway through her meal. Anyway, that's again stuff we'll talk about later. Yes. Okay. So

and comfort level with you know, will happen.

Yeah. And because, and by the way, and this, these, you have to you have to have these experiences like I'm going to leave this in this episode so that you know, that things have to happen that you don't expect, because it's data, right it's, it's, I did this and this happen next time I'd like this to happen, so I'm gonna do sooner or later. More or less, whatever it is I'm going to do. But you can't know that unless something goes wrong. Right, right. And so and so here's a great tip for somebody starting over or who is newly diagnosed. There are no mistakes. There are only experiences that build on for next time. That's it, I see something happen. Instead, you can't get dramatic. You can't get upset. You can't cry. You can't go, Oh, my God, I'm killing her. You can't do it. Right. You say to yourself, Okay, bare bones, what just happened here, I put insulin in here. It went up to there. And then it came down and crashed. I bet you if I would have put that much insulin in sooner and spread it out a little bit like I could have created the resistance that that blood sugar needed. Right and right. But if you're busy running around, wringing your hands, and just you gave away an amazing opportunity, and, and I will use this as an example. This past weekend, I was helping a mother with a five year old four or five year old boy. And while I was talking to her, this kid's blood sugar went to 300 off of some Cheerios. And we talked for 20 years, that breakfast cereal. Oh my gosh, we're talking about 20 minutes or so. This poor kids blood sugar's at 300 It's not moving. And we're getting ready to get off the phone. She's like, he's hungry. I don't know what to do. And I was like, Are you? Would you like to do something that's gonna sound insane. I'll help you. And she goes, I think I'm desperate enough to try something insane. I was like, great. How much insulin Do you think it'll take to bring a 300 to 90? And she says a unit? And I said, How much do you think lunch is going to take and she said a unit and a half. I was like cool. Bolus two and a half units right now. And she said, she's like, what's going to happen? We're going to put his blood sugar into a freefall. And then we're going to add the lunch at exactly the right time. And then with a little bit of fast acting carbs, if we need to, we'll bring it in for a landing. I said, I'll never leave you. We'll we'll text the whole time. We'll talk again and we have to, so she does it. We get diagonal down to 90 to 75 to 52 hours down to 50. She's texting. Oh my god. I'm like, no, no, perfect. Like, a whole lot. I actually texted her a picture of the guys from Star Wars who are trying to blow up the Death Star. Stay on target like just don't don't flinch. Like don't flinch to 52 down to 42 3200. I said, Okay, now's the time to start getting the lunch together. And she laughed. She goes, Oh, it's already it's just here on a plate. And I was like I said when we get the one ad given the food. So one ad to down kid gets the food 10 minutes later. Now isn't this interesting? We're dropping 10 points every five minutes on the CGM. Then he eats. Then all of a sudden the dropping stops. The arrows are still there. But now it takes longer to get to 170 took even longer to get the 160 and she gets the watch this happen 150 Still to down 140 Still to down. I said okay. It's not going to catch the arrows. Do me a favor, give them a few ounces of juice. She says we don't have juice in the house. And I thought to myself, Oh, I just killed a kid over the phone. Give it wrong number. So she said she says we treat Lowe's with jelly beans because they hit him so hard. I said that's great. But do you have any liquid in the house that has carbs in it? That's not soda. And she said oh, we have lemonade. I said that's great. I want you to give them four ounces. Eliminate. So she gives them I said and don't go crazy measuring it. Just give them a little bit of lemonade, right? So she gives them the lemonade boom. goes to one arrow goes to diagonal down. The kid comes in I swear to you 75 Nice and stable. Yeah, it's foods been in for a half an hour. And when it was over, she's like, wow, that was nerve racking. I said, Okay, I know that. Clear your head, and then go back and look at the boluses. Look at the time you put the food in and look at the CGM and figure out how that insulin works in him. Because you just had a Master's class how insulin impacts blood sugar and how food impacts insulin.

Absolutely, absolutely. And that's, that's the place that as you know, clinicians, they don't have the time to do that. And it's unfortunate is it's unfortunate in the stance that with somebody something like diabetes, type one diabetes, specifically, you need that hand holding in an instance like that. You need the ability to be with somebody who can say, you're okay, write it out. You're okay. He's going to be fine. You've got jelly beans, you've got juice, you've got honey, you've got something in the house. You've got a mini glucagon that you could use if you need to. You're going to he's going to be okay. She's going to be you're going to be okay. It's it'll be fine. But you do you have to use those learning pieces. I think it kind of goes Along with a really good friend of mine, who has had diabetes a bit longer than me, which is 30 plus years, her, her doctor actually gave her kind of a good little hint for numbers, you know, we we start to view numbers in diabetes as good and bad, right? And that comes with that feeling of frustration then, and oh my gosh, I'm like killing myself, I'm doing something bad or whatever. And he said, you know, the numbers are information. So just like you said, it is okay, I'm here. Why am I here? You know, what can I learn from this? What can I do better next time. And maybe you analyze it, you know, three hours from now, maybe not in the instant, but it's information. So he told her, you know, when the number is going to come up on the glucometer, you put this test strip in, you put your blood on the strip, and you tell yourself, I am awesome. And here comes a number,

right? Yeah. Because I just need to be it'll tell me what to do next. And it can't be a judgment, you can't feel judged by it. You can't let you can't, you know, you can't look at it and say bad luck, you can say not what I wanted, not what I was shooting for. But what makes me what gets me to what I'm shooting for. And you know, it's funny as, as you and I are pretty much wrapping up this first thought, right? I have so many people asked me when they're first diagnosed, what are the things I need to know? And I find around diabetes in general, everyone's looking for an amount or a number from you. Just please tell me how many minutes I should Pre-Bolus? Please tell me how many units I should do if his budget is like this. And I tell them all the time, I don't know figure it out for yourself. And you will write like you have to but I can't give you no one can tell you that a 10 minute Pre-Bolus is going to be what's right for you. In any given situation, let alone all the time. I think it's insane that we think that just because we've set a Basal rate of you know, one and a half units at 2am, that we think that that's what our body's going to need every day at 2am. It's, it's insanity to think that it's just the best we have with the technology we have at the moment. Exactly. And so if you listen to this thinking, someone's going to tell me the rules about what I need to do. And I'm starting with diabetes, we did, we told you what to do. It just isn't what you expected. Right? Right. And so I get that, I understand that it's, it's not a pill disease, it's not take three of these a day, and you have to have food with them. Like it's not that easy.

And I think as a general too, in the beginning of of learning that comfort level and learning, you're learning what works for you by watching, you also have to take into that the variables, that can mean what you did figure out needs to change because of such and such variable, right. So you know, my breakfast in the morning, if I don't get to go to the gym before or after my normal breakfast, which I just I like it, which is why I eat almost the same thing every single day. And it works nicely blood sugar wise, but I like it. So it's easy. So but I the variables that I had to figure out were pre eating it, exercise, post eating it, exercise there, those are the variables, you know. And so what works in a morning, where I'm not exercising at all, is completely different than the mornings when I have exercise at such or such time.

The variables are forever changing, which is why you have to, interestingly, know what they are, and at the same time completely ignore them. And what I mean by that is that you're not a machine, right? So there's certain things that are going to make sense. Like you just said, I know if I exercise prior or post that this changes how this Bolus needs to be. But if you're walking around trying to decide constantly, am I anxious? Did I just bang my knee? Like, like, you know, like, am I going to get a client the thing I see people saying online all the time, like his blood sugar is going up, he's gonna get sick three days from now I'm like, Oh my God, just give him more insulin. Like, who cares if he gets sick three days from now, I and so that's what I think of. When I say be fluid. I just that it's going to keep changing at such a rate that for you to try to apply static rules to it is insane.

You've got that piece of of life with diabetes that you can then bring into education, which is why people usually come to us because we understand it from the Living standpoint, not from the this is what the clinical book says should be happening. So do this.

I'm incredibly proud to say that I've gotten to the point where if I can talk to somebody for about 45 minutes or an hour they can have a major change in just a couple of days. And that's that's communication that's what that is right? Well, that's what I have in mind Jenny for this series. Today we talked about being newly diagnosed or starting over. The next episode will be about multiple daily injections or MDI. We'll do an episode about insulin bolusing pumping CGMs and on and on until you and I finish covering every aspect of the things that we talked about on the show. I want to thank Ascensia 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 Gvoke glucagon, find out more about Gvoke HypoPen at Gvoke glucagon.com. Forward slash juicebox. you spell that Gvoke glucagon.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. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com If you're interested in hiring Jenny, you can learn more about her at that link. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two in Episode 1018 teen pregnancy 1019 teen explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025 We talked about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son 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 A1C 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.

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 CDE 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 revisitable. 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 Ascensia 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 Juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org. And on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke HypoPen Find out more at Gvoke glucagon.com. Forward slash juicebox. How frequently does someone leave a diagnosis with an insulin pump?

I would say never part of the reason for that not leaving a hospitalization or a doctor's office with a pump is because of all of the red tape that you have to sort of go through for ordering and you know that kind of stuff. I would say the rare case, this is probably 10% of the time, maybe even less, somebody's pretty quick to get the order written by their prescriber. And in fact, I worked with somebody maybe a month ago that her little boy was diagnosed and had a pump within about six weeks. Okay, but that's pretty quick. It's not typically that fast.

Most people are going to get diagnosed with type one diabetes and leave with either pens or syringes or syringes, right? Yes. And so whether you're a person who thinks right away, I have to have a pump and you hammer through insurance and get it six weeks later. Or if you're a person who gets told, we don't give pumps to people until you've had diabetes for six months, or any of those arbitrary times that doctors throw out one year or until you're in perfect control, then you can have a pump as soon as you know how to do this so well that you'll never want to pump we'd be happy to give you one which will never come and so so people are going to need to know what managing with just MDI looks like so multiple daily injections. These people are going to get some sort of a fast acting insulin that they can use at mealtimes and to try to adjust highs and they're going to get a slow acting insulin that's going to be their Basal insulin. Right? Well, so let's start slow with the Basal insulin. There's a lot of them on the market at this point back when Arden did MDI we were using love Amir, and we found that we had to split it half a dose every 12 hours. How how much of that is really good advice about slow acting Basal insulin, specifically,

that what you found with the love Amir as a specific brand or type is very common. Okay. While while the you know the makers of love, Amir will say that it is a 24 hour acting insulin. What we find, especially with the smaller doses, is that dosing twice a day or two injections of it works much more optimally because it doesn't carry a full 24 hours.

That was absolutely my finding. I think a lot of people find that so that's the first thing to understand. If you Save yourself every day a certain time my blood sugar goes up. And I can't understand why I bet you it's about 18 to 20 hours after you've injected your slow acting insulin. And so the important thing to remember when you if when you make the decision to split your Basal insulin is that it might not be a 5050 split. So say you have your five units or a one unit, it doesn't matter, it doesn't mean you're going to put in a half a unit and then a half unit again, 12 hours later, it might end up being three quarters of a unit or one and then a half later, there's your because your body has different needs at different times.

And that kind of goes into understanding the needs of the different age groups, kids and teens tend to have a much more profound increase insulin need in the overnight like literally like as soon as their head hits the pillow kind of thing and through and into the overnight. So splitting doses for you know, multiple daily injections with the Basal insulin, you may have a heavier dose in the evening than you do with that morning time, the heavy dose in the evening carries you through the increase in need overnight, as well as the morning which is a little bit higher resistance as well. And then your dose in the morning kind of carries you through the day when you're more active, right? And you likely will need a lower Basal amount. And so

all we've really said here, and I repeat this a lot to people is that setting up your slow acting Basal insulin when you're on MDI is about amount and timing, right? Yes. We're gonna say this in the next episode, but so make sure you get to that next episode, but you have to balance the impact of the insulin against the action of carbs or body function, right. So it's just, it's about a tug of war between those things. And that again, I'll talk about a little later. And that's where

watching you know, glucose values, especially if you are privy to getting a CGM early on, which I do encourage over I've said it a million times to people that I work with, if I had, if I had to decide on a technology piece between CGM and a pump. If somebody was going to take one away, I would 100% Keep my CGM, right 100%. Take my pump, I'll figure out my multiple daily injections. As long as I've got the data and the trend of what's happening, I can figure it out.

If you are going to I would 100% agree with you. If you're going to say that one thing is more important than the other, which I think is a bit of a you know, yeah, right. I I'm not looking to give one of them away. But am I by any means when you when you lose your pump when you're using MDI, what what that means is that if you want that kind of like, tighter control, I guess you're going to be injecting more. If that doesn't bother you, then right on, you know, like, that's absolutely fine. You also

see what my friend ginger does. Ginger Vieira, who I wrote the book with the pregnancy book, which you know, she long term has been multiple daily injections. She uses CGM. She is not scared to give 1216 20 Micro dosing adjustments through the course of the day to keep things tightly managed.

So and I think so I always say the same thing. Here's what you gain with a pump. You don't have to inject all the time. And you now have the ability to manipulate your Basal insulin. Yeah. But other than that, there's no more precisely

right, right can manipulate basal with injected basal, we don't, we don't recommend it. Like we would on a POM it's difficult to difficult, it's difficult to manipulate. But you can use your precision to do that on punk. Yeah,

the first time I thought about getting on a pump, and I didn't know anything about them, and I went to a pump class at our children's hospital. You know, even back then I didn't realize that, that my Basal insulin would just be fast acting insulin given by the pump, but in smaller doses, like, like, spread out over minutes and hours, right. And I didn't I didn't think about that. It was explained to me in that room. And then I thought I could shut it off. Like because how many times I thought, Oh, I wish this level mir had an off switch right now. Because it turned it off. She's so stable and she's at but I know she's gonna go down because this, this level here, she's gonna keep working in the background. I

don't want to feed her three juice boxes just to prevent it right. Yeah, looking for

that. I have become adept at manipulating artisans, blood sugar, with Basal insulin through her pump. But that's not what we're talking about right now. But we'll get to it in a different episode

leads in it goes very well with MDI, because you can manipulate differently even if you are on MDI.

And so, so I guess the first thing, just very basic ideas you're injecting, you need to pick multiple sites, keep rotating your site you can put in so on and over and over in the same spots. It's incredibly important because you you're Your spa your spots will become saturated you can actually what do they call that when that when you can actually see like bumps under this under your skin from Yeah, it's

it's really a either a scar tissue development or potentially fatty tissue under the skin that that light lipo hypertrophy, other big, you know, fancy words for it. But really, it's just when you inject in the same place over and over and over and over again, you're damaging the underlying skin tissue. And it can lead to, like I said, either scar tissue or fatty deposits. And unfortunately, then the absorption in those areas is quite variable, variable, if anything at all,

and you could lose your favorite place and never be able to use it again. Exactly. So when your doctor or your nurse practitioner tries to scare you with whatever, Jen, whatever Jenny just said they're like or something like that. Just think to myself, just think to yourself, Well, that sounds scary. What she meant was rotate your sights,

rotate your sights, and there you know, there's so many places on the body to use mean the backs of the arms, the lower back the upper, but the legs, the tongue, the tummy, the sides of your tummy. I mean, you've got a lot of places to use. So I think with little kids. That's always a it's a question with parents, you know, mainly because little kids are, there's so little, I mean, Arden was too, right. So it's, it's like it's finding the place on such a little body.

That remastered diabetes Pro Tip series is sponsored by Ascensia 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 Juicebox free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash Juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen, it fits well in your hand, and features Second Chance sampling, which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one. Contour next one.com forward slash Juicebox free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips, you can use my link and save time and money buying your contour next products from the convenience of your home, it's completely possible that you will pay less out of pocket in cash for your contour strips 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. And let me veer off for a second to say something that I think people will find valuable, especially parents. I did some quick math and in the time between art and being diagnosed just after her second birthday. And when we got her on an on the pod when she was about four and a half. I think we injected or you know or stuck her fingers a combination of 10 to 15,000 times those years, right? A lot. And every time broke my heart in a way that I find difficult to put into words. And years and years later, we had been on the on the pod for years before we ever ran into a situation where I thought I should inject here just to see if my site is bad, right? So we had had we were on just a really great run with with insulin pump sites. But one day, a number of years after we switched from from MDI. I said to Arden, hey, I'm not sure if this site's bad. And I don't want to change the pump if I don't have to. So I'm going to inject some insulin. If it starts going down right away. I'm going to say the pumps, sites bad. And if it doesn't, then you're just resisted for some reason. We're going to give you more insulin. So I put her up on the counter. There she is, you know, she's like six, seven years old. And I pull out the insulin and she's just going along. And I bring out the syringe and she says, what is that? And I was like it's a syringe. It's a needle, I'm going to put the insulin in and then she goes and then what? And I was like, Well, I was thinking of injected and she was like whoa, wait a minute, like really? Like, what are you doing? I'm not getting a needle. That's not something I do. And I was like Do you not read Remember these? No idea, no recollection of ever getting a shot ever. So I know it breaks your heart as a parent. But I don't want to say kids are resilient, but time has a way of, you know, blurring the past. So yes,

absolutely. Absolutely. And that's, you know, even pump sites, then, you know, same thing with rotation. Yeah, yeah, they all need to be rotated. And that becomes the, I think it as an as an omni pod. Plus, there are so many more places that you can put that pod. And easier, especially from the kid standpoint, or anybody who has dexterity issues or whatnot. You know, because there's no tubing, there's no tubing, and you can pop it on. And that's even easier than an injection.

I've seen people put them backs of arms. Arden, where's hers, you know, the left of the right of her navel on her stomach, and you can even and she wears them on her thighs. You can even rotate within a rotation. So you could put it on your stomach cannula facing your belly button. And then the next day turn it and you know, put it the other way like you can. If you have four spots, you have 20 You know what I mean? Because you can just kind of start moving around a little bit of grown grown women who wear them on their breasts like that one, like I show that every once in a while somebody will kind of like pull their shirt down online. I said it's the art and art like I've never doing that.

Yeah, I've not tried that myself. Although, you know, this year, Chris Freeman.

I was gonna bring Chris off. He wears, he

wears it on his chest. Yeah. And I know, he also wears it on like his upper back. And I've seen people on many of the like the Facebook, diabetes groups and whatnot. The places that I mean, people wear them on their calf, I've seen people wearing them on their forearm. Now, although not approved sites. Again, this is where your diabetes will vary. And you've figured out what works for you. But you know, yeah,

and for people who don't know, Chris is a four time Olympian and a cross country skier. And there is a picture that he shared years ago that is to this date, the most popular thing I've ever put on my website. So ladies, you might want to look at why you're clicking on things. But it's a Chris without his shirt on. And he has no body fat to speak.

And just wear the reason he wears it there he does. And my

point is he's still pumping and using a Dexcom. And so if someone tells you, you're too skinny for this, or I've heard it both ways, it's so funny. Oh, you're too your kids, too chubby for that pump. Your kids too skinny for that pump. i There have been I've heard a million different excuses. But okay, so MDI, so rotate our sites, what are other good practices around MDI.

Other really good practices, make sure you are changing the syringe, if you're using a pen, really, really important is syringe itself, as well as the pen needle caps. In fact, one of a very, a very common practice for people to do is reuse the pen cap. And by reusing, they actually store the insulin pen with the needle cap, screwed on to the pen. Really not a good idea, it can introduce air into the pen. And it can change the way that the pen dialing can actually dose the insulin. So if you are going to reuse the needle cap, I don't recommend doing it. But if you are going to do it, take the needle cap off in between those uses. Always make sure that you're wiping the top of the needle or the insulin pen itself, you know, with an alcohol swab, just cleanliness. Those are kind of the basics.

Okay, well, what about and I realized to go back for a second you were starting by saying Don't reuse a syringe, which never in my wildest dreams even occurred to me, but you're telling me people do that, too.

People do that. Absolutely. And, you know, having worked with people across the spectrum of economic setting, just like insulin is expensive. I mean, even though a box of syringes is not expensive, even off of the shelf, it's not expensive without a prescription. Again, it may be something that people are reusing because it's an expense that they could decrease

somewhere, right? You know, so if you can avoid that, please do. So I have a question and here's a good place to put it. I'm probably gonna bring it up again when we talk about pumping. So the quickest story would be that one day I took off Arden's pump and I saw little redness under where the adhesive was. And I was quite literally standing in my house, rubbing my hands together thinking because I was scared oh my god, is she allergic to this adhesive and we can't pump anymore and like my brain was racing, and I'm rubbing my hands together and rubbing my hands together and as I was doing and I thought, Why are my hands so dry? And then I realized I'm constantly touching alcohol. Yeah. And so I do a little research and I find out that in Europe, it is not common practice to clean anything, a site with alcohol. And I was like, huh, so I stopped doing that. And Ardennes never had that problem again, and my hands don't crack as much in the wintertime. And so is that a lawsuit? Decision? Like do you say to somebody clean this with alcohol first? Because every once in a while someone's gonna get an infection? Or why do we teach it and some other places don't?

Alcohol itself is not a I guess the best thing that that I can call in layman's terms, it's a degreaser. It literally wipes clean, that area of any grease, any any skin, moisture, any lotions, anything that could be on there. It's it's not antibacterial, okay, it's wiping the area clean. Sure, right. But the real reason for cleaning the site is just to make sure that you've, you've taken care of anything that could be there. And as far as adhesive component, it's very likely, of course, that the adhesive isn't gonna stick as well as if you've got body lotion on it. Or if you haven't taken a bath in two days, and you're putting it on your skin and your skin has done its normal thing, and you've got oily skin. So the adhesive isn't really going to stick as well. What do I tell people, I also do not use alcohol. Oh my gosh, a CDE. That doesn't use alcohol swabs. But I do, of course, have a clean site. And by clean sight, I make sure that I wash the area. Soap and water, make sure that it's clean, dry it and that's what I you know, apply on top of then you're entirely 100%. Right? Alcohol is it will dehydrate the skin and used over and over and over, especially for kiddos little kiddos who have very sensitive skin to begin with. You're just asking for more. I mean, there are skin barriers, if you do truly have, you know, a slight problem. But yeah, even for injections though, making sure that the injection site is just clean. I mean, obviously, if your kids been outside rolling in the mud or in the sandbox or doing whatever they've been doing in the rain puddle, clean the site.

We do the same thing, I use warm water, a clean towel, a clean towel to dry it, let it air dry, something like that. It goes on, you know, schedule your pod change around your shower, you know, get out of your shower, pod change. Sometimes, you know, I see some people like they call them naked showers where they change all their gear, they take it off before they jump in, they're free. They're free for a couple of minutes and they jump out and they do it then there's a bunch of different ways to do it. But I think the important thing here is to use your common sense, right like to and that's all I did that day, I thought I'm drying her skin out and then throwing this adhesive on top of her No wonder there's a reaction here. Absolutely. There is a wonderful post on my blog about how to treat real severe at ease of allergies it is is one of the most popular posts over the last five years. And I'll link it in this so that people can find it was written by a mom who devised a infallible plan. And when you see the pictures of the reaction that her poor kid was having, it was an all over body reaction. And she figured out a way for it not to happen and him to keep using this stuff. So that was really good. I remember the first time Arden was in like a thin pair of like yoga pants as like a four year old and or a three year old or four year old and I wanted to give her a shot in her leg. But we were out and I just was like, I'm just going to jab the needle right through the pants. And that's what I was like, Okay, maybe all these rules aren't that important. And you know, and so she was like, Oh my God, what are you doing? And I said, No, it's fine. I brought it up in you know, now I say I've done that in the past and she was mortified. She's like, why would you I was like, listen, we were in the mall, you know, like, like, what do you want me to because I and here's something I really believe. And I think this is a great place to bring it up. I don't think you should hide when you give yourself injections. I think I agree. I think that not just not hiding. But why in a public place? Would you go to what is arguably the dirtiest, the bathroom to open up a hole into your body?

Absolutely. kind of goes along with nursing for women. Why should you have to go to the bathroom to nurse when it's the same thing? It's the comfort level of other people. It's not your comfort level that you're worried about? got

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Level of other people. It's not your comfort level that you're worried about

exactly. And so let me tell you the briefest story. I'm in a restaurant one day with my kids. And we're leaving that day and there's this little girl seriously a little girl injecting at her table. And I stopped at the table none of my business I said excuse me. I just wanted to May I say something and they looked up at me in horror I realize now and I said my daughter has type one diabetes too. And I want to say good for you for injecting here at the table. There is no reason for you to hide. You're doing a great job, little girl like last year. I had to do the math. Last year, seven years later, I had to make a phone call about jury duty. And I said look, I would like to skip jury duty because I'm the sole caregiver for my daughter, I help her make her insulin decisions. And if you listen, if you'll let me be on my phone while I'm there, I don't care. But if you don't want me on my phone, I need to ask the skip. And the woman says oh, I completely understand. My daughter has type one diabetes too. And I gave her my name. And she says is your daughter's name Arden and I was freaked out and I thought Yeah, why? And she goes, I read your blog. And I said great. She goes actually you're going to find this strange. You've been a real help to my daughter through her life. And I said why? And she said, Because you bumped into us in a restaurant. The week she was dying. The week she was diagnosed, and you told her she was doing a good job and she shouldn't hide. And she's like, and it's been such a big deal in her life. And I was like, wow, that is so touching. I'm gonna get out of jury duty. Right? And but, but absolutely 100% on a story. Like don't, don't hide, you know, and because Jenny's right it is for other people. It's not for you, and it quietly you'll you feel shame, like it quietly will make you feel shameful about what you're doing. And you should not be ashamed of having type one.

Not at all. It's just like, you know, I mean, everybody wears it. I mean it kind of goes along with everybody wears their pump differently. And there are a lot of people especially Omni pod wearers who wear them you know, only in like, unseen locations, man I like I wouldn't buy pods they're get decorated with stickers and I used to like color them with markers and now that I know that you know we have the 3d printer kind of thing. We don't but I ordered a Wonder Woman 3d print pop snaps it snaps over the top. It's awesome. I actually let my six year old pick it out because he was like wow, all those are cool. You have to get wonderful mom You're wonderful. I was like great.

But Mommy was gonna get flowers but okay.

Exactly one of my favorite places to wear it is on the back of my arm because honestly because it isn't visible. Yeah, not like the other places on my body aren't good. It's just I like to wear it good spot visibly, you know,

I would tell you that Arden has in the past seen other people using insulin pumps on the pod and CGM and it she's not the kind of person who runs around excited about it but it has quietly given her a lot of comfort.

Yeah, yeah. It's always fun to when you run into die I call it diabetes in the wild. Like you run into somebody at the grocery store who's like, you know, boldly got their pump like hanging off their pants or you know, clipped to their jacket or you know, something like because I've, I always reach out, I'm always like, hey, you know, look, you know, pumps, we've all got pumps, and it kind of starts up a conversation. And it's, I don't know it just because diabetes is so like, it's such a silent unseen. For the most part, it's just a nice way to bring it to have visible

and make it make it normal because and here's why that's important. I interviewed a singer a long time ago, a Broadway singer named Kelly. And if you go back and listen to Kelly's episode, which I'll link in the show notes, she hid for a long, long time, and it was not good for her. And when she finally decided not to do that it was freeing. So I'm saying don't put yourself in that position to begin with, you know, just be yourself. And, and this is who you are. And look, I'm not judging you, if you can't bring yourself to do it in public. I'm not saying you're a bad person. Yeah. But I'm saying if you can do it, do it. You know, I think you'll be happy with what happens. So, okay, so what are we not? I haven't, I haven't injected insulin in a really long time. So let me tell you one thing that happens to me all the time, every once in a while when I have to give a needle, I'm not good at it. rd tells me I'm not good at it. And so what what is, like, what should I be doing? Is there a pinch? Is it quick? Is it slow? Like, what's the right way to stick that needle in there?

Do it? Yeah, I mean, you know, obviously, the age old recommendation is to pinch up. To put the needle in, when I was initially diagnosed 30 years ago, we were told to inject at an angle almost at like a 45 degree angle. Quite honestly, now the the recommendation is just like most 90 degree pump sets, just straight up, putting it straight in, no angle is needed. A lot of people have question too, about the needle length, and all of the research and studies that have been done. Regardless of body type, and body stop body size. Even those really, really, really micro looking needle lengths, they give you the same, the same ability to put the insulin under the skin in the place that it needs to be, which is the sub q tissue, like the that kind of fatty layer for absorption. So pinching up the skin, putting the syringe or the the needle that's on the the pen straight in 90 degree angle, and then just push the insulin in,

that I have to keep the needle in for a second or is that a pen thing?

That's for the pens, really, the recommendation is it does vary. I've heard people being told that they're supposed to count to 20. I've heard people say that they're supposed to count to five. When I was initially educated, we were told that to tell people count to 10. So that is what I educate with. And it's interesting because if you have ever given a syringe injection versus a pen injection, you will notice a difference if you pull that pen needle out right after and you don't give that count to 10 the insulin can leak out. Okay. So that's the reason for that count. And whether it's a Basal insulin or your rapid acting insulin or a regular insulin. If it's a pen, you do need to do that count.

Okay. All right. Let's see what you think of anything that I'm going to ask you about because I'm at a disadvantage when talking about MDI.

Um, I mean, the only kind of, you know, Basal insulin, of course, rapid acting insulin, you know, there are multiple of them on the market. There also is still some use of regular insulin which we called short acting insulin, it had a longer profile of of working in the body, then our rapid acting insulins have, it also didn't work as fast. So again, this is where figuring out what your needs might be, for the most part, the rapid insulins on the market, the three age old ones, you know, Humalog Novolog, Apidra, technically, they're all supposed to work pretty much the same way. I can tell you my personal n of one is that Humalog and Novolog work pretty much the same for me, a pager does not I've tried it, it doesn't work the same for me. Then there's also of course, the ASP, which is faster acting insulin aspart, which is just faster acting Novolog insulin, it does have a faster onset of action, and has, in my experience, having used it for a bit of time, it seemed to have almost a more clean finish to working. It was done and that was kind of the end of its actual Elon by Basal was kind of kicking in and doing what it was supposed to do. But you know, determining what again, works for You insurance wise, many insurance plans have a preferred or a tiered kind of both basal and rapid acting insulin for you to choose. monetarily, if you can go outside of you know, tier one or tier two, most insulins are tier two. If you can go outside of that, they'll usually be a tier three and your copay is just going to be more. But if you prefer one over the other, that might be the course of action you have to do. If you can't, then you're kind of stuck using what the preferred is.

Okay? And I'm going to ask you one question, and then we're going to switch to another episode and talk about insulin. So the one thing I've found is that when I talk about Pre-Bolus, sing with people, and you know, Pre-Bolus thing is a pumping word, it just means putting your insulin in before your food, right. So you can you can pre inject you call it whatever you want. But but some, but a lot of times, what you'll hear from especially parents is I don't want to inject them twice at a mealtime. And I say, Look, I understand that, but but if you can't be sure of how much insulin or how much food the child is going to eat, you still need to get some moving first. So if you're on MDI, and you're seeing crazy spikes at your meals, it's because you're not Pre-Bolus thing, I'm guessing, or a lot of other reasons that you'll hear through the next bunch of episodes. But you're gonna have to make that leap in your head like I'm going to if I can't trust he's going to eat all this or she's going to eat all this then I need to put some in now, and some and later, right. Please remember that the Juicebox Podcast wouldn't be possible without its sponsors for today's episode on the pod, and Dexcom Dexcom, the makers of the G six continuous glucose monitor, and of course on the pod is the tubeless insulin pump that Arden has been wearing for over a decade. You can go to my on the pod.com forward slash Juicebox get a free no obligation demo of the pump sent right to your house. Or you can go to dexcom.com forward slash Juicebox to find out more about art and CGM. Heck, you could do both. The next episode of my series with Jenny Smith is called all about insulin. And it's available now at juicebox podcast.com. are right there in your podcast app. If you're enjoying the podcast, please leave a rating and review on iTunes and take a moment to share the show with someone who you think it can help. Thank you for listening for being bold with insulin, and for remembering that nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, and to Always consult a physician before making any changes to your health care plan. I want to thank Ascensia 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 Gvoke glucagon find out more about Gvoke HypoPen at GE Vogue glucagon.com Ford slash juicebox. you spell that Gvoke glucagon.com Ford slash juicebox. 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. 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 popping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs. In Episode 1015, Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two, in Episode 1018 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, 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 A1C 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.

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 CDE 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 revisitable. 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 health care plan or becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by Ascensia 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 Juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org. And on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke hypo pen, find out more at Gvoke glucagon.com. Forward slash juicebox. What is it about insulin that people need to understand at its core? And I'll start by telling you that it just a very simple story that that I was in my nurse practitioners office one day, you know I like to say we are at the Endo, but honestly I never see the Endo.

Right. It's always a nurse practitioner who is Yeah, yeah. And most often they've got more time anyway. So that's good. Yeah.

When people say who's your I know, I sometimes I have to pause. I'm like, huh, I don't really know. So this was a number of years ago back before I think I would quote unquote, say that I started to understand. And I would say that I've understood diabetes on a different plane for about the last five years or so. Okay, but the run up to understanding it was reaching out into the world and picking these little ideas and really wrapping my mind around them. And as much as I tried to understand bolusing, or understand, you know, the, the peaks and valleys my daughter was seeing and all the problems we were having. It wasn't until the certified diabetes educator in my daughter's practice, answered a really simple question for me. I asked her if you had a magic wand, and you could change the way people do one thing around diabetes, what would it be? And without hesitation, she said, I teach them not to be afraid of insulin. She said that would be the core step one. Nothing else matters if you're afraid of the insulin. And I took that to heart. So I guess let's start with why are people afraid of insulin? What do you think it is?

I think the main reason is because the initial education includes so much about hypoglycemia, insulin, I mean insulin is one of the very very few medications on the market that doesn't have a tremendous amount but really doesn't have any effect on anything else. You know, it's not going to cause your eyeballs to turn green or you know, your toenails to grow extra inches or anything funny, right? It's its side effect, let's call it is hypoglycemia, low blood sugar. If you don't understand how to use insulin, right so that I mean it is drilled into you if you be careful of low blood sugar. This is how to treat low blood sugar. These are symptoms have low blood sugar, I mean, low blood sugar, low blood sugar, low blood sugar is drilled in. And so what are you going to get from that? I mean, if you're told every time you come to the stop sign that some car is going to come and swipe you, you're not going to like go into a stop sign either, are you?

It's funny, I think of when you say that I thought of driving in my mind right away and a little differently I thought of when you first teach someone to drive, you teach them about the brakes. Right? Right. Right. So it's the it's the first thing you think, right? Like, even if they steer wrong, or anything, they're doing wrong, if they can stop, maybe they won't get hurt too badly. Right. And so it is really the same idea. I guess for doctors, they look at the giant picture that is type one diabetes. And they say what's, what's the thing where these people could run into a wall, they could use their insulin incorrectly cause a scary low a scary low might mean if you're an adult, loss of your own function, inability to stop that fall from continuing. Right, right. And then so let's talk about granularity for a second because I don't think we do this enough about diabetes, insulin extracts sugar from your blood. That right? Yes, yeah. And unlike my body, which knock on wood has a pancreas it's working in my body knows when to stop, it gets me to a nice level on it, and it stops, manmade, insulin is going to work until it's not there anymore,

gonna work and work and work and work. And it's going to work in an interaction setting with the food that it's meant to work with, or the glucose that's in the in the bloodstream for it to work with. Now, there's too much insulin there, and there's not enough glucose for it to continue to work with. And it's still gotten whole hour of action, right? Absolutely low blood sugar.

Yep. And it's not going to cause low blood sugar. Like you said, if there's impact of carbs impact of body function, then that's what the insulin is working against. The minute that carbs are going from your system or the adrenaline you had is gone. This insulin, if it is still there, if you've Miss timed, it is going to continue to work so that we know what we are scared about. Let's be more more honest about it. I'm going to test myself and you'll tell me if I'm wrong. Sugar is the energy that our brain works off of. It's the get the gas for our brain, right? It is yes. And if there's not enough sugar in our blood, our brain shuts off like a light switch. Is that correct?

In an easy way of saying it? Yes. If our brain is not getting the that sugar? Yes, we That's why all of those strange symptoms come about with low blood sugar, your your brain is being deprived of the food it needs to function to think the right way. Yes,

let's just throw it out on the table, what everyone's really afraid of right. Nobody wants to die when they're sleeping. That's what everybody's concerned about. I don't want to say that that's not an issue. Because if it happens to one person, that's an issue, I would say that I do think of it again, like driving like I think driving is incredibly dangerous. But I do it every day. If I happen to have an accident one day where I'm killed, I will not be thrilled about that, as I see the telephone pole coming for me, right. But I think that's maybe the cost of doing business for being alive. I have to get around, I have to travel. Right? I think the same thing about diabetes, you need to use the insulin in an effective way to make your life healthy, longer, happier, you know, all that stuff. So you have to learn how to do this. And then the rest of it just like driving, you throw it away, you're like, Okay, going out there and I'm going to do my best. The first thing that's happens is people get dizzy, confused, they're easily agitated. But then as your blood sugar continues to drop, you lose the ability to what, like what happens as you continue to get lower.

And again, this is where symptoms are different for everybody. But truly what can what really continues to happen is the the loss of the right way of thinking you it just continues to decline. And if it gets far enough, you could lose consciousness, you know, you could certainly no longer be awake. It doesn't mean doesn't mean death. But it does mean that you could certainly pass out from a low blood sugar, which

is why you'll hear it adults sometimes say they knew it was coming, they consumed a ton of food, then wake up on the floor because then the food gets in and it turns things around for them. Yes. So I'm gonna I've said this before, but, you know, for context in this episode, prior to technology, I mean, honestly, back when we were needles and little tiny like I've said before, like a diabetes bubblegum eater, right. I have caused Arden to have two seizures. One right after she was diagnosed, she was only maybe a few months into it. And I had this grand idea that I had figured the whole thing out which probably meant she was honeymooning Right, right and we go to the mall One day to pick up some stuff real quickly. My wife's going on a trip and we need I think, another bag or something. Everybody gets hungry while we're running through the mall. And here's this like, mall Chinese food. And I thought, this doesn't, no big deal, right? I'll just count the carbs and I'll shoot the insulin and she'll eat the food and she ate and it was good. And she was little two years old. She had a little bit of food. I gave her no, not a lot of insulin for of for 20 pound person, right, bought the bag went home, she fell asleep in the car later in her crib. My wife and I are helping her. I'm getting her packed up for what she's doing. And then I hear what sounds like a wild animal in my house. grunting and snorting and like like that. And I go into the room, and there's my daughter, she is having a seizure in her crib. And so I pick her up and I don't know what to do. I mean, I know the doctor told us about glucagon. But for the life of me in that moment, I couldn't, I couldn't hold my hands still, I couldn't reconstituted It was a disaster. While she's on the floor, and my then seven year old son is dialing 911. For us, my wife is rubbing glucose gel in her cheeks. And as I'm fumbling with the glucagon and really messing it up, Arden is blind. If you touch her, she overreacts in a way like she thinks she's being shot like, right, like it scared her. She is grunting, and incoherent. And then it just ended. Like, the glucose gel worked. And she came back and the police came into the house and the rescue squad and we went to the hospital. And now I look back, we didn't even have to go to the hospital. Like the hospital was nothing. By the time we got there, her blood sugar was back up and she was fine. And this whole thing, but it's scary.

I mean, just one of the worst moments of my life. Yeah, you know, I mean, and I talk with and work with so many parents with little, little little, you know, and it is it's, it's scary when it's when it's your child, and it's not even you, you know

the worst thing. Now I tell the scary story to tell what I think is the funny story. Yeah, so a year and a half later, we're at Disney for the first time. It's our first time outside in the heat. On a big day with diabetes like diabetes. A whole day's going great. Again, no CGM still using needles. End of the night we're walking back to the hotel and coming at us is a vendor holding these giant popsicles. And I remember looking up and seeing them and thinking we're like 200 yards from the hotel, like make a left turn, what are you doing, you know, but it's hot out and it's late. And my kids see those and they're like, can we have them? And I thought, sure, I'm going to do what the doctor told me to do. I counted the carbs, I gave her the insulin. And of course, it turns out and I know now, you know, I could have just let her eaten that popsicle it would have been it was a fast acting carb, it might have hit or spiked her a little bit and gone away. She didn't need any of it. But there we are back in the hotel room. Packing again, always packing with seizures in my house. And so we're packing because we're leaving the next day. She's laying in a bed off in another room sound asleep and I hear that noise again. And this time instead of being confused and thrown off. I say to my wife Arden's having a seizure. Now remember, it had been a year and a half since it happened before. And my wife runs and grabs art and brings her back she's holding her and I have the glucose gel in this Squeezy tube. Now the gel we owned, you had to screw the top off of them pull the foil thing off it, I guess keeps it fresh, and then you can use it

as your gel spoil. She is

because you never because you know because honestly now in the of course the ensuing 12 years later, we've never gotten to never had a seizure since then, but so I unscrew the cap, and I go to squirt out the gel, and I don't pull off the foil cover. And I squeeze it so hard with so much enthusiasm that a pinhole breaks on the opposite side of the thing. And I'm squeezing it. I'm like what's going on and then I look up and on the ceiling of the hotel room is a kaleidoscope of jello. I'm shooting all over the ceiling. So I don't even pause I flip the thing upside down. And now I just scored it from the pinhole in the Ardennes mouth, we rubbed around, she wakes up, we put you know get everything straight, put her back to bed. We were traveling with my brother, when it was all over and to say that it might have been a four minute experience right? When it was all over. I look in the corner and my brother is cowering in the corner, just with a look on his face. Like he can't believe what he just saw. And my wife and I look up and see the gel on the ceiling. We crack up laughing wipe off the ceiling clean it up and go back to packing.

His experience is a good example of of the fear.

That's exactly right. Because no matter how much I explained it to him, and I said look, you know I don't want to call this the cost of doing business but we've never been in this situation before we're completely blind. We don't know what her blood sugar stowing, I think the point is this. And my point is this, I don't think my point is this. I know my point is this, I don't want Arden to have a seizure. But in GS two to 15, in 13 years of having type one diabetes, it's happened twice, it was both when she was tiny, it was both when I didn't know what I was doing. And it was well before the technology that exists now

than before experience of walking around. I mean, in this example of walking around a park all day, and not really knowing, hey, she can probably get away with having this little bit of extra sugar, she'll climb, she'll come back down, and the exercise is going to hit all night long. She doesn't need insulin, you didn't know that I

had no idea. And now I do. And now Arden can go play softball for nine hours on 105 degree day, and she doesn't get low at the end of the day. And because now I know what I'm doing. But that fear that exists exists for that reason. And so I don't know how comfortable you are talking about this, because I haven't asked you ahead of time. But how real this is, then we'll get off the fear. And we'll move on to other stuff about insulin. But how real is the concern that I'm going to go to bed one night and not wake up the next day?

I would say that the concern? It's a real concern. 100? Absolutely. It is. Is it a concern that it could happen? wildly out of the blue with? And I bring this up with the technology we have today? I would say that piece is it's not going to be as common. Okay. And it's not because we have alarms and things that set now is technology always perfect. No mean, we can get alarms and alerts for blood sugars that are ultra low or look like they've dropped off the map and you do a finger stick. And it's that the sensor was not right, you know, it was a, you know, kind of a compression low. Or you could have a low alert and you could actually be lower than the low alert already. Right. However, the fear of going to bed and not waking up. While I would believe that it's there. For 90% of people with diabetes, the other percent, maybe don't even think about it or know that it's a potential again, education piece there. But I think that there is the knowing about insulin and action going into that time of the night. I think that's a piece that can really help to prevent that from happening.

As we move forward, you'll hear me say a number of times that I think that highs cause lows, because highs create situations where you have unbalanced insulin. And and eventually, like we talked about earlier, body function, blood sugar will will be pushed away by the insulin, it's there leaving more insulin behind. And there are a lot of times that people will say to me, you know, I get low at 2am. Or, you know, it always happens. And I think well, I don't know that you get low at 2am. It's very possible that something's happening hours before or you're using insulin hours before. And it's and this is what the residual of that. Right. And so when you use insulin more thoughtfully, I guess is the word I want, right? Yeah, that's

a great word.

You don't have as much of it laying around later in your body that has nothing to do except for to make you low. And I'm hoping that we get to that as we speak. You've addressed fear and insulin, it's a real thing. It exists for most people. There's good reasons why you shouldn't be afraid. But how do we stop people from being afraid?

But I think the fear to it just to kind of clarify there, it's okay to be afraid. But it's also really important that you do something to understand and be able to get rid of the fear. It will be there it is certainly but it's important to learn how to not worry so much with the fear.

Right? let it overtake you. I think of it let it overtake you. Just like they tell you with fire when you're three years old. You're you have to respect fire. But you can't be afraid

of it. Right? Yeah, be afraid of it. Exactly. Yes.

And that's what I do. I it was the first delete that I made that brought me to the place where I am now. And I think that I think that no matter what tools you give people, if they're afraid to use them to kind of it's never going to work out quite right. And it's always going to become unbalanced. They're always going to end up in a situation where they go see look, this is diabetes is unpredictable. And and this is always going to happen and then yes, you know, and that that's that So okay, so All right. So what's the first step to not being afraid? It's got to be understanding how to use the insult, right? Absolutely. Okay, all right, so we're gonna get

100% 100%. Yes.

So let's understand a couple of things first that the insulin can do that cause issues for people and one, right people say, I started using insulin and I started gaining weight. Okay. Now, very recently, I had an interview with Chris Rutan, where Chris said, That's not as really nearly as much about the insulin is, as it is about calories. And that was his take on it. Like if you eat extra calories, you're going to gain weight. And that a lot of times we have low blood sugars that we treat with food, but we don't think of that food as food and access where we think of it as as necessary because it is the moment because you're allowed, but what is the act what is the what is the technical reason why people see weight gain with insulin. The remastered diabetes Pro Tip series is sponsored by Ascensia 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 Juicebox free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash Juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and 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 Juicebox free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips, you can use my link and save time and money buying your contour next products from the convenience of your home, it's completely possible that you will pay less out of pocket in cash for your contour strips 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. Why do some people see weight gain with insulin?

The easy answer there is that the insulin is being it's being mismanaged the dosing of it is being mismanaged and mismanaged why? That takes in depth analysis of what's going on in the person's individual setting. Right? The and I work with a lot of people weight management wise type one who I you know, I just I've gained weight or I've done this my blood sugar's are now better, but I've gained weight. Now, if to start with, if you're running really consistently high blood sugars, you're actually peeing out calories, okay emptying out glucose because that's how your body is trying to get rid of the excess because there's not enough insulin there to bring it into your body and utilize it. So you may be maintaining a weight that you love. Your blood sugars are high, that's it's not healthy. On the second side, once you do rein in control, and you're now taking insulin to contain blood sugars, you may be gaining weight because your body is now retaining some of those calories that were being lost before that you didn't realize right. So that comes then to the point of understanding lifestyle and the Management of insulin. And I bring up a really important piece that people don't, people don't realize insulins job is a storage hormone, insulin job is to pack the food into different places in the body, right? It either packs it and moves it into your muscle cells or at PacSun, and moves it into fat. Right? It's usable, or it's going to be hopefully used later. If there's too much of it, your body has to pack it away and utilize it later. So that's a that's a lifestyle piece. That's something to look at and say, Okay, where's my activity level where it is my nutrition intake needs to be is my insulin matching that, am I driving my glucose values too low, and like you said, Am I taking in too much because of low blood sugars that are consistently happening, and then you're adding more insulin to correct the high that follows, and then you're dropping, and you're adding food and you're correcting and add. So it becomes this vicious cycle of management, if you don't understand how insulin works. And in a body, I think a good point is that in a body without diabetes, insulin plays a very big role in weight management. And people without diabetes aren't injecting it, their pancreas is making it. So if they're themselves not managing lifestyle, they're having to produce a heck of a lot more insulin, to bring food out of their bloodstream for their body to maintain that normal blood sugar, the way that it's meant to do, they will likely gain weight too.

So do me a favor and go over that cycle for a second, I take something in through my mouth that has carbohydrates in it, it goes into my stomach, my bug, my body begins to break it down. It basically those carbs are leached out, that's sugar, which is the sugar is carbs, the sugar comes out. And the insulin actually helps it go into my blood. Right it or how does

it insulin takes insulin, you know, we take it, we inject it or we pump it into our sub q tissue, it gets absorbed and dissipates that into our bloodstream is I guess the easiest way to say how it works. Insulin in the bloodstream then matches with the glucose from the food that we've eaten in whatever form you know, it could be rice, it could be celery, it could be an apple, whatever it is, sugar in the bloodstream. The insulin kind of combines with the glucose they latch on together. And insulin is then the key to the door on the cells. With insulin, the doors open, the key unlocks the door on the cell, the glucose is allowed to enter the cell muscle cells then use it for energy. Fat cells, pack it away, right? So that's how

it works. And so with, so without insulin, we go into DKA. Right? And so MDK is what is it technically, but what what is it that's happening.

So technically, with DKA, it's it's a significant deficit of insulin with high blood sugars. Right now, there are cases of DKA at more normal blood sugars. The DKA, however, really is it's a deficit of insulin, meaning that your body it has no way to clear the glucose out of the bloodstream and move it into the places it needs to go. Now your body tries to compensate. Like I mentioned before, with the weight management piece, if it tries to compensate, you get really, really thirsty with higher blood sugars, you take in more fluids your body up because you're drinking more, and your body is trying to flush a lot of that extra glucose out. And the only way it can if it can't do that forever, though, at a deficit of insulin. And so your body at the point of not having energy from glucose, it starts to break down fats and proteins. So ketones are produced with the breakdown of fat.

Is that why when I think back on Ardens diagnosis prior to which she was ravenously, hungry at the end, because she her body was starving, and it's telling her eat, we're starving, except the food went in. And then there was no insulin to move it into the cells where it was needed.

Correct? Correct. I mean, I could have I remember, I mean, I was older than your daughter and I very, I very much remember the two weeks leading up, especially the week leading up to my diagnosis. I very much remember it. I mean, I at the lunch table at school with my friends. I was asking them for their milk. I was so thirsty and so hungry. And so they would they would get two milks, and they would bring one for me. I mean, I was consuming probably six of those little curtain Have milk at every lunch and between classes in the hallway I needed to get to the water fountain. I mean, it was. It was unbelievable. The unquenchable thirst and hunger.

No, that's crazy. It really is. threw me off for a second thinking. No, I was thinking back on Arden's diagnosis. And it, it just, it always just makes me think like, how do I not see her dying? Because she was, you know, like, like, no insulin in her body. And she was withering away and you look back at it.

I think for kids, it's hard to because kids are hungry all the time. I mean, I've got a two year old and a six year old and man, like every hour, they're like, I'm hungry. Grab this. I am hungry. Can I have that kids are hungry? Yeah. But it's a different. It's a very different ravenous in that setting.

Oh my god. Yeah. And so let me ask you something when a blood sugar starts to get low with a person who's being managed, but maybe they have theirs, their insulin is on balance, and they're getting lower. Arden will say she's hungry, prior to a low blood sugar. And I always tell her, Hey, if you feel hungry, first thing we should think about is are you hungry, hungry? Or is your blood sugar getting lower about the same function right there?

In a in a similar way, just in an opposite, you know, high blood sugars, you're hungry because your body is starving for the energy. Right? And it's not getting it. low blood sugars. You're hungry because again, as we talked about, initially, your brain is being deprived. Okay? Your brain is saying, Hey, you're hungry. There's not

enough. There's

not enough food here. i There's there's too much of this insulin, it's calling. And sometimes even that precipitous drop in blood sugar that can happen.

That's why manifests as hunger. Yeah, is there

with Lowe's. I mean, you could literally go to the refrigerator and eat the whole roof. I mean, there, there are people who have done that, or just the whole box of cereal. And they're like, Okay, where's the next box? You know?

It's yeah, and it's commonly referred to as eat the kitchen. Right? So yeah. And then and so. But when Arden was younger, and before sensor technology, and I was staring at her trying to figure out ways to understand where her blood sugar was. One of them was if she said she was hungry at what I thought were odd times of day. I thought, Ooh, she might be low. And yeah, yeah, because the looking for the bags under their eyes was not working. I'll never forget, she's diagnosed and the nurse practitioner goes, you know, dark circles under the eyes could be signs of low blood sugar. And then she paused and she goes are high blood sugar. And I was like, Wait, what was that gotta help me. And by the way, it never came to fruition. I spent, I spent the first year of her diagnosis, staring at her face looking for a sign of something wrong with her blood sugar, and it doesn't exist.

I have never heard that before Scott in that, right. Yeah. Never heard that as a symptom of high oil.

And it makes me think of the insanity of like when Arden will say to me like you know, you'll be in the middle of a CGM changeover. And I'll say, hey, look, it's been an hour since we reset the CGM, or since we put it on whatever, why don't you go ahead and test let's just make sure we are where he thinks you're at. And she'll say, I feel fine. And I always go, ironically, how you feel is not the best indication of what your blood sugar is. So and so she still won't wrap it, she still doesn't wrap her head around that right away. If she feels okay. Then she thinks I'm okay. You know, well,

and there's some children that have not quite even gotten to the point of realizing what the difference of body feeling is. Yeah. Right. And if they've lived with diabetes long enough, they may not necessarily know what, quote unquote, normal should feel like, right? Yeah, they may not know that at your diagnosis at two or three. They're not even realizing outside of like, an ear ache, that they're like screaming in pain, or they're pointing at their mouth because their tooth hurts or whatever it might be. Kids that young are not in tune with

how their body's supposed to feel, and and

associating it with oh, I'm low mommy, or I have high blood sugar. And so then moving on through life, because they've had diabetes, from such an early age when you do start to make those connections. It's very difficult to translate that then into you know, older age.

So I was it's funny you brought that up, because this was gonna be my next question for you. So I just was interacting with somebody on Instagram. 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 Gvoke glucagon.com. Forward slash juicebox Gvoke shouldn't be used in patients with pheochromocytoma or insulinoma visit Gvoke glucagon.com/risk, who, you know, found the podcast is bringing their blood sugar down. And now they have a beautiful stable 85 blood sugar where they feel dizzy. And, okay now, so I'm talking to this woman, and she says, I'm going to ignore it, I know it's not real, like, I know I'm not in trouble. So I'm just going to power through on my maybe I'll give myself a little bit of carbs to, you know, kind of help it a little bit, but I'm gonna power through it. Because I know my body's going to adjust to this. And I spoke to a different person who said that they got to that that nice, stable, good number, and they stopped themselves from eating too much. But it's still they had trouble doing it. So my question is, when you've spent such a long time with an elevated blood sugar, you know, thinking 180 was a great day, you know, your 250 for six of the hours of the day, and you finally get this all under control. You keep listening to these podcast episodes, and you get to a place where you're at five and stable. When that first happens. You feel like you're low? What's the function of that first of all, and tell people that it's going to get better, please?

Yeah, the I mean, the function of that is because your body is having to adjust to values that it hasn't seen as the norm, you know, an average of one at an average of 200, an average of 250. While it's high, you're you may feel normal at that, because you don't know what a normal value or a target value feels like. So as you start to notch things down, your body has to readjust to that new normal value, and it does take some time. So hovering, you know, now at even 110. For somebody who is averaging 200. They may feel low. Okay, that may very well feel low, it doesn't mean it needs treatment, is it's truly not a low value, but it does feel low. And so it's hard. It's hard to work through that.

I don't know. But I can imagine. Yeah,

yeah. So I you know, I think as far as CGM, especially I think that's that's good technology now that at least they can also see where things are going. I mean, if they're at 110, feeling low, and they're all were all red, they're consistently still dropping very much, especially, you know, fingerstick wise, they might be lower than that. If they're on a trend, if they're hovering nice and stable, nice horizontal line at 110. No need to treat that.

Yeah, fight through it. How long is it, I realized it'll be different for everybody. But what's the average amount of time before stable in range, blood sugar starts feeling normal,

usually, at least a couple of weeks. I mean, from starting, you know, at the end, depending on timeframe of how long things were higher, it may take a couple of weeks for that to feel normal at those lower in target values. And again, stability there, and lacking this big jump up and down and whatnot, that makes a difference for resetting those symptoms in your body. Okay.

I have one last question. And then we're gonna move on to something else.

Can I show you my line right now?

Yeah, sure. But look at you. Okay, I'm looking at at Jenny six, our Dexcom line that looks like it's been right at 100. It might have dipped to was that where's your low at 60? Or 70? Was at 770. It hit 70 for a little while, maybe for about an hour, and then it banged up at 85. This is very, pretty good for you. Are we? Are we are we are we gonna? Okay, let me compare. So Arden has one compression low in the last 12 hours. That isn't real. But other than that, let's see if you can see that.

Very nice. Thank you. She's even averaging lower than me right now.

And we it's a new it's a new pump to get the best day. Yeah.

Those pod change days are like, it's almost like magic. Well, can be almost like magic.

I actually just walked through walk somebody through how to pod change without a high and we'll talk about that when we talk about pumping. But yeah, so here's my last question about insulin. It's gonna I'm gonna go back to something scary for a second, but I think it's, well I know how impactful it was for me. So back when I had to dispense with my fear of insulin, like we talked about at the beginning. How do you do that? Right? Like how do you make a leap like that for me and it will probably be different for a lot of people. I started thinking more about long term health. I realized that the doctor was telling me to leave Arden's blood sugar high so that she wouldn't get low. We We were trading today's Health for tomorrow's Right? Like, we won't die today. But we might not live a long healthy life either, right? And I thought that can't be okay. But I still couldn't make the leap. And finally, I thought about it in as technical and scientific away as my brain would allow. And what I, what I came to, to think about was, I actually spilled some sugar out on the table, and I looked at how kind of coarse and granular and sharp it was on its edges. And I thought, well, at its at its microscopic, like existence, it's probably still course and sharp like this. And our bodies are built to handle a certain amount of it flowing through our blood. But if you pack that blood with too much, that must be and this was me thinking my way through when people say, I, he died of a heart attack, you know, because of his diabetes, or he went blind because of his diabetes, or he couldn't feel his foot anymore. What that really means is that the sugar has basically sandblasted you from the inside, damaging, right, making damage to the inside of your veins, capillaries, all the places where bloods covered, right, if you have a heart attack, and they say it was because of diabetes, it's because the flesh in your heart got rubbed thin, and it burst. And

and you know, and beyond that, beyond that are the other the other pieces of those complications, such as heart disease, right? That come about, and most actors don't teach this. And I think you know, it may be a time thing it may be that they don't want to get the in depth piece of it,

I think might be a good thing to bring up on day three of your exactly your sandblasting yourself,

you know, I have a good and I wish that I could show this to everybody. But this is a tube full of a glucose solution. Do you see how slowly those little they're supposed to be particles of sugar are flowing through the bloodstream? Yeah, sugar or nutrients, right, I like to refer to them as nutrients because this is the other piece to overall long, long health with diabetes is as you mentioned, glucose I love your rough part of that example, because it is high glucose levels cause your cause your blood to get thick, almost like molasses in winter, okay, which means that all of the nutrients your bloodstream are also flowing very slowly to all the places in your body that need to get those wonderful, micro macronutrients. So healing and everything gets slowed. If your glucose level stays high, the the roughness of that sugar that you're talking about or the high glucose values it is it's very damaging to vessels almost creates like rust on a car, it creates damage on the inside of the vessels, your body tries to heal itself and self heal healing machine, your body actually makes cholesterol. It's like a band aid. So even if you never ate cholesterol, again, your liver is meant to make cholesterol and cholesterol is like it does a lot of other things. But it is also a patch. The more damage the more patch Do you see how narrow my vessel is now getting the more and more patches, those vessels that narrow that leads to high blood pressure, high blood pressure damages your kidneys High Blood Pressure puts a lot of pressure on the vessels in your eyes. So it's a it's a snowball effect right? With consistently maintained high blood sugars now have a 200 blood sugar because you decided to eat the whole you know Disney princess cake or whatever and then you bring that blood sugar down that's that's a different story than this consistent maintenance of high glucose that's different

Yeah, I think that when people when I say that Ardens a once has been between five two and six two for five years I think people imagine a steady 85 blood sugar forever which is not the case no right she spikes up just like everyone else you know if you're gonna if you're gonna eat with diabetes and not have you know, you know not not have boiled it down to low carb or no carb or somebody that you're gonna miss sometimes I miss on boluses you know, insulin pump sets aren't as effective on day three is they aren't day one. There's reasons why right? Yeah. So it really is. It's not a perfection. You're looking for it. It's it's a fluidity it fluidity. It's a consistency to how you manage that's what keeps your Awan cielo. Right as you were describing cholesterol coming in and making patches on you know, arteries or veins. And it it thinning. You know, that's what people would commonly think of as needing a stent in their heart, right like eventually it has to open up that space again. All right. So for me back to what I started to say, I got past the fear by saying to myself, I can't let my fear of something happening to Arden today affect her entire life. Like, I just can't do that. And, and if that means she's gonna have something bad happened to her, or my life's gonna be a little more hectic managing insulin, then that's got to be what it's got to be. Because the alternative is, I put all this effort and heart and love into my daughter, and at the end of my life when I'm 65 7080 years old, and I'm looking back at my 40 year old daughter, and she's in incredibly poor health. I'm gonna think, like, what was this all for? Like, you know what I mean? Like what I spend my whole life doing? So I'd rather get in the game now, and do the best I can let the chips fall where they may a little bit, then just to ignore it, I can't I am not across that bridge when it comes to IT person. I find I find when you think about life like that, people have heard me talk about it on the show before you get a bill in the mail. You can't afford it. And you know, you can't before you open up the envelope, just open it anyway. Be an adult and go I owe the electric company 400 ollars. Like, no, they're

not gonna be better tomorrow, it's gonna be the same bill. Absolutely.

It's the same idea with your blood sugar. Like, don't ignore it. Don't say to yourself, it's okay. I'll deal with it later, because later is going to be worse. Now Sox laters worse. So, get in the game, do it. Now.

I've always thought about myself, personally, I've always thought about all the things that I am able to do. Because I choose to manage because I have chosen to understand how to manage. I mean, I, I've done a lot of awesome things. I've had two kids, I, you know, I want to see those kids grow up. I want to be around with them. And that that is the biggest thing to look out to future wise. And remember every day Yeah. And that's

why you and I are doing this like series inside of a, it's a series of podcast episodes inside of a podcast. Right? Right. It's because somebody's going to hear that and think, yeah, that's nice, buddy. But I don't know how to keep my kids blood sugar at 70 and blah, blah. But I'm telling you, we're going to talk about how to do that in a way where you don't have to when you hear the idea of keeping your blood sugar stable to lower number, it doesn't make you think, well, that's impossible. We're, we're going to talk about the tools that make it possible. And I'll leave this episode with this thought. Three nights ago, a man in his 40s I saw him on Facebook, and he was basically begging people, he was at the end of his rope. And he had had diabetes for a long time. And it was just not going well. And people were all jumping in given them, giving him their best piece of advice. And I always think the same thing. When I see people on social media. I'm like, wow, that's valuable. But how do you make sense of it, you know, then somebody will say something else, like, oh, well, that's not really that valuable at all in this situation. But I see why it's well meaning. And so then the person's frazzled, to the point where they thought to reach out into the world to strangers, right. And now these strangers are throwing 20 ideas at them. None of them are cohesive, even if they're good. And so I just couldn't take it. And I, I stepped in and I said, if you want to message me, I'll see if I can help you with us. And they were very kind people who all jumped on and said I would mesh with Scott if I have a show. So we got on, we got on the phone. And 45 minutes later, we got off of the phone. And the next morning, he sent me his steady overnight graph. And then at the end of that day, he sent me his 30 Day graph, and then next day, and the next day. And my point is, I can't talk to all of you on the phone and Jenny can't speak to every one of you personally, but I think we can give you enough tools to get you to that spot. So so keep going with the with this series and I think you're going to be happy that you did. I want to thank Ascensia 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. A huge thank you to one of today's sponsors Gvoke glucagon find out more about Gvoke HypoPen at G Vogue glucagon.com forward slash juicebox you spell that g VOKEGL. You see it ag o n.com forward slash choose box if you're enjoying the remastered episodes thirds 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. 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 may 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 popping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two in Episode 1018 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, 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 the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active. Took me already from a decent 6.5 A1C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She has 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.

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 CDE 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 revisitable. 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. 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's 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. This episode of The Juicebox Podcast is sponsored by Ascensia 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 Juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke hypo pen, find out more at Gvoke glucagon.com forward slash juicebox. In the episode about insulin, I told you that that my nurse practitioner CD told us that fear of insulin was the biggest sticking point for people making good decisions with their diabetes, right. And after I got past my fear of insulin, the next hurdle I had to get past was Pre-Bolus. And I am now years and years later at a time where I will tell you that if you do not Pre-Bolus a meal, the likelihood of success is near zero. And if you have success without Pre-Bolus saying all that means is that you gave yourself too much insulin prior to that. And it's just catching up now. And so this is it. We're going to talk about Pre-Bolus and we're going to talk about how about insulin action right the action of the insulin and how to balance it against the impact of the carbs or your body function. So tell me let's go over the part that people aren't going to find comforting at first right which is the amount of time it takes insulin to begin working in a person varies person to person and insulin to insulin is that pretty fair to say?

It's pretty fair to say yes and insulin to insulin. I would definitely say most of the the rapids on the market should be fairly similar okay? The rapid acting insulins on the market and their time of action should be fairly similar now. Person to Person yes, that may vary situation to situation as well as situation it may vary but again, that's the learning part of it.

Okay, so person the person could end up meaning just your body chemistry could mean where your infusion set is right, you know, your your injection site,

absolutely. Say

you're a person who gets stuck on, I always injected my belly in the same place, that spot might not be as reactive to the insulin as if you would just try a new spot. If you went to a new spot, it might work quicker than it has been in your old spot. Right? If you're wearing an infusion set it could we alluded to it before you could get better action from your insulin on day one than you do on day three or better on day two, then, you know, two hours after you've put it on, there's a lot of different variables. But we're speaking generally here to you'll apply them to your variables later. Now, if you've heard this podcast before, you'll know that I have alluded to how insulin works in a number of different ways. So I'm gonna give my kind of cartoony description of it, and then we're gonna let Jenny talk about it for real

cartoony, might be better, actually, we'll see.

So here's how I pictured in my head a couple of different ways. The first way is I think of a tug of war. And I imagine a rope with a with a flag hanging in the middle of it. And on one side of this tug of war rope is insulin. And on the other side is your carbs and your body function. It could be adrenaline, it could be fear, it could be anxiety, whatever it helps to drive your blood sugar up. That stuff's on one side of the rope. The insolence on the other side, unlike a tug of war in a schoolyard, our goal is not for one side to win, our goal is for them both to pull and pull and pull until they get exhausted, they both go, I can't do this anymore, and they dropped the rope and our flags still in the center. That flag represents the blood sugar. You start at when the impact of the carbs begins in my mind, so I'll explain a little more. If you let them both start pulling at the same time, the carbs are generally speaking, going to gain power and momentum before the insulin begins to work. So now your rope is going towards a high blood sugar and you're you're starting to head up. Now suddenly, you're 50 points higher. And what if you started with 150 blood sugar, now you're at 200. And now these carbs have momentum. They have speed, they're pulling your blood sugar up. Now all the sudden, 1520 30 minutes later, the insolence like, oh, no, no, wait, I have a job to do. I remember and it kind of comes online. But now it's pulling, it can overpower the the momentum that the carbs have created. Plus, you now have another 100 points of blood sugar to contend with. And all you have is the insulin that you counted your carbs for. So even if you counted your carbs perfectly, and realize that this meal is five units, once the momentum of the carbs is rocketing your blood sugar up, once you have a number that is higher than you started with those five units are not even going to begin to cover what's happening, let alone the food that you've put in. But if you put the insulin in first, and let the insulin come online slowly and begin to pull down and create the momentum in the other way, then you flip the script. And now the carbs are fighting. So instead of having a fight at 180, blood sugar, you're having a fight at an 80 blood sugar. And instead of your blood sugar falling at 80 It's being the attempt is that it's now trying to be pulled up by the carbs. And that's how when you see people with a stable graph, that's how they're doing it. And so for me, in a perfect situation for me, my daughter's blood sugar is diagonal down when I give her most foods. There's differences you know, food to food, situation to situation but in a perfect world. To me, that's it, you want your insulin working, your blood sugar trending down, creating some momentum down, when you allow the carbs to begin to pull up. Correct. Now, you to explain that in a technical way that sounds

and in most in most settings, yes, that's 100% I mean, insulin, our rapid I've always thought that rapid is such a misnomer. Honestly, rapid indicates like now rapid is like you know, click, click click light switch. It's on, it's working. And it's you know, still education is take your insulin and start to eat. I mean, even from most endo offices, it's take your insulin and start to eat, it's going to be working very, very quickly. That's not the case and anybody who's been taking insulin long enough, and you've seen the spikes, and you've seen the issues, despite counting your carbs as precisely and weighing them and everything and you're still seeing these issues. It's the mismatch of insulin timing. It is so our rapids take anywhere between about 15 to 30 minutes to really get that active peak, not peak but that active phase where then when you start putting your carbs in there They will match. As you said, the carb digestion will start to match with the insulin, you'll get a nice gentle curve up. And it should then start to curve back down. And there is a lot of, there's a lot of education that also focuses on, as you mentioned, watching for that curve down, watching for the curve down to start so that you know, the insulin is already moving things.

Yeah. And to give you some context that a person I spoke about in a previous episode, who was having trouble, told me, but what am I gonna do, I'm going to be scared. I said, well try it a little bit, this time, and then a little more next time and a little more next time and go forward. And, and so I always tell this story somewhere. And I think here's the right place to tell it. Prior to glucose sensing technology being a thing that anyone knew about prior to Dexcom, I was again in the office and the CD says to me, Hey, you're gonna get one of those Dexcom things. And I thought, I don't know what that is, you know, and she starts telling me, it's a continuous glucose monitor. And I'm like, Yeah, I again, don't know. And then she tells me this simple story. There's a 17 year old boy in her practice, who loves candy, certain kinds of candy, and he can't figure out how to Bolus it. So he gets a Dexcom, whatever the first one was, I don't even remember anymore. His whole goal was to eat this candy without a spike. So he goes out to the store. And he buys like little grab bags of these candies, and a number of them enough for a week and every day starts on this experiment first day, just like you said, eats, gives himself as his insulin, just like he'd been told his whole life, blood sugar goes up to 20, something like that sits there forever. Eventually, he has to give himself more insulin to bring it back down again. Next day, he tries a little sooner, give himself a few minutes, 510 minutes gets a little less of a rise. So the next day, he goes even sooner. And then before you know it, it's a little sooner, a little more, and he starts adjusting it back and forth a little more a little sooner, a little later, until one day, he eats the candy. And his blood sugar never moves. And she tells me that story. And I thought immediately Wow, that means it's possible. Yeah, that was the first time I thought I was like, if that kid can do it with candy. I can do it with anything. Like anything, right? And so yes, give me that CGM place. And I got it. And I started dispense with my fear. And I started learning about it. There were hiccups along the way, right? I've given her insulin, and she's gotten lower than I meant to for two when she's eating. But you know, once twice, I'll go back to this over and over again, when something goes wrong. It's not a mistake. It's a learning experience. It's data for next time. Right? Right. So I put the insulin in, and she goes down to 70 and sits at 70. While she's eating. It's beautiful. You know, like, there she goes. And then and then then a spike. Even if I really messed up on the amount of insulin, I used a spike takes you to 120. Right? Right, right. It's not right. It's just, it's all about that timing and amount. And I repeated over and over again, that you all the things you and I are going to speak about all the things that people hear about on this podcast, if you want to know how to use your insulin, at its core, the very first step is timing and amount. If you get used the right amount at the wrong time, you can use the wrong amount at the right time, that it's too much, you have to have the right amount of insulin at the right time, you have to balance the action of the insulin against the impact of the carbs. If you do that, I don't want to say it's easy, because that's insulting to people. But let me just say I don't think about diabetes that much anymore.

It's easier, it's much easier if you do that. It is easier. Absolutely. And it's a lot more. It gives you a lot more visual than to understand. Because it's not so much of an unknown Well, gosh, I counted the carbs and it took the right amount of insulin and this is always happening to me. Why. And if you can start to put those pieces together, it's not a wi anymore. It's like turning the light bulb on.

Here's how I explain what Johnny just said, 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 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. Bowl for a cause their awareness campaigns and the annual conference that I've spoken at a number of years in a row. It's just amazing, just like touched by type one touched by type one.org or find them on Facebook and Instagram. links in the show notes Lynx 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. The remastered diabetes Pro Tip series is sponsored by Ascensia 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 Juicebox free meter will you use my link you're going to get the same accurate meter that my daughter carries contour next one.com forward slash Juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips 10 lancets, a lancing device control solution and 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 an easy to read screen, it fits well in your hand, and features Second Chance sampling which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash Juicebox free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips, you can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips, then you're paying now through your insurance. Contour next one.com forward slash Juicebox free meter go get yourself a free starter kit. while supplies last US residents only. 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 Gvoke glucagon.com forward slash juicebox Gvoke shouldn't be used in patients with pheochromocytoma or insulinoma. Visit Gvoke glucagon.com/risk. Here's how I explain what Johnny just said. I think of it as this equation that it's a mathematical equation that doesn't have any math in it. I did this that happen. So next time I'll do more less sooner, you know, little less little more, that kind of thing. And I always just I always just keep looking at it like that. I did this and that happen. It's the idea of being in a fistfight and you want to hit first because now you have cause and effect. Right? And if you and so now you know I've done something. And that's what happened next. Now I can make a good decision about what what I do next, instead of waiting for diabetes to do something to you. And then you're just covering up your face hoping not to get knocked out. Right? Like because you don't know what's happening. You don't know why it's happening, you have no context for what's going on. But when you make the first move, you can be sure that what happens next was impacted by what you did. I put insulin in 10 minutes before you ate 10 minutes before I ate. And my blood sugar went to 150. So the next time I'm going to try 15 minutes. And if it goes to 130 I might try 20 minutes. And you know if I get low than later, I might say okay, I might need a little more a little less. Now here's where people always say, Well, how much Scott How long? You know, give me the time give me the amount? That answer for me. It's always going to be I don't know, figure it out for yourself. Okay, you have to

this is the starting place. Yes. This is where to start. This is how to start. You have to do your own. I mean, diabetes is a science experiment. It's a daily, I feel like every day you're almost given like this new petri dish. And you're told, keep the dots growing purple today. Okay, let's work on keeping the dots growing problem is that something green pops in and then these like little horny pink things pop on? You're like, oh, no, but it is it's like it's a science experiment that for the most part, when you figure out what does work, the timing around the most typical foods that you eat and whatnot. It takes a lot less thinking out of the equation.

Yeah. And while this isn't about Pre-Bolus and it will come up later, but it's important for me to say because I think this is impactful. When you really stop and think about your your habits around food. They're pretty similar Right, right. So, you know, you're not I always say like this, like, if you're a person who gets a pizza on a Friday night and has two slices, you don't suddenly next Friday have seven slices. You don't go from being a two slice person to a seven slice person, right? Like, yeah. And so, so you can start making these decisions about how much insulin and when, and you can make them based on Yes, historical knowledge about what's going on. Yes,

I usually tell people as the Pre-Bolus piece, you've got, most people have about 20 to 25 foods that are the most common for you to eat regularly. Yeah, that's at least 80% of your control there, at least. So if you can nail the Bolus timing around those and figure it out, for the most part, you know, variations in setting will happen, whatever, yeah, but for the most part, if you've figured that out, you're also much more likely to be able to figure out food that isn't your norm, because of the similarities to what you've chosen. And what you're usually eating, because you

can stay flexible, I call it saying stay fluid, right? So here's, here's where I'll tell people this, don't get mad. I don't count carbs. I actually think about it a little backwards from maybe how most of you think about it. I don't look at the food and say, you know, weigh it or measured and say okay, well that's 25 carbs. And my pump says that I get one unit for every 10. So that's two and a half units. In honesty, there is no accurate insulin to carb ratio set up in Arden's pump. We don't even I don't even pay attention to that. I look at a plate and I say to myself, that's seven units. I think that if she's going to sit down and gorge herself on nachos and cheese, the last time that happened, it took 10 units. But I think of it as insulin, not as carbs. And of course that takes a little practice, right? It does, it does. And it is a little contingent on you having a CGM. I'm not going to lie about that, right, because I start with a healthy Pre-Bolus. And healthy would mean in amount and time. And then I watch her CGM, and I don't really watch it, I have her tolerances set tightly enough that if she leaves that range, I find out about it. So as an example, if I were to give art in something incredibly carb heavy, I might use a Temp Basal increase, and a Pre-Bolus to try to spread out the action of the insulin across this timeline where there's going to be these carbs, right? If I make a Bolus, and 30 minutes after I do it, she's 121 30 Diagonal up. I look at that line. And it tells me something based on my previous knowledge, it's I say to myself, ooh, this I missed, like, this isn't enough insulin, and I will give her more I will bump it and nudge it back. It's not a ton more, it's enough to stop the arrows,

right. And the arrows are very important to bring up in this in this as well. Because if you are using a CGM, those arrows do indicate a rate of change. And again, that's not something that most people realize. They don't understand that and not understand and people won't tell us but it's that they've not been told they've not been told, Hey, these arrows tell you that you're increasing by 30 to 60 points in the next 30 minutes. Okay, if that's the case, and I know what my kind of correction factor is, or whatever, I can say, Okay, I'm going to need this much more insulin, because if I don't correct my rising 130 blood sugar in the next 30 minutes, I could be 30 to 60 points higher. I could be as high as 190. I don't want to be 190 I've obviously miscalculated someplace, I can throw in a bit more insulin to counter that expected and stabilize it. Yes. Yeah.

It very much. It very much is remembering to like I guess the way I usually say it is that you have to trust that what you know is going to happen is going to happen. Right? Yeah, you see. And I think that the least important aspect of what the Dexcom does is the number. It's the direction and the speed, direction and 100%.

I wish more please say that again. It is the direction it's the trend. It is not just the number.

The number is nice, like don't get me wrong. It's a starting point. But, you know, if you're 60 and stable, and you haven't had insulin for three hours, you haven't had food for three hours when maybe you could get away with like a Temp Basal decrease of 100% for half an hour, maybe you'll rise to 90 Right? But if you're 60 and you're falling well Then you don't have enough time because as we've now discussed over and over again, insulin doesn't begin working right away. Also, Temp Basal is our insulin. It's funny how people think of bolusing. And basal is different. But once you're on a pump, it's the same thing. You can't just turn your basal off, and it starts happening right away,

takes about 60 minutes for circulating insulin level to be different.

And I always write and I always try to think of it a little bit as like Ardens Pre-Bolus. Time Like if Ardens Pre-Bolus time is 20 minutes, well, then setting a Temp Basal is not really going to start working for at least 20 minutes plus, it's a fraction of the Basal rate, if, if you're getting a unit an hour, and I say to it, okay, let's double it, let's double it to two units an hour, that impact of that doesn't begin for 20 minutes or so plus, it's not the whole unit extra. It's the it's the fraction of it. So when we talked about basal, we'll get to that. But so Pre-Bolus thing is really just the idea of balancing, again, the action of the insulin against the impact of the carbs, giving yourself a chance, not letting the carbs wash you away, because here's what happens when the carbs wash you away. Count your carbs exactly right, you put your insulin in, you spike up the 200. When that happens, that insulin was only for the food. It wasn't for the 200 blood sugar, and it wasn't for the momentum of the rise. And so when I see that, like, I guess an easier way to say this when when I don't have time for a Pre-Bolus. And Pre-Bolus thing to me is never about the number, you can Pre-Bolus a 65 blood sugar, you know, you can Pre-Bolus a 90 blood sugar because still no matter what, if you're stable at 65, the insulin you put in, it's not going to start working until it starts working. So you have and so don't get me wrong if I see a 65 blood sugar and an artist needs 10 units for what she's eating. I don't put all 10 units in at a 65. I might do an extended Bolus which we'll talk about and extended Bolus but I get some insulin moving, I make sure the insulin is on the winning side of this tug of war to start. But in a situation where I can't Pre-Bolus Let's say I know the meal is five units. 100% certain it's five units. But for whatever reason life, let's call it I can't Pre-Bolus and Ardens. You know, I'm going to start eating right now. I'll give her seven units. Because I Pre-Bolus for the food, the five units for the food I knew. And I pray. And I'm Pre-Bolus seeing the rise I know is coming and the end, the number I know is coming. So I'm already treating a high blood sugar that hasn't happened yet. Because I know it's going to happen. Because I didn't Pre-Bolus Right.

John Walsh goes into detail about what you're doing in a little bit of a different way. He calls it super Bolus I call for bolusing. Yeah, and he calls it super Bolus in the way that you take that five units, let's say in your example. And let's say your basal behind that meal for the next two hours is one unit an hour, you actually take your basal running for the next two hours, and you add it into the Bolus for the meal and you take it all upfront. And then to decrease the chance of being too low leader. Because of so much upfront action and the blood sugar staying normal, you actually set a temporary Basal decrease, he recommends starting with 100% Because you've loaded that onto the front to avoid a low but on the back end. Some people find though that attempt basal 100% off is too much. They only need a 50% they still call the spike and prevent it. But in the back end, they're not having a low then. So similar kind of concept. Yeah,

I consider that trading Bolus for basal. So So you know, say 120 Diagonal up 3040 minutes after a meal and I go oh, geez, I got to stop that arrow. How much do I Bolus to stop there? I usually Bolus an hour's worth of a base of Basal insulin. That way if the arrow stops and I stay steady, and she doesn't go down, I say okay, well obviously I was just wrong on the initial amount. But in those situations where you push the button, you know the unit and a half goes in, and five seconds later the arrow goes from 122 Diagonal up the flat you go oh, I didn't need that. Right Temp Basal off off half hour. All I've done is trade the basal for the Bolus. Absolutely. Here's a good place to say this. And we'll say this in each of these little vignettes. Never suspend your basal. It's always temporary basal is when you suspend your shutting your pump off when you shut your pump off.

It does not turn back around. You have to remember to turn it back on. Yes, yep.

It's always temporary because you can set a Temp Basal for a half an hour or an hour, two hours but at the end of that time, it goes back it'll go back on to start delivering your basal it's always temporary basal is not not don't suspend your pump. Oh Okay, so I think Do you think we covered Pre-Bolus there?

I think that's pretty good. Good. Yeah, that's awesome.

I want to thank Ascensia diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free Contour Next One starter kit at contour next one.com forward slash 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 Gvoke glucagon, find out more about Gvoke HypoPen at G Vogue glucagon.com forward slash juicebox you spell that Gvoke glucagon.com. Forward slash juicebox. 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 has also had type one diabetes for over 35 years and she works at integrated diabetes.com If you're interested in hiring Jenny, you can learn more about her at that link. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed you're starting over episode 1001 all about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two in Episode 1018 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and an episode 1025 We talk about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with 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 A1C 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.

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 CDE 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 revisitable. 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 health care plan or becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by Ascensia 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 juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org. And on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke HypoPen Find out more at Gvoke glucagon.com. Forward slash juicebox. Temporary Basal rates do a number of different amazing things,

lots and lots compared to what your doctor told you.

Yes. And so here's how I always think about it about Basal rates in general, it is bizarre for us to think that we can set up a static Basal rate that will always work at 2pm for the rest of this week, or this month or our lives, right. It's just an odd statement. I don't have diabetes, my blood sugar varies based on what's happening in my body or what I eat. And I bet you even though I have no medical training whatsoever that my body is more aggressive with the amount of background insulin that I get the amount of force it pushes on my blood sugar at different times,

because it's got natural compensation. Yes. And I think that that that piece about about Bezos is also really, really, really important for women. Right?

Okay. Yes, because of their periods. Or, by the way now I've been told not to say, Lady time by people that I should say period, so that I went back to period to make that person happy. Then I got a beautiful note from somebody the other day, who said, I think Lady time is delightful. And I'm like, I can't win, but that's not the point. So the so so here's a couple of ideas. We get Chinese food coming into the house, right? Or pizza or something that's high carb that breaks down slowly in your system. Okay. My Pre-Bolus For Chinese food is this Temp Basal increase 95% for two hours, boom, I start right there. Then I get a healthy Pre-Bolus in you know, and I start the I went to a decline when when Arden starts eating her food. Chinese is a good example because it's not it's simple sugars and complex carbs at the same time, right. So the coating on the meat might have a lot of sugar in it like the sauces will hit you quickly. But that rice could sit in your system forever and take hours and hours and hours to break down and to go away. So I think of it as carpet bombing insulin. I went to I went to cover the entirety of the timeline that this food is going to have impact on Arden with an increased Basal insulin. It I would also use an increased Basal insulin. When Arden's hormones are affecting her. Yeah, we just got done doing that this week. There was a day and a half or Arden ran a Temp Basal increase of 80% for two days straight. Yep, get a straight. Yep. If your Basal is not right, your Bolus is aren't going to work. Right because you're just replay acing basal with your Bolus. So even again, you count your carbs. 100%, right. But if your Basal insulin is set at, let's say a unit, but it should be at two units, then when you make a Bolus for a three unit snack, the first unit of it is only covering the basal you don't have. Plus, you haven't had enough basal leading up to that. So you're probably so insulin resistant and having a higher blood sugar to begin with. None of this works without basal. When people come to me and say, Oh, my God, look at my roller coaster. I'm 60. I'm 400. And the first thing I say is okay, let's get your basal is right. If your basal is aren't right, the rest of it doesn't work, right,

and temporary bases that are not going to work either because they're working off of a setting. That's not That's not right to begin with. Yep.

Inevitably, while I'm talking about bases with people, they say, Well, what about my insulin to carb ratio, and I went, That's not even worth thinking about until we have your basis, right. So now you can think about Basal insulin as Basal insulin used, you know, in the normal course of your day to keep your body function low when you don't have any food. And if you really start to think about them around food, that's when they become incredibly powerful. Yeah. And so there's also a time where, like I alluded to before, you can bump in nudge with basal, right? So not only can you create a hard basal that helps you with carb, heavy meals, but you can look at a blood sugar that's at, you haven't had insulin for hours, and then suddenly, it drops to 75. And it sits there for a little bit. And instead of feeding that 75, you can Temp Basal back. So Temp Basal is unlike the, you know, when I think about the tug of war with with Pre-Bolus Singh, Bezos, I think of this way. I imagine if you and I put our hands out, stood up and put our hands together our palm the palm, and we pushed equal amounts on each other. That's you don't fall back, I don't fall back. That's a perfect Basal rate. Right now there might be a situation where my my blood sugar is starting to fall. So I need the body function to push a little more. So I, I take a little power away from the Basal which allows me to push up. Same thing if I'm at a 90 that's going into a 95. And it's creeping up. But a Bolus is definitely even a tiny Bolus is going to make me a little later I might just do a Temp Basal increase to stop that kind of creeping. Yep. This all occurred to me when I interviewed someone about artificial pancreas and they told me that most of the adjustments that an artificial pancreas makes is through Basal insulin. Yes, not through Bolus

100%. If you're doing anything within the looping community, the do it yourself insulin pumps, either OpenAPS or looper, AndroidAPS or whatever that is, that's the gist of the algorithm. It is most of most of the incremental adjustments based on the trend in glucose are being done by positive and negative what's called tamping you get a bit of a bump up, you get a bunch of a bump down, you had a bit of bump bump up, and it's all being based on your current Basal setting. Right? Right. But the incremental ups and downs are what keep you stable

that remaster diabetes Pro Tip series is sponsored by Ascensia 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 Juicebox free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash Juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and 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.com forward slash Juicebox free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips. You can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips 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 the back of people living with type one diabetes. Take for instance, their D box program touched by type one knows firsthand the intricacies of living with type one diabetes. And so their team has created a D box which is a starter kit that provides important resources and supportive materials to individuals with diabetes. They want you to thrive. The D box is completely free and available to newly diagnosed people. All you have to do is go to touched by type one.org. Go to the Programs tab and click on the box. While you're there, check out all the other resources and programs available at touched by type one.org. Speaking of support, touched by type one.org is available in English and Spanish. Don't forget to find them on Facebook and Instagram too. You do not want to miss what touched by type one is doing. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. Gvoke hypo pan is a ready to use glucagon options that can treat very low blood sugar in adults and kids with diabetes ages two and above. Find out more go to Gvoke glucagon.com forward slash juicebox Gvoke shouldn't be used in patients with pheochromocytoma or insulinoma. Visit GE voc glucagon.com/risk. So when I talked about bumping and nudging, which is going to come up in the future a little more, it's the idea that if you don't use too much insulin, it can't cause a wide swing. Correct, right. So bumping a 120 Diagonal up back to 90 takes a smaller amount of insulin than ignoring your blood sugar till it gets the 180. Now you're putting in a bunch of insulin, it becomes miss time and you get low later. So using these little bumps, just make sense that you can accomplish that with Temp Basal. Again, remember, Temp Basal is going to start working right away. You can't save yourself a va 65 one arrow down with a Temp Basal. No, that's, that's juice time. Right, right. But, but but a 70 that's drifting low and has no impact from insulin really could be saved with it, it could be saved it maybe it won't be but you try and figure it out for yourself, maybe that'll end up being a 90 that's drifting low that you'll eventually use Temp Basal for. But they are, they are such an important tool. And if you're not using them, you're missing out. I will say it here I'll say it again. an insulin pump is not just the way to get less injections. It's also a way to be able to give yourself micro Bolus is to be able to manipulate your Basal insulin to be able to manipulate your Bolus is to spread them out. These tools are are vital. So please tell me and I know you and I are short on time here. But tell me how you talk about Temp Basal with people like where do you where do you really focus in on on education about it.

So i we i and i usually really, really focus in on all of the scenarios that are likely to come up where temporary basal is really an important piece of management, that that bumping and nudging that you talk about, you know, unfortunately, most people are only taught about exercise and the benefit of temporary basal. And they're usually told, well just, you know, just set it for 0% or turn your basal off during that time. Well, that's 100% incorrect to begin with. But exercise is one of many reasons that you may want to change your Basal for a, you know, a duration of time, illness, a woman's menstrual cycle, or that woman's time of the month or whatever you're going to call it. That time you're going to definitely need temporary basal, you're going to need it for sedentary days, I can go to a conference where I'm literally sitting for eight hours. And while I might be walking between conference rooms, the sitting and sedentary I need a 25% increase in my basal. In order to not run high that whole day. I've figured that out right? I figured out what I need to do to take a five mile run versus a 12 mile run temporary basal changes. I figured out what to do for different kinds of illnesses stomach bug may require a decrease. An illness like a sinus infection or a bronchial infection may require an increase. Even even temporary basal around food like you mentioned before with the Chinese high fat food

Yes

100% requires knowledge of using temporary basal because I know we'll talk about extended boluses and things a little bit too but temporary basal for high fat man. Fat can affect you eight to 12 hours after you're done eating it and it keeps you high. And you may go to bed with an awesome looking blood sugar thinking that man, I nailed that I really got it. What do you get an alarm at two o'clock in the morning? Where are your 300? And you're like, what happen?

And those are the examples, by the way, when you can't say to yourself, oh, well, that's just diabetes. It's not just diabetes, if you didn't use the insulin, right, and so every time you think diabetes is just this, this, you know, magic fairy that runs around messing with you, it's something happened, like, you might not know what it is in that moment. But something happened, and you can figure out what those somethings are and stop them. And there's a great example high fat, you might need a Temp Basal increase that goes on for hours and hours later, and maybe

maybe fat 50%, at least 50% increase for at least six to eight hours after the meal. Right?

Right. It's just it's, I know, it's a little mind numbing to think that, but that's a lot to think about. But I want to, I think now's a great place to say this. As much as we're breaking things down and really stretching them out. So you can see the tiniest little aspects of these ideas. For people who understand them, I will speak for myself. I do not think about diabetes that frequently during the day, this stuff just kind of happens. I know that sounds crazy. But I look at a plate and I go, Okay, here's what this needs. And if and if I miss I readjust. But But I don't spend a lot of time, of course aside of this podcast, but I don't we don't say the word diabetes in our house very frequently, I guess is what I'm saying. We're not always fighting and, and you know, scary lows, and oh my gosh, she's been high for three hours. Like that doesn't happen around here. And you can live that life too. By understanding how insulin works. 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 want to thank Ascensia 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 Gvoke HypoPen at G Vogue glucagon.com forward slash juicebox you spell that GVOKEGL You see a ag o n.com forward slash toolbox. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two in Episode 1018 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1000 21 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 in my learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active, took me already from a decent 6.5 A1C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link.

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 CDE 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 revisitable. 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 Ascensia 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 Juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org. And on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries, Gvoke hypo pen, find out more at Gvoke glucagon.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's 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. We are back talking about insulin pumps today. Awesome. And the idea of pumping in general not any specific pump, although we might go over the ones that are available at the moment. So we discussed in the MDI episode that it's tough to get an insulin pump right away, you'd have to be have great in insurance, you'd have to be able to get over the what do we want to call them roadblocks that some endo offices put up to you getting? Right getting in? It's on top. But But congratulations if you've gotten that far and you're thinking about getting an insulin pump. Why do you think? Well, do you think let me ask you, do you think pumping has advantages over MDI and if so, what are they?

Yes, I mean, a broad a broad statement. Yes, there are advantages. I think there are pros and cons to everything. But there are a lot of pros. I think one of the biggest ones is precision in dosing. I mean, you know, from the standpoint of injections, we can dose accurately, like, quote accurately, to the half a unit with an injection, right? I mean, I've even got a couple of friends who still do MDI don't like pumping and, and they've sort of figured out how to get that quarter unit in an injection. But is that accurate? No, it's not like the pumped accuracy, you know, pumpkin, pumpkin, pumpkin get down to the point 05 Or the point 025 of a unit. That's, that's precise, that's miniscule, you know, and for the broad spectrum of people that need insulin in different doses, the very, very little to the adult who Who is very, very sensitive for whatever reason, that can be important. So,

okay, and I agree, I think that when, especially when they're younger, I've used Mo, I've had moments with art and where it's a point one or a point to Bolus that can really move somebody and the, you know, obviously, the lower your body weight, the more that kind of precision makes incredible differences. I guess the con to that can be if you are so small, it's possible that it might be difficult to set your Basal rates up. Because if your Basal needs are that little in the beginning, you can do that I've seen people do all kinds of crazy stuff, like set a Basal rate on for one hour off for the next one, back and forth. And that's, there's a way to get through that. I think if you have a smaller child and you want to pump, there's a way to accomplish it.

There is Yeah, absolutely. So precision, definitely. And then, you know, I, the icebergs that kind of pop up in your day. You know, you I know your strategy. And a lot of people strategy is kind of the navigation of blood sugar, right? And utilizing the smart tools on an insulin pump smart being things like the extended Bolus and the temporary Basal feature. You cannot do that with an injection. You just can't. And that is that's another huge pro pop.

Yeah, I can't say I agree anymore. I am in full agreement. I didn't understand at all about pumping. When Arden was injecting, right. There were just a lot of words, I didn't understand people were talking about bolusing and all that. And what's that? What's an insulin to carb ratio? I have no idea. I know a little bit from objective, but it was so much more specific talking about with pumping ahead its own language. And I've mentioned before that as we were in Arden's pump class at at her children's hospital, and I recognized that insulin was going to be used, like fast acting insulin is going to be used as Basal insulin. Yep. And that I could turn it off and turn it back on and increase it and decrease it. I'm telling you angel saying like, light bulbs are going off, like everything happened. I was like, okay, immediately. Yes, please. I genuinely think that before you have a pump, and for a lot of people after you have it. People just believe the pump is a way to avoid injecting. And I want to I want to, as we do the overview about in some pumping today, I want to show them that it's just so much more than that. So it is

yeah, absolutely. And I think another piece to definitely clear up, even for anybody who might be listening to these that doesn't necessarily interact or is a caregiver for somebody but with diabetes, but they've come across it because they just want information. A pump is not the magic, do it all. You don't plug it in, and it takes care of everything that is is not the case. And for those who might be newly diagnosed in our hearing oil pump is like the magic thing. It does all these ones. It does what you tell it to do. And it does it based on the parameters you set within the pump. Yeah, there's it's it's personal input is what makes the pump as beneficial as it can be. So you can then see that if you don't know what you're doing. It could be not that the best thing.

Sometimes you hear people say I've had this pump for a month, and I'm thinking of going back because I think they have doing what I need. Yeah. And I think they had that expectation like, look, I bought the pump, I put it on why did my agency not go down? How come my spikes aren't going away? Why is my blood and in some cases, people's blood sugars get worse in the in the in the beginning because they don't get their basal setup correctly, right. Or, or I think for some people, your insulin needs change, sometimes greater or lesser, when you go from injecting the pumping

because of the precision, especially if that Basal, sometimes with the imprecision of an injected Basal insulin, and the fact that it isn't based on your physiologic need and the change through the course of the day, that Basal insulin could be off via injection at a time when you need less insulin. And so things look like they're happening around a Bolus when it really isn't the Bolus is problem. It's the Basal. So getting that Basal set is huge. It's like the foundation of a house

and the opposite as well to not instead of the Bolus is problem. You can't you can't give the Bolus credit. Sometimes Sometimes you have a lower stable blood sugar that you think you made this scrape Bolus off Bolus but but your 11 Me or your Lantis you have too much of it or it's just it's working stronger at that point or something like that. So when you switch to a pump, and you go to these more precise Basal rates, using a fast acting insulin in the background And then if you don't have that correct at that number, you don't you no longer have that sort of like, I don't know what to call it like when you inject Basal insulin, it's just sort of a is it a catch all? Is it a is it it's a blanket of insulin that you may or may not? Yeah, good way

to think about it. It's kind of a blanket of insulin. But it's not a blanket that's always warm and cozy at the right places through the course of the day. I mean, I My example is, before I started pumping, I was using Lantis was my Basal insulin, and I took it in the evening, if I did not have a snack, when I went to bed after taking it, I could have bet a million dollars that I didn't have that I would have a low blood sugar between two and 3am.

And that's because your new Basal insulin starts coming online, and it works.

And it worked the way that it did, I needed less insulin at that time, but Lantis didn't know that Atlantis was like, Hey, you put me in here, I'm gonna get this, I'm gonna do my thing that I was supposed to be doing right. So I needed at that dose for the rest of the day. But I didn't need that dose for that action time of the morning. So that's

our first kind of lesson here. With pumping when you get an insulin pump, your Basal rates need to be dialed in. And there's two things about that. The first thing is, and this of course, is not true for everybody. But I do meet a lot of people whose doctors under whelmed them with Basal insulin, when they put them on a pump i because they don't want to cause a low, they don't necessarily tell you that going out of the office or you don't expect it. And so you get hot, you get home, you're high all the time. And it doesn't ever occur to people that it's basal. So get on a pump, get the basal right, I think the next thing is done

one comment about that as adjustment factor. And you mentioned it before insulin means may change going on a pump, we usually find give or take, we usually find that when you start on a pump, your Basal injected insulin dose in the pump will need to be about 10, sometimes 20% less than what you were injecting in your Basal dose. So let's say your Basal insulin is giving you 20 units a day via Lantus or levemir, to you know, to jail or whatever it might be 10% less than that is two units less, okay, so we would actually dose your basal in the pump on 18 units across that 24 hours versus 20 units. Because it's it seems to be that the body responds better to that one type of insulin or rapid and coming in at one precise point in the body all the time, rather than being injected like all over.

So then it can really be either then you can you can get your pump set up with Basal insulin and find yourself high all the time and realize your Basal is not enough or, or too low or where you have to come in. So that is why doctors start that way. Because I guess more over the likelihood is you'll need less. But for the people who that's not true for it's the situation I described. Right? So what we're really saying is, you're not going to know until you know, but but figure it out, get it in there and figure it out. I also want to know what you think about multiple Basal rates in the beginning, because in my mind, I think you set one up, and then you start adjusting off of that one. Right?

Agreed? Absolutely. Even when I started pumping, you know, as an adult, once there were finally pumps, like I'm ePad. So it wasn't about tubing. I wanted that pod. But when I started doing that, you know, I actually did I started on one solid Basal rate. And I was already an educator. So I knew about poems, I just, you know. But yeah, you have to test you have to evaluate and see what does that one salad basal? Where do I need it to be less? Where do I need it to be more right for how long?

Yep, I think we're going to talk about the adjustments in our own little piece of this. So okay, so let's, we'll move on now to to the idea of bolusing. So I want everyone to understand that, that doctor, your doctor is going your pump trainer, whoever you talk to is going to do their best based off of what they know about you to set up an insulin to carb ratio in the pump. But it is incredibly important to know that that is a number that is not completely made up. But it is a guess on some level. And so if you're putting insulin in for a Bolus, and you just you say to yourself, Man, I counted these carbs 100% correctly, and it's telling me three units. But I used to eat this food on injections and I had to inject four units or two units or it was different in some way. I just think it's incredibly important to remember that your doctor just did the best they could putting that in there. And this becomes where sort of the next step of how people We'll get confused starting pumping, because things don't go the way they expect. And they never diagnose the idea that it's the it's the insulin. And I mean, this series is obviously, it's all about timing and amount, right? You're using the right amount at the right time. Their minds. I think Siri just heard me say something. Sorry, Siri wasn't for you. But it says, Hey, Siri, have it's obviously it's all about timing. Shut up, Siri. Oh, wait, sorry. My point is, is that you're our brains somehow focus on the idea of the pump, specifically and not and we forget about the insulin. So I got on a pump and something didn't go the way I wanted. There's something wrong with the pump. That's the LEAP you make. It's the it's, it's very likely the insulin. So you can't jump over the obvious answers to get to the other ones, then then we run into the problem that people don't want to make insulin adjustments in their pumps in the beginning. So for all of you listening, who are about to start pumping, or a noodle pumping, and you're seeing something in your heart, you know, isn't right. I would implore you not to sit around for three months waiting for your next endo appointment. Right? Okay. So if you're not, if your blood sugar's high, you probably have not enough insulin, it's possible that you know, you haven't timed it, right. But there's safe ways to make small adjustments to your insulin on your own. Right. And so and so. Would you talk to me about how you would How would you if someone called you and said, Hey, I don't know what to do. And you you looked at their graph and said, I think your Basal insulin needs to be turned up or turned down? What percentage do you tell them to move at the remastered diabetes Pro Tip series is sponsored by Ascensia 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 Juicebox free meter. When you use my link, you're going to get the same accurate meter that my daughter carries. Contour now next one.com forward slash Juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. 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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 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 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 What percentage do you tell them to move at it depends

on what the overall picture looks like you know if there are small if there are small, less aggressive looking changes to their blood sugar's but it's in a Basal only time period and you can tell that obviously something is wrong. We recommend making an adjustment If there's more than a 25 to 30 point shift up or down from a set blood sugar, so let's say if you're testing the overnight, you go to bed at this rock solid, you know, 102 blood sugar, but by you know, and that's 9pm. But by 1am, your blood sugar's at 201. That shouldn't happen on Basal insulin, that's there's something incorrect there. So, you know, with a shift like that, we would bump basal probably by like a point one in that time period to offset the incoming flux of or incoming need for extra insulin. Usually, if it's a smaller incremental change to blood sugar, you know, you're going from a blood sugar of 102 to 152, you probably don't need that much of a change. And so maybe more of like the point 05 In a rate, smaller increments to the point zero to five, which most of the pumps on the market can do, not all of them, but some of them. So that may be something that you play with, especially if you feel like you're pretty sensitive to small changes in dosing, then you may want to start smaller and make an adjustment up or down,

right. And so again, it's a good place to point out that the numbers not important, because we can't tell from one person to another. And I'll give you an amazing anecdote about that I was with a group of people this past weekend, there was a college age kid there who in my best guess was 610, and must have weighed 230 pounds. And his Basal rate was lower than my daughter's who is five, six and weighs 125 pounds, my daughter is also growing, and you know, gets a period and things like that. So you can't, you can't reach out into the public into back to your doctrine. So just tell me how much to turn it off. You know, like, you have to pick an increment. That's not, that's not crazy, it's not dangerous. Obviously, you're not going to take 8.5 basal and make it a one. You know, you're right, you'll try point six, you know, like, if you're, if you're a little high, try point six. And then if you do it for a few hours, and nothing's going on. I mean, try point seven like and you know, we might get to a point where you Oh, now I'm a little too low. And then again, I'll dial it back point six, five and, and make that decision on your own like, think it

certainly communicate with your provider, if you want some assistance, saying, hey, you know, even calling your endo office, most often you get connected with a nurse, the nurse is then going to relay your message to the Endo, you might get a call back, hopefully 24 hours, maybe 48. Or, you know, whatever it might be, but at least you're acknowledging, hey, I'm seeing this issue. I'm making my adjustment because I'm the one living with diabetes 24/7. I'm just I'm telling you, so that if you've got any additional feedback,

great, I'd love to hear it. Yeah. But you can't. You definitely can't do what happens to some people where you just freeze because I want you to really consider what we've been talking about what you've been listening to going back to your doctor four times a year, and saying, Hey, look at 90 days worth of my blood sugar's and adjust this and make it correct. It's just they're not guessing. But they're just doing their best and their best is limited because they're not with you. And so I know your that it's probably happened to you before you sit and you stare at these blood sugars. And you think, well, this isn't what I was told. But just remember, you're getting this machine and it needs to be dialed in. You just you have to get it right, you got to get it running, right so that you can start enjoying the benefits which are significant. Once you get it going. And I will say that I was one of those people who got a pump for my daughter when she was four years old. Oh my god, over 10 years ago. Wow. Yeah. And, and I slapped it on her. And then I stepped back and I looked at her blood sugar and I looked at her agency and I'm like, okay, just start going down. You know, like here comes Everybody get back this this this Oh, my gosh, back then this 8.9 A1C it's going to be magically lower. Well, it did go down a little bit. But not a lot. It only went down a little bit because I guess I was able to bumper insulin a little more. That's where we started right? Well, I guess a little more because back then if you missed on a Bolus, doing it again meant injecting again, and no one never wanted to do that. So you just waited and hoped and crossed your fingers right? But now I could give a little more in a little more but in honesty, just adding an insulin pump without understanding it did not bring Arden's a one seat down that that far.

I think it's kind of like I mean, the adjustment is kind of like getting wheels aligned on a car. Right? I mean, if you have if you want to ride this straight line, you have to do these incremental adjustments so that you're not consistently like veering off the road.

You got to rotate your tires. You need to get your your ball bearings all straightened down everything that was just the extent of my knowledge of cars. That's what You've heard but you want, you know the engine, I joke a little bit I understand. So people who really understand cars, there's tau in Canberra, there's these, these tiny adjustments that get made to your front wheels that keep your car moving straight. And it's the same situation. Those again, just like bumping and nudging blood sugars, these are tiny adjustments to get you where you want to be. And the difference between being 190 all day long and 90 all day long, could just be point one, a half a unit of a change, depending on your size and your weight, your needs, the tiniest amount. And just imagine that, you know, we talked about it all the time, if you if you don't have enough Basal insulin going when you Bolus, a lot of your Bolus is just replacing the Basal you don't have. And so

that's why Bolus isn't there. You're wondering, well, why I didn't even eat at this point today. And what's happening here?

Why is this happening now? And so so you need to get these things straightened out. Now. I guess moving on to the idea of bolusing. Yeah, before when you had your shots, you were counting your carbs, doing your thing sticking in your pan or your needle and pushing it in there and just hoping you know, hoping for the best right? You are now opening yourself up to an entire world of Pre-Bolus saying and and doing it with different and what Pre-Bolus Pre-Bolus boluses all the things you're pumped, you know, well, first of all, Pre-Bolus is not a setting. It's just the idea of putting in your insulin and giving it a head start over the food that you're about to eat right. But an extended Bolus. So we're talking right now it's 11am. And 40 minutes ago, Arden texted me and said lunch is soonish I want you to really hear that. She didn't say she didn't say in 10 minutes. Right? She didn't say 20 minutes from now she said soonish and I know based off of how this year is going at school, we're going to Pre-Bolus here. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. Gvoke hypo pan 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 Gvoke glucagon.com forward slash juicebox Gvoke shouldn't be used in patients with pheochromocytoma or insulinoma visit Gvoke glucagon.com/risk. And I thought about what was in her meal. There's not anything incredibly like simple sugary, that's going to spike her right away and she was 106 when we did this. So she'd been a little resistant towards the end of her period this week. We did a Temp Basal increase of 40% for an hour and a half. And so that takes Arden's Basal rate from 1.4 to whatever 40% More of that is for an hour and a half. And then I did a 11 and a half unit Bolus. We did 20% of it upfront and the balance over an hour. So 20, whatever 20% of 11 and a half and 11 and a half units is goes in when she pushes the button. The balance of that goes in incrementally over the next 60 minutes coming online and getting active along the way. And now it's 40 minutes later and Arden's blood sugar is stable and 90. And she probably started eating 20 minutes ago or so. I'm expecting the food to begin to impact her right now. Right right. And so we got we got momentum on our side for the insulin, we've got her going down. You know we've got that tug of war set up we've we've given you know, we've we're letting the insulin cheat. And we're going well, now, I'll tell you right now, if 20 minutes from now she starts curling back up. I might you know if there's any time if there's any extended Bolus left, I might cancel it and put it all in at once. If the extended Bolus is over, I'm gonna go I might have missed a little bit. There's all kinds of different adjustments you can make to change the timing and the amount of the insulin. I want you though to talk about first about extended boluses and I want you to talk about it the way I know I can't which is technically in smart play.

I think you give very good description. I think the biggest thing to understand to begin with when with an extended Bolus is that all pumps can do them. They all term them or call them something a little bit different. And it really just kind of boils down to how you're telling the pump to give this this dose for a meal whether you want it all up front, meaning like you'd give an injection you get this whole normal amount of insulin deposited under the skin all at one time. That's normal and extended allows your pump to drip drip, drip drip almost like your basal is dripping all day but in an The time period you've defined whether it's 30 minutes an hour or three hours, you told the pump I want to deliver 11 units over the course of some now, and some in an hour time period. That's what we kind of refer to as a dual wave Bolus. Being you get some normal upfront, meaning a bump right now like an injection, and then the rest of the the meal like you said, 2080, right. 20% Now is the normal 80% over an hour. So your pump is now saying, Okay, I'm going to drip drip, drip drip drip this 80% in and by the end of an hour, that whole extra 80% will have been dripped in. But it's action time then is pushed out, because you didn't deliver it all right now that last pulse of insulin at end of our one still has now an active insulin time for whatever you have set in your pump, three hours, four hours, five hours out from that last active pulse. So I think that's the important thing to know about extended boluses some people first start to think of them as Okay, well, I'm going to get some insulin, but then three hours from now it's gonna give me the rest of my insulin. That's not how extends work. They always give some and extend some drip drip. Or you might want to say, for this meal, I'm eating a big ol plate of broccoli and a chicken breast. There's carb in that broccoli that you do have to count and cover. Is that broccoli going to hit you like white rice? No way. It certainly isn't. So a meal like that. You may say okay with these really low glycemic carbs. I'm going to extend the full Bolus, something we call a square Bolus, you take that meal that suggested as a Bolus, and you drip drip, drip the whole amount of it out over your designated time period. And there are different reasons for all of

those. Yes, and you got to figure them out. And you can I was with a person eating low carb this past weekend, I Vicki and we sat down at a restaurant, she had a meal that you would expect had almost no carbs in it, but a ton of protein. She sat she ate it, she sat and ate it. We got in the car drove away. It's now 20 minutes or more past when the food was and she grabbed her PDM from around the pot and gave herself insulin. Because she does know she needs insulin for that protein. And but she didn't need it. If she would have Bolus and sat down or Pre-Bolus sat down, she would have gotten incredibly low. Yeah. And she it was amazing to see somebody figure that out. I was and I'm going to add what I learned about that to me like how the protein needs more later. Absolutely. It

takes into the immune takes into the fact that we know these things from a set of rules. But I mean, the classic your diabetes may vary. Your diabetes bolusing strategy will vary. Well, yeah, not not me. It will vary. I mean, I my breakfast every morning, I've got a friend who eats the same exact breakfast after talking to me, she was like, Wow, that sounds awesome. I like it. I want to give it a try blah, blah, into them. Now she loves it her Bolus strategy for it. similar, but not 100% of what I do. It's different because physiologically, she's different. Yeah.

And so if you've ever heard me speak live somewhere. There'll be a moment where someone in the audience asks the, you know, the question, how much how long, you know, and I go, I don't know, figure it out. You know, I

think places there are some starting Oh, sure. Things. Yeah. It's like kind of like, you know, the How much do you adjust the basal up? Oh, point point. Oh, 5.1. It's a starting place, right? Sure. Give it a try. If it doesn't work. Okay. Next time you adjust different,

right. And I'm more aggressive. Like when I adjust Basal rates, I adjust them like 30% of the time, because I'd rather cause a low and then back down from the low to find a level spot than to stay high for several days, I didn't nickel and dime the high, right? Because also because I feel like you're getting a more accurate depiction of what's happening. If you're using more insulin, when you're using less insulin than there could be resistance going on and maybe, you know, maybe in

the field too, then that you have to correct and so you never really get a true picture of what does the Basal adjustment really just do because now I'm high and I want to correct and I'm not going to leave it Hi. So I don't understand what the Basal I know. I just know it's not enough,

you'll get a look into my parenting style that way too. Whenever my children asked me something, I respond immediately with no, and then we work backwards from now. And so I sort of do the same thing with the innocent I slammed the insulin, and then I work backwards from there to find a level spot. I wanted to say about insulin action time. It's another idea of settings in your pump, right? So there's an amount of time that they, you know, insulin should work in your body, like how long from when you put it in to when it stops working. And you'll see people say all different kinds of numbers, you know, for hours, you know, it's different for me here and there. Same insulin, you know, they're using one kind of insulin. Some personal say, Well, my action time is four hours by x times three hours. Arden uses Apidra, and her insulin action time in her pump is set at two hours. And so I have found that when you Bolus Arden that Bolus stops having any effect on her in by two hours. Wow. Most of the time. Some of the time now, I don't know how to tell you the difference. But most of the time, it's Yes. Last night it was now last night I couldn't get Arden's blood sugar to budge off of one ad, it didn't matter what I did, she had incredibly Karva, terrific afternoon. Like I said, she still has her period. And you know she's going along. Now there's a moment where I'm like pushing and pushing and pushing. And I'm finally that guy. This is enough, like this incident is going to start working eventually. And it did later at night after a hot shower. Her blood sugar started coming down and we had to catch it and it was hours and hours later. That doesn't make Ardens insulin action times six hours. Right? That's a specific situation. Most times insulin I put in now doesn't cause her to get low two hours later. Now keep in mind, insulin on board is calculated by the insulin action times set up in your pump. Am I right about that? Correct. Can you explain that for us, please? Yes.

So insulin on board specifically uses your active insulin time that you have set in your pump. So for Arden, two hours, if she were to get a Bolus now for you know, at 11:07am. Two hours from now at 1:07pm, the pump would no longer identify active insulin on board from this Bolus, which means that if she chose to Bolus at 115, it's only going to factor in blood sugar and the carbs she tells it she's eating to give a Bolus suggestion. However, with in active insulin time, let's say, you know an hour from now somebody's birthday comes up and they bring a bagel, big old treat to school and she's like, Hey, Dad, I'm totally,

I'm going to eat another 30 I'm gonna eat another 30 carbs over overtop of what we just Bolus for an hour ago.

Exactly. But that was an hour ago. So your pump still assumes, hey, there's still insulin on board from this Bolus that she gave an hour ago, there's this much active insulin left. Important thing about iob is that you have to feed the pump information in order for it to consider iob information being blood sugar, and carbs. If carbs are a piece in the picture here, right? Because if you do not feed the pump, a blood sugar, it doesn't know the effect of the insulin on board that's still left. And to calculate the next Bolus correctly, it sees the insulin on board, but it may not be able to adjust because it doesn't have a pinpoint of glucose value to now say, okay, she was an hour ago at 82. Now she's at 179. That insulin on board that's left is coming into the picture but the pump also sees a higher blood sugar. So it's going to say, okay, she's high. She wants to eat this much more. This is how I'm going to calculate the Bolus despite there being active insulin left

but in a situation where like for instance, now Arden's blood sugar's 111. Okay. And I'm seeing a curve up on her CGM, but her pomp right now if you test it right now say she didn't have a CGM she tested right now for that, you know, surprise treat an hour later. And and it says, Oh, your blood sugar's 111. You have all this insulin on board from the meal, go ahead and eat that you don't need insulin for this or you don't need you don't need as much insulin for that. That would be stalking. Now that would be okay. And that's a word that doctors are going to throw at you. And they're going to mean for it to scare you. And maybe maybe it should in the beginning. I'm not 100% Sure, but what they're going to tell you, you can't stack insulin because eventually it's going to it's going to catch up to you and it's going to make you low. I say to that. Yes. If you don't need the insulin, if you do need the insulin, it's not stalking it's bolusing. Knowing the difference is the is the trick, I guess it is to go back to I'm going to layman's terms a little bit more about insulin on board and action time if I can. So if you decide that your insulin action time is three hours and by you I mean the doctor sits down says that's is what it is for most of my kids this age, so I'm going to set it for three hours for you. But your insulin action time is actually less or more, then your pump is going to make decisions based off of that number. It doesn't make it right, I want to be clear to everybody, the pump doesn't have a magic sensor that's in you somewhere that knows that it's telling you the right thing it's making, it's making a static decision from a static number. That's not necessarily correct, it's probably a good guess, it probably won't hurt, you know, it's going to err you on the side of caution a lot. It's going to keep you from being, you know, from getting low.

And I think that's a good, that's a it's a very good point to bring up. Because what we've actually found, especially in the community of people who are doing the do it yourself looping types of pumps, which is a whole nother broad topic, but I bring it up in this mainly because what we've found is that the action time of rapid acting insulin is actually beyond what most people have it set in their insulin pump. And the reason that we have it set for less time and an insulin pump, is because we inherently do not want to run high blood sugars. And so if we give the pump and active insulin time of three hours, when really that Bolus is probably lasting about four hours for us. What it means is that at three hours, and one minute after this Bolus was delivered, if your blood sugar is still high, your pump now no longer sees any active insulin and it can Bolus you more aggressively for the blood sugar that you now want to drive down. Right. Whereas if you had it set for four hours, at three hours in one minute, you were like I'm high, I want to Bolus to get this blood sugar down. Your pumps give me like, oh, let's be a little conservative here. Because you still have this like quarter of that last Bolus still working.

If you have an Omnipod, your pump is going to be completely self contained, it will adhere to your body, the insulin will be in there and all the smarts and everything and you'll use a wireless controller to tell it hey, I want you to change my Basal or put it a Bolus or something like that. All other pumps have tubing and an infusion set, right. So you'll have an infusion set that will put your cannula in tubing will run to the pump, and that pump will have its insulin in it, you'll need to keep that with you. It'll be clipped to somewhere, right. And that's

a good point to make to about the difference Omnipod, the PDM does not have to be on your person for the pod to continue delivering. That's a big question that a lot of people have, well, I don't want to carry around this extra thing all the time. You don't have to once the pot has been told what to do. It does it as soon

as it beeps and it recognizes the signal you're done. Actually you can walk away from if your insulin starts in like say you're putting in 10 units delivering right. As soon as it starts delivering, you could you could run to you could run across the state and your PDMP in your house and the insulin will keep delivering Yes. It's also important to talk about their about pumping in general is that to bathe or swim on a tube pump, you're going to have to disconnect to most of them for most right. So even in more aggressive like sports, for instance, like give, there's a lot of people who disconnect to go play soccer or football or something like that. With Omnipod you'll always be wearing it. I think to me, that's a huge point that made me want to do it. Because you always hear people say like, oh, I went to the beach and I got high. I get high at the beach. And I always think back to someone who was on the show. I think it was just a few episodes ago, where he said if you put a pencil in your back pocket, and then rob a bank pencils don't cause bank robbery. And, and so the beach doesn't make your blood sugar high, taking your insulin pump off major blood sugar high. Right, right, like that kind of an idea. So just understand that there's different ways to manage with different pumps. I'm not telling you which pump they get.

And that's a lifestyle look, right. And that's the biggest thing when I work with people. They're always like, what what do you think is the best? There isn't a best, there's the best for me. Yep, there's the best for you. You need to take a look at you know the pros and the cons of all of the pumps. What are the what's the pump that has the most pros for your life 100% navigate your lifestyle your needs, you know an athlete, I've got a lot of athletes who really prefer Omnipod because of the tubeless piece I've worked with a lot of triathletes who really they need I mean from going from a swim into a bike into a run. They need something that's a seamless management then they're not having to clip in and pop in and reload and you know everything. So there. I think it takes a lot of examination of your lifestyle. Yeah,

no, absolutely. There's no I would I would jokingly say that you know you I'm sure you think that I think you should get an Omnipod. And probably if you ask me my personal opinion, I would say yes, right? Not just because they advertise on the show, but because ardency just wanted for 11 years. And it has been nothing but absolutely fantastic for us. But I completely agree with Jenny, you should decide what works best for you. You really have to do that. Not everyone's going to see the same pros and cons as everyone else.

And all of the pumps despite delivery, and mechanism of driving insulin, they all do have some features that are different and may apply better to your lifestyle, then another brand.

Absolutely. So. So again, figure it out for yourself, do your due diligence, do your homework. Yeah, I think the greatest thing about the Omnipod might be is that they offer a demo, they'll send you one to your house and let you try it like that's where it and the other companies are at a loss, they can't really do that. Because of the way there's a setup

very big and expensive. Let me just send you this. I'll send it back to

you. Please, please give it back. And a couple of other ideas. And he's right, so what I was getting to whether you're using an Omnipod, or you're using another one, there's going to be some adhesive of some sort, you know, a simple preparation, like we talked about back in the MDI episode. I think I don't over prep art and skin bright, clean skin.

Dry without lotion or anything on it, you're good.

Put it on, you could see. You know, if you have soreness with a pump, right, it shouldn't hurt. No, right? So it should not. So be careful. Like if you start if you have soreness that you know, I mean, after it first goes on, obviously, you know, it's not fun to have a hole poked in you. And that's going to be done by any one of these pumps. But an hour later, whatever it is, if it's hurt, so it's hard to bend your arm. Sometimes the cannula can hit a nerve, or muscle like looking up again. All of these companies will if you call them up and say, Look, I had to put it in an infusion set and it hurts so bad. I took it out. Can you send me another one? Generally speaking, they're their customer service is good, they will

correct and that's it's really important because it can affect absorption at the site. If you've got a site that isn't it that's hurt, or you know, maybe getting infected or for some reason there's irritation under the site. If that site is bothering you, there, that's not good. Remove it, pop in a new one do something

yeah, don't sit in pain. And that I think that's important. Tubing is something I don't completely understand i How much tubing do I need is it just as much to get me to where I want to store my pump?

Correct. It's it's in that depends you know, tubing comes in many many different lengths for the tube pumps being of which there are only two on the on the market either tandem or Medtronic or the tube pumps that are available now, at least here in the States. So the tubing length depends on exactly where you're going to move that pump to and pop it in. If it's in a pocket, you may need short tubing 18 inches. If you're going some some of the guys I work with, you know where the shirt stays around their lower leg to keep their shirts tucked in, well they end up just clipping their pump down their leg and then they can easily lift up their pant leg to Bolus during the day. So if that's the case, you probably want 40 plus inches Oh tubing to kind of reading how tall you are. Right You know, if you're Shaq, you probably need like inches but yes

and and the two pumps also when you go to put them on they have to be primed, which means that you have to fill all of that tubing with insulin rack before you can put it on the Omnipod self Prime's so you when you know tubing, and there's no tubing. There's a tiny little cannula that that obviously goes under your skin and stays there. Yep. So, again, there you go. There's pros and cons with all of them. You know, I hear people say that. So Omnipod has a failsafe, right? If it gets around too much electrostatic electricity, and it and it affects the internals of it, it will shut down and ask you to write to change it. Yep. I've had it happen in 11 years, six or seven times, you know, it's happened. And people go well, that doesn't happen with a two pump and I'll say Well, yeah, and my daughter has also never walked past a drawer in the kitchen and gotten her tubing caught on it and yanked out her infusion set right that's the tube pump version of that to me like they all have something if you're looking for something right if you're looking for perfection. Don't Don't ask a machine to do anything.

salutely and I think you know one even that might be going towards the tube pump potential need would be if for some reason, the angle of the cannula is a concern or an issue for you. That is one I would say potential drawback of Omnipod is that there is only one cannula When it comes on every pod, it's exactly the same cannula. And it goes in exactly the same angle for every single person, which may not again, your diabetes will vary because your body physiology may be very different. So you may need to choose a pump. Despite not wanting to being you may need to choose a pump. That's too because you need a different type of cannula or what's called infusion set. You may need something to go in at a 90 degree angle versus an angled, you know, you may need a steel cannula versus a plastic cannula for various body reasons. So there are a lot of considerations.

Absolutely. But don't take, don't keep this in mind, no matter what pump you're thinking about. I know this is gonna sound a little dirty, but it's it ends up being true. Companies have salespeople, salespeople influence doctors, doctors get stuck prescribing things, the same poem right over and over, you walk into an office and say I want it Omnipod and the guy goes, no, no, you want one of these? Trust me. You don't need to trust him. You know, you can say that you appreciate your input. But I'd really like to try the Omnipod or vice versa. I don't want it Omnipod. I really would like to try that. Eastland you can you can you can speak up for yourself, please, please do that. Absolutely do that. So at the very end of this I want to talk about about something that can't, it doesn't happen with injections that could happen with a pump, right. So as long as you inject your insulin with your injections, you remember to put in your Atlantis you'll ever mirror your true zebra, whatever it is. And you you know, remember to put in your insulin for your food or your high blood sugars. You're watching the needle go in your arm, you're pushing the button, you pull it away, you know the insulin is in there. With any insulin pump, the possibility could exist that your cannula could get bent, that your tubing could get kinked that the pump could I don't know, the batteries could die like like, you know, on the pot doesn't have batteries. And there's the but the other ones, there's mechanical,

leave the house and totally forget that your reservoir only had five units and for the rest of the day, you actually needed 20 units. And now you have no incident you're

and you're in trouble. Right? Right. So these are things that can happen when you try i We have a radius in my mind if I'm more than 30 minutes away from my house for any extended period of time. I bring insulin and another pump with us. The other day, we drove an hour and a half to something stayed there all day had all this extra diabetes supplies with us didn't need one of them. You know, most of the time you don't need it. But when it happens, it happens. Now, in 11 years, I'm happy to tell this story in 11 years, we've had one insulin delivery problem with Omnipod. And it wasn't the pump it was us. We changed a pump by sight. And it you know it was at a pool. Right so we put it on and I she got back in the water and I think the adhesive didn't have time to adhere and it loosened up a little bit and it pulled her cannula out through the course of a day right along July day of swimming. We got home her blood sugar was still fine now, was it still fine because the cannula was still in it hadn't worked its way out yet because she was so active during the day. She didn't need as much as I don't know. But what I can tell you is, is that overnight Arden's blood sugar started to skyrocket. And I kept bolusing. And it took me a while to figure out that my Bolus is weren't doing anything. That's not going to happen to you injecting, right and so is it is it I actually saw a person say the other day, I'm scared to get a pump because of that. And I think if that's why you're scared, I think you're worrying about things you don't need to worry about. But you do need to be aware of them. Correct, right? Your tube, tube kings, something happens, you're not getting insulin delivery, you're also don't have any slow acting insulin. And so when you lose your pump, you lose your slow and your fast acting, you can go from everything's right on to DKA. Pretty fast, quick.

Exactly. Absolutely. And that's, it's a really good piece, you know, to discuss because it's one of the primary things when I work with starting somebody on a pump that we discuss, right in the pump training is the risk for DKA or the risk for a pump malfunction and how do you how do you navigate that without having such tremendously high blood sugars that then take forever to bring down because you're at such a deficit of insulin right? I mean, our our recommendations really are with a pump, an odd high blood sugar or now with the use of a CGM blood sugars that are like you said, just all of a sudden skyrocketing and there should be no reason for that skyrocket like you didn't go eat the whole Dairy Queen cake and just not Bolus for it right. There is something wrong you Bolus from the pump. If that initial Bolus doesn't start make a dent in that glucose within the next 30 to 60 minutes, you change everything out, you change the site, the tubing, the reservoir, the pod, whatever, you might even change the insulin, you know, especially if it's been a day at the beach and your insulin hasn't been kept change the insulin out really important

I bail on in a pump site. As soon as, as soon as I know too, I will sometimes if I if I get stuck number, but it's not too high. Sometimes I'll inject a little bit. And if you inject instead you go, Oh my God, it started moving right away, maybe I'm gonna get off this pump site like a little sooner. And that's, you know, to just go over a couple of like ideas, you can't keep reusing the same site over and over again, they eventually become less effective. For reasons we talked about in other episodes, you have to understand that when you when you put in an insulin pump, you've you've a needle has poked a hole in you and left behind a piece of plastic in most cases, right. This plastic is a foreign body. It's an irritant, right, it's an irritant. I remember discussing with Aaron Kowalski from the JDRF, one time that he thinks one of the most ignored technologies for people with diabetes that we don't spend enough r&d time on is cannula, materials, and how to make them less irritating to the body. Because when your body thinks it's injured, it sends white blood cells to the place it believes there's an injury. And I don't know anything technical, but in my mind's eye, in my mind's eye that draws cartoons of what I think the world looks like, and how I understand things. There's little white blood cells, sort of like the beginning of Jurassic Park, when they show that cartoon to explain that I know DNA, in my in my mind, I see little white blood cells coming and attaching themselves around that cannula and making my insulin not flow correctly. I know none of that's probably technically correct. But I do know that when when a place gets irritated like that, that insulin becomes less effective. And there are times you have to bail on a site sooner than you want to.

There could be and it's also a good just around site change itself to be very aware that the potential for that new site to be less absorptive, from really what you're talking about, there is inflammation. Anytime you introduce something underneath the skin, you ask your body to become irritated. And inflammation is what follows. So absorption at that site is significantly decreased. Everybody's a little bit different. Some people it's for about an hour, some people it could last as long as four or six hours, that inflammatory response. It's also I guess, for those who are using a continuous glucose monitor, you know that two hours sink in window? Yeah, it's a big reason for that to our sink in window, besides that sensor needing to get wet. You've put something to sit underneath your skin, your body's got to get used to that and you don't want glucose values coming in from a site that's probably injured. Right? So same with a pump, you really have to pay attention. What do your site changes look like? How does your glucose level change around site change times? And is this normal? Is this a normal flux in glucose? Or is my gosh, my blood sugar's never 300 after I change a site, right, therein lies the difference of change it out or figure out how to navigate the site change, so you don't have a high blood sugar.

And I think it's incredibly important to know that while this may sound scary, that you'll figure it out very quickly. It's not something that's going to dog you for your entire existence. There's little is the word peccadilloes, there's small things about everything that you have to you have to figure out along the way. And the only way just like we talked about within something, the only way to figure it out is to do it. Let it go the way you didn't expect, you know, suss out what happened and fix it next time.

But I think just the fact in you know, this episode, especially talking about these little pieces, it's really, really important because these are pieces that are often not talked about from an endo education standpoint. They're not they're missed. They're things that you've figured out along the way. And you've talked to other people, and you're like, Ah, I'm not the crazy, man. This is what's happening. Right? Me, me, too. I mean, I, I could have sat and asked my endo about it. But there are things that in interjecting and working with other people and my own self experience. I'm like, I'm not crazy. This is what happens. And I'm not the only one great

example, that when Arden was younger, and we changed her pump, she'd get high. And people say oh, that's a thing. That's a pod chain tide only happens with Omnipod and blah, blah, blah. And I'm like, you have to Bolus boring with Bolus with the old pod before you change the new pod because the new pod won't work and everything. None of that was the truth. You want to know the truth. Arden was incredibly nervous. To get her insulin pump changed when she was little, and the adrenaline would hit her and shoot her blood sugar up. And one day, Arden stopped being nervous about having her insulin pump changed. And that all stopped. There was no magic. So people had had imagined this entire story around this. And I started buying into it. At first I was like, oh, obviously, the pump doesn't work right away. And, and all this. And by the way, it doesn't it that's not an unnecessarily incorrect statement. There. Like you just said new inflammation. There's an injury, you do sometimes need more insulin upfront, and I don't disagree with that. But the LEAP she got wasn't the pump change. It was it was adrenaline. And I still, like we talked about earlier, a new pump. As soon as I put on a new pump, I double the Basal for an hour, like right, just to get it going. But But I started thinking down the it's again, this cause and effect, it's the pencil in your pocket, right? Like, I changed the pump in her blood sugar went up, obviously, the pumps not delivering insulin anymore. Make sense? didn't end up being correct. Right? Right. So just you'll figure it out.

And my experience was coming from a tube pump to Omnipod. So I had experience with site change from a tube standpoint on to Omnipod. And I'm glad that I had that because I do experience that site change inflammation. And I had experienced it on a tube pump with the cannula. And so I knew it was likely going to still happen on Omnipod. Yep. So, you know, again, your experience is

gonna be different from somebody else's. It's 100% Right? Ah, good. Oh, did we didn't miss anything? Do we do okay? I think I like what you said at the end. I appreciate it because I wanted this to be a real world conversation, not some like shiny. Oh, you'll get a pump and you'll love it and it's gonna and by the way, you will love it. It's in where you won't. I don't know who you are. You know, I can tell you it's been an amazing experience for us. I believe wholeheartedly that the Omnipod is one half of the reason that we are able to keep Arden's a one, see where it is

where it is. Absolutely. population of people that come off of a pump is small. But there are people who I've got a good friend who pumped for years and was like, Man, she had a major issue with her pump and she was like, No, I'm, I want to make sure I know I'm getting my insulin. She's been on bolusing she's gone through pregnancies with bolusing via MDX. It works for her. But again, that's her choice. And most people will stay on their poem. Listen, here's

the here's the key, be happy, be healthy. That's all I care about doesn't matter to me what you do, just no differently than the way I talked about using insulin. I talk about pumps and glucose monitors the exact same way. I want you to know how it works. I want you to know what to do when you try it. And once you try it, if you don't want to do it, whatever, man, I don't care. You know, like, I'm not going to tell you what to do. I'm here telling you, you shouldn't make decisions based off of bad information when you have good information, make good decisions, do whatever you want. I want to thank Ascensia 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 Gvoke glucagon find out more about Chico Capo pen at Gvoke glucagon.com. Forward slash juicebox you spell that Gvoke glucagon.com. Forward slash juicebox I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 Fat improved Between 1013 Insulin injury and surgery 1014 glucagon and low BGs. In Episode 1015, Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two, in Episode 1018 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022, weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025, we talk about transitioning from MDI to pumping. Before I go, I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with this and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active. Took me already from a decent 6.5 A1C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link.

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 CDE 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 revisitable. 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 health care plan are becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by Ascensia 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 Juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke hypo pen. Find out more at Gvoke glucagon.com. Forward slash Juicebox.

What's on our agenda today

we are going to talk about continuous glucose monitors.

That's a big topic it is right.

So I tell a story that I think is going to fit here in this episode. We were in my daughter's endocrinologist visit a long, long time ago, probably a decade ago. And the nurse practitioner asks me Are you going to get one of these CGM M's. And that's how new the whole idea was. And I said, I don't know what you're talking about, you know. And so she begins to tell me a story about this 17 year old kid in the practice, who loves m&ms but can't seem to eat them without a spike. So he gets the Dexcom, which I think back then would have been the seven plus maybe 10 years ago was that the first one with a seven seven.

I know that in 2006 is when I got my first CGM and the seven was on the market, along with whatever came with Medtronic and then Abbott's navigator had come out. And that's actually the first CGM that I had. And I loved it. It was unbelievably accurate.

Yeah, I remember that one, too. Yeah. So it probably was

the seventh when

you were there. And so she's telling us about this thing called Dexcom. I don't know what it is. I don't know what she's talking about. The letter CGM mean nothing to me. It's like Chinese, right? I just I was like, it could have been any language except English. I didn't know what she was talking about. But then she tells me this story. And she says that the boy gets the glucose monitor. And he goes home to the grocery store and buys those little single serving packs of m&ms. But he grabs seven of them. And the first day he goes home and he eats the m&ms as he always would, he puts in his insulin as he always would, and he watches his blood sugar go up. And it kind of stays up after that. So the next day, he thought, Okay, I must need more insulin. So it gives himself more insulin, his blood sugar goes up less. So the third day he thought he had it fixed. He's like, This is it. I just need more, but give himself more. He barely goes up at all, but then he crashes low later. So the kids like Okay, so the next day a little sooner, a little less, a little more. And he messes around back and forth, back and forth with this, and then she looks at me, I'll never forget the look on her face. Because she was astonished, right? And she goes, I saw his graph. He put his insulin in, ate the candy and his blood sugar never moved. And she's telling me a story about that. And all I could think in my mind was well if that's possible with that, then that's possible with anything. Like that's what I left with that feeling of like there's information coming back to me that can do that. That's amazing because I used to be one of those guys. People, we'd go into the, I don't really show them the pump anymore. But we used to go in and they download your data. They'd look at, you know, your boluses and all this stuff and where your blood sugar's were and she'd say to me, Hey, you tested she, you know, Arden ate lunch at noon, then you test it at 1230. She's like, why would you do that? And I said, Well, don't you want to know what's happening? Like, like, I want to know what's happening. So it was a number of years later that she she said back to me, she was I realized, now prior to you having a glucose monitor, she's like you were doing it yourself. Like you were trying to act as a glucose monitor. You were figuring out what was happening, which made sense to me back then.

My finger sticks prior to CGM, on average were about 14 a day,

I'd have to say that's where we were to, because I literate

similar as you. I wanted to know where things were not only before, but especially after because it's a learning piece. Yeah, it's just like the m&ms. It's how did this work or not work? And what do I need to do to make sure that it works the next time because I like this, or I like to do this kind of exercise or whatever it is.

I was so amazed. Just doing that just you know, it fried my mind back then like to test and go but but she went to 300. And then 45 minutes later, she was 340. But then she fell in like all that stuff. It was it was interesting information. It was valuable. But it wasn't enough. Right. Right. Like it was It wasn't enough to make sense. At least for me. I couldn't make sense of it still.

Because you literally when you do finger six, then you have to do the connection of the dots yourself. Yeah. And I couldn't do nothing in between.

I couldn't make that leap. I just couldn't figure out what, like what you're like those gaps. Like I couldn't figure out what it was. And it's not Jurassic Park, I couldn't just use frog DNA to fill in the gaps. Right? Because you see the gap. You see what happens and they're they're, you know, they're making babies by themselves. And it's just it's not good. But you don't want to fill the data in with something unknown is what I'm getting at. So I did as best I could. I heard her story. Oh, my goodness, I ran to get a CGM. You know, we got the Dexcom right away. I can still remember sitting in that we the endos office, right. And the nurse practitioner put it on for the first time and Arden didn't like it. And I remember breaking my heart. Like I remember thinking like oh, God did that hurt. You know and and now you know with the G six Arden Arden honestly says like, I can't even I don't feel it at all. Yeah, it just it's but back then, you know, there she was. Gosh, I don't know it'll four or five years old right? When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. Gvoke 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 vote glucagon.com forward slash juicebox Gvoke shouldn't be used in patients with pheochromocytoma or insulinoma visit Gvoke glucagon.com/risk. There she was four or five years old, this little dress and she's so like sitting up on the table and trying to be tough and everything and oh, and it wasn't good. But we stuck with it. Because of what I was getting back from it. I just found it to be amazing. And now today, today, I think that if you're listening to this podcast and is of any value to you, I have to give half of the credit to the Dexcom. And the other half of it's Omnipod like I I took those two tools and figured out how to use insulin with them.

But you also have to give yourself a big part of that credit because you took tools. It's like any kind of tool, you could have a hammer as one of the simplest tools that there is. And if you don't put it to use. It's a great tool, but it doesn't do anything else for you except sit there.

Well, you're very kind I was avoiding saying something nice about myself. But let's do that for a second. But let's let's translate it out to the people listening. My goal with this podcast is just to be your Eminem story, right? Like, I want you I want to hand you off tools that you then take home and learn how to become proficient with right I'm not I'm not gonna stand with you forever, Jenny can't come to your house, right? But we're gonna, we're gonna throw these tools. Somebody said to me once can you come live with me with me? I started thinking there might be a number or I'd say yes to that. But I don't know what it is exactly. How much would it cost for me to abandon my family? And guys, I'm leaving. But But But seriously, I genuinely mean that like you, you're gonna get these tools. You learn how to use them in situations and before you know it they work in more and more what you would have called complex or difficult situations is exactly the same thing. When people come to me and say, Sure this is great, but how does this work during hormonal time or during a growth period during illness or during you know, when your daughter is playing softball, I always say the same thing. exactly the same way. This tool

makes me more comfortable, of course, right? Especially when I mean, we talked already about insulin. And it's actually, I mean, this tool shows you not only effective food, but more. So how to be more comfortable with insulin use. Yeah. No, it does.

So not unlike the first time I thought about an insulin pump. And while everyone else was yelling, oh, you won't have to inject so much. I was thinking, Oh, I could manipulate the Basal insulin. Like that seems like the exciting part to me. And we CGM and you probably you've heard people say this before if you have considered a glucose monitor. But the most exciting thing about a CGM isn't the number that it shows you. I'm sitting here now Arden's blood sugar 75. She got insulin for lunch, I'm going to find out when 47 minutes ago, she was 9547 minutes ago when we put the insulin in. She's 75 now. So that's comforting to see that she 75. But what you don't hear me talking about when I tell you that is that there was a moment when she was 89 Diagonal down and she was drifting down. But she wasn't falling that fast. I could see how quickly she was falling. That's the information from the CGM. That's just mind blowing. Sure, she's going down. But she's going down at a speed I'm comfortable with based on the food that I know is going in, because that battle is about to start really happening, the foods really going to kick in. And the second. I love that she's drifting down at that moment, because you know, when lunch hits her, I like like, you know, we've talked about before, I like the insulin to have momentum. Right? If you think it's about the number you're misunderstanding the CGM. If you think about the m&m story, you have to know it's about timing and amount. It's about speed and direction. Right? Like, which way is my blood sugar moving? And how fast is it going? When you know that it's everything, it's the difference between treating a 75 blood sugar and leaving it alone. So I can see right now Arden's blood sugar is steady, which means I want you because

the trendline is horizontal, and her arrow is probably horizontal. And

that arrow is still telling you something, right? Like even being horizontal, it's telling you we're steady and Dexcom gives you the breakdown of what that means study could still mean plus or minus a point every five minutes. But great, you know what I mean?

But it's happening so, so slowly, at that horizontal arrow, they usually say that it's less than a point a minute, right? And so and that's where to bring in that that angle, the arrow that you saw with the ad something blood sugar, I mean, had it been angled up or angled down, it's still the same rate of change, right? It's about one to two points per minute.

Yeah, yeah, it's it right. And so when people talk about, Scott, I don't know I don't understand how you don't count carbs. So here's here's a way I don't count carbs. That remastered diabetes Pro Tip series is sponsored by Ascensia 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 Juicebox free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and to carry case but most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen. It fits well on your hand and features Second Chance sampling which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one. Contour next one.com forward slash Juicebox free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips you can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now through your insurance. Contour next.com forward slash Juicebox free meter go get yourself a free starter kit. while supplies last US residents only time reached 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 at school, the D box program, golfing for diabetes, dancing for diabetes, which is a terrific program. Just click on that to check that out, both 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 shownotes links at juicebox podcast.com. To touch by type one, and the other great sponsors that are supporting the remastering of the diabetes Pro Tip series touched by type one.org. Sure I go historical I look at a plate and I say I think this is 10 units, right? But Arden had pancakes this weekend. Big homemade not measured pancakes. And I have a feeling that pancakes are going to be 12 units ish. So I double her Basal rate for an hour and a half. 15 minutes before she gets the pancakes her blood sugar is already 78 Then she's coming out of bed 10 minutes ish before the food starts. I do the 12 unit Bolus. But I take out one unit that I've added from the Basal right so now it's an 11 unit Bolus I extended out 80% Right away 20% over an hour. Now I'm creating kind of like that blanket events on like we talked about. Now if I get it wrong, I adjust. The most times I expect by getting it wrong means I won't even be aggressive enough. And I'll have to come back and bump it down again. When I see a diagonal up arrow 30 minutes after pancakes. I say to myself, ooh, I messed this up. Maybe I shouldn't have extended the Bolus or maybe I should have put more up front. But anyway, I'm going to bump that arrow back down again. In this situation last weekend. I was so aggressive that I had to bail on the Temp Basal rate. So about 45 minutes after Arden ate. She was 70 which was fantastic. But I was like I still have insulin going. I don't need any more clearly. So we cancelled the Temp Basal rate. And she wrote low forever. I mean, it was was great. 85 like right in there. Right.

Healthy. That's not low. That's right. Healthy. She wrote health lower

than you. Yeah, of course. I definitely misspoke. They're lower than you would expect after pancakes. Yep. But But I had a great blood sugar. Because I was able to use what the CGM was telling me and what the CGM was telling me was she was starting to drift lower from like 90, and I read that drift as these pancakes are through her now to enough of a degree that we shouldn't be going down anymore. Right. Alright, so I bail on the Temp Basal. I don't shut her Basal off, I just go back to the regular Basal rate. So we're going along like that for hours. I mean, hours and hours. Now there's nothing. There's nothing now I know the insulin is gone from the pancakes. Now I know the pancakes are definitely out of her body. And at some point, that arrow kind of diagonals down a little bit. And we were getting ready to go out to the mall, her and her friend. So I said to her, Hey, take your vitamins, the little gummy vitamins, they must have like six carbs and she pops her vitamins and we get in the car. The arrow kind of bangs back up a little bit again, right in that 75 area. So we get to the mall. And I'm like, Okay, I'm gonna ride this out to see what happens. Like, I'm not panicking here. But we were there for about 20 minutes or so. And I wasn't sure if like the excitement of the shopping was going to make her go up or not. And it didn't. She was walking around. And my wife and I left her alone. Went did something else. And I texted her at some point. Hey, I think you should shut your Basal off for a half an hour. And she did. And we stayed right at like at the whole time she was shopping without the CGM. There's just in my opinion, I don't know how to make any of that happen. Like maybe there's a way. But if there is a way you're listening to the wrong podcast, because I can't quite figure it out. Right, right. So I think those CGM are absolutely stunning. I want to know how you talk about using a glucose monitor with with your patients. I want to know how you talk about using a glucose monitor with with your patients.

One of the big things I usually say when people are really either considering one or they have been using one for a long time, they've may not really be using it to their benefit. Let's say they're looking like you kind of alluded to just the number, right? What's the number? What's the number? They're not learning from it because there certainly is some optimization when you start using a continuous monitor but of any form of technology. GM I have said this before, I mean, if I were to have to choose between a pump or a CGM, I would say please let me keep my CGM. Right, right. Because even then, if I had to go back to multiple daily injections, I can micromanage that as long as I know the direction of where things are headed. I can you know, and with a pump, then it just brings in more precision. So using a CGM, along with a pump is a another huge beneficial tool, you know, to management. So I guess as far as that it's really helping people to learn what is what's the benefit of that trend that they're seeing? And I think, in the end, many people I find, tend to overreact to the trend too. And you know, oh, my goodness, I you know, things are going up or going down? Well, you do have to make you have to make some considerations within that trend then to because have you just eaten? Is there a load of insulin here? Have you just exercise all of those variables that could be there? There a reason for some of that trend? That trend just like the guy with the m&ms, right. He knew something was going on with his m&ms. He didn't want to be high. So he was like, awesome. I'm gonna use this and fiddle with it and figure it out. So you know CGM is can give you that figuring piece that you don't have with finger sticks alone. I mean, you know, again, doing a million finger sticks before I actually had a CGM. per day, I was still missing all of the pieces in between. I was missing. When did it start to rise? Or when did it start to fall? Yeah, I know that I'm like, 40 points higher now than I was after I ate my meal. But why and where did the rise actually start? Right. So those are some of the biggest pieces. And I think getting people over the over the overreaction to the trending is something it's hard for many people to be able to try to say, okay, things are rising. You eight now let's do some self experimentation. Let's see. You know, is this happening today, around 80% of your most common foods, which most people have about 20 to 25 foods that are pretty common for them to eat over and over. Use your CGM to your advantage. That's 85% of your management then is figuring out and that's the reason that you have outside of not, let's say carb counting in the real sense of doing it. You have a sense just based on the meal because you've done it so much. You can say this should probably be about 12 units, or that's more about five units. I mean, Ginger actually does the same thing. She doesn't really carb count. Truly, she's like this green apple that I eat every morning with peanut butter takes two units. Yeah, you know. And using a CGM, then I think that's the biggest thing for management is the fingering that it allows.

Yeah, so I think that you hear a lot of people in the beginning talk about like that anxiety, right? There was a huge concern in the beginning of CGM, a lot of old school people in the in the diabetes space were like, This is gonna make people crazy. They're just going to stare at that thing all the time. And that probably did happen to some people. But again, it's like I say all the time, like if you're looking at what's happening to your blood sugar and thinking of it as a mistake, that's your mistake. Right? It should be like let me experience this let me see what this is. Let me see what happens when I put the insulin in here versus in there. And that quickly died down i You quickly heard even some of the more ardent I don't know what to call them. But naysayers calmed down after a while, you know, and saw the value in it. I thought the most important thing was to explain to people that it's not just an alarm for when you're allowed. And I use that phrase in anytime I speak somewhere on this podcast. I say, Look, if you're looking at your CGM as a don't die alarm, you're making a huge mistake. But it is it is the it is the very least of what it does. And so I mean, it's cool that it tells you oh my god, oh my god, your blood sugar is getting really low really fast. That's amazing. Don't get me wrong. It's gonna it's gonna help can't

turn one of those alarms off that it's always there. No matter how much you hate that, that noise. It's, it's there. The FDA

tells them look under 55 We're gonna bang and we're gonna bang an alarm in people's ears and there's nothing they can do about it and fair fair, right? But that's what you're looking at it as it's incredibly short sighted. When people say to me all the time like Arden's tolerances are. Her low alarm is set at 70. And on my phone, her high alarm is 120 on her phone, it's 130. So I like to have a if she's raising up, I like to be able to think about it for a couple of minutes before I involve her in the conversation. I don't want her beeping at 120, right. But people say Oh, it must be all the time. It must be beeping constantly. And I'm like, No, it never beeps. And that's actually how Don't worry, I'll get back to my thought about moving down the hi Dexcom alarm after these messages from Omnipod and Dexcom. Let's start first with Omnipod. The tubeless insulin pump that Arden has been using since she was four years old over a decade now, choosing Omnipod all of those years ago was, and remains to this day one of the best diabetes decisions that my family has ever made. And I'd like to tell you why. Without the pod, you do not have to disconnect for activity. With a tube pump, you'll have to take your pump off to play soccer or to go swimming to take a shower, you know, and if you're an adult, and you're having adult time, you might want to take it off for that too, but not on the pot on the pot is always with you. And why is that important? Because you're always getting your Basal insulin. It's a completely under appreciated idea. But when you take your pump off for half an hour, an hour, two hours to go play a sport, you're not getting insulin. And sure while you're running around, it might seem like oh, this is fine. But eventually you're going to experience a high blood sugar from that getting a constant flow of background insulin is incredibly important. And only Omnipod allows you to wear their device throughout your life without having to take it off for any of the you know, activities that you enjoy so much. I want you to go to Miami pod.com forward slash juicebox. Or to the links in your show notes or at juicebox podcast.com. You can do that today. And absolutely for free. And with zero obligation Omnipod, we'll send you out a pod experience, get a free demo of the pod that you can actually hold feel touch, keep it in your hands, see what it is. And then where it you get to test drive it before you buy. It's a nonworking pod Don't worry, it doesn't have insulin or, you know, a cannula or anything like that. But it's an exact replica of what you'll be wearing. So you can feel the weight and the size and decide for yourself if you'd like to try it, my omnipod.com forward slash Juicebox. Now on to Dexcom. The Dexcom G six continuous glucose monitor is without a doubt, the Cadillac of continuous glucose monitors. Everything you hear me talk about on this podcast is predicated on the data and information that comes back from Ardens Dexcom G six, we don't need a big long ad for this dexcom.com forward slash Juicebox get started right now. You need to see what direction your blood sugar is going and how fast it's getting there. And you want to be able to see your loved ones remotely with an Android or iPhone. Come on dexcom.com forward slash Juicebox get going today. If you've been hesitant, please trust me when I tell you there's absolutely no reason to not move forward with Dexcom. There are links for all of the advertisers that juicebox podcast.com Or in the show notes of the podcast app that you're listening to right now. I implore you don't wait another second. Go to Bliss with Omnipod. Get the information you need from DAX calm and support dancing for diabetes.

It must be beeping constantly.

And I'm like no, it never beeps. And that's actually how the kind of this way that we talked about doing this here. This being fluid. It it makes diabetes a very much a very much a smaller part of your day because you're not thinking about it. Because when it does beep, you know, oh, it's trying to leave this tight range. I'll just bump it back down again. Right when you put that threshold up at 400 because you're like I don't want to hear this thing beep. Well, that means that by the time you think to look at it two hours later and your blood sugar's 280. Right now you're dead. Yeah. And now you've all this mistimed insulin. Now you're putting in a bunch of insulin to bring it down your insulin resistance so it doesn't work as well. Suddenly, you're going to be low later, later, you'll feed the low, you won't have the Bolus you get on the roller coaster. I'd rather know now I talk about it in a million different ways. I open bills. I don't think I can pay you on day one, because I want to know what they are right. I want to know when her blood sugar is trying to go over 120. And if you do that, there's a great episode way back in the podcast with a scientist from Dexcom. There was a study done the lower you lower your high alarm on your CGM the lower your agency goes yeah because you react sooner with less insulin stopping arise and staving off a future low because you're only using a tiny bit events when we talked about before you're gonna listen through these things again, they're going to make total sense to you. I want to address when people say why don't want to wear a bunch of stuff You know, some, some adults just don't want to wear things. That's fine. But I hear a lot of parents. I don't want to look at her. I don't want to look at him and see him attached to something I don't he's not a robot. He's not like that kind of stuff. Arden hated that CGM. The first day she put along right. And I wouldn't think she thinks twice about it anymore. Not even a little bit. She rolled out that she rolled out the door this morning for school. In a pair of leggings. You can see her CGM on her hip. She doesn't care. She's wearing a top that doesn't go all the way down to her to her belt, her her Omnipod is sticking out like in that gap of space on her belly. She doesn't think twice about it. You can make those things normal and they will be you know, at some point. So I don't know for me, CGM is about reacting. And instead of, you know, appropriately

reacting rather than, rather than being you're being proactive, really, if you have a CGM, you can be proactive, rather than having to always be reactive at the like you said, Have you CGM set at 400. And you're finally seeing it at 280. Because you're not feeling the greatest? You could have been proactive well above are well ahead of that, right.

And that proactiveness, by the way, takes less time and less of your involvement than it does to be to 80. And fighting with it for hours after that. It seems it seems counterintuitive, because people say to me all the time, you must be so involved all the time. And I'm like, Man, I don't think about diabetes for more than about 10 minutes a day. You know, like on the really bad days, 20 minutes, but but I'm not mired down in it. Like there's no hand wringing in my house all day long, like staring at big numbers wondering when they're going to come down, or they're going to make lows. We just don't have that. I mean, don't get everyone. I'm generalizing to make my point. It happens sometimes, right? But but as a day to day idea, it is not something that occurs here. And I if you've heard me speak somewhere. In my slide presentation, there's a picture of Muhammad Ali standing over top of someone he's just knocked out. And I always start that part by going Has anyone ever been in a fistfight? And inevitably, it's always a little kid who's like, I have, like going off into the background. And I was like, Well, you shouldn't hit people. But but but you know, I tell people all the time, like you, you want to act, like like we talked about, you want to react, but really, you want to be able to act be first, right? You want to make a decision first, because besides stopping an arrow, there's the concept of cause and effect. Right? And there's this idea that, you know, people always run around yelling, well, that's just diabetes, every time something happens, they don't understand that was just diabetes. And I always say that when you're saying, well, that's just diabetes, what you really mean is, I don't know how to use insulin correctly. Right, right. Right. And so your blood sugar doesn't go up to 400. Because the diabetes fairy tapped you on the head. Like, there's a reason I don't know what it is. Maybe you might not know what it is. But there's a reason. So at the very least, if you act first, then with some some confidence, you can say that what happened next was a result of your action. At least you're not always covering your face in defense, like, like a boxer who just can't, can't get a punch anymore, right? diabetes is not pummeling you in the face. You you maybe you hit it too hard. Maybe you end up with a 65. You didn't mean to, but at least you know, wow, I put that insulin in here. And I got to 65. Next time, I'll use less. Next time, I'll do my Pre-Bolus, five minutes shorter, whatever it ends up being I don't know. Right? Right. But I'm a big fan of acting first, and then taking that feedback and making a better decision next time with it.

Absolutely. And that's why I think it's, it's when you're especially if you're new to CGM, or starting out, sort of over with a CGM, or you haven't used it consistently on a day to day basis, because you have felt more frustrated about it, I think, if you get it down to some basics of use to begin with, and like you said, kind of tighten up those targets. Even if it's just a short time period, you can designate and say, Okay, for the next seven days, I'm gonna have my target set the high alert for 130 in the low alert set for maybe 70 or even 80. If you're hypo, you know, hypo unaware or you just really worried or whatever about the lower end, because tightening it up helps but also then fitting in more of your more more of your regular habits. In that testing time period, your typical foods, the things that you like to eat for breakfast or lunch or for dinner or for snacks. Because if you're committing to using something by applying it to your body, and you know being a robot, essentially,

for a pound. That's right, exactly.

If you're committing to using it, then get everything that you should be getting out of using it and there's

a there's a way to start in my opinion. I'm interested in what you think But I think that when you first have a CGM on and you're accustomed to wearing it finally, you know what this information means. The first thing you do is you get your basal, right? Like to me it's basal. First, make sure your basal is right. And I tell people all the time, if you haven't had insulin or food for three or so hours, and your blood sugar is not 85, your Basal is not right. And so and so, if you're 180, or 200, shoot lower, I don't like don't shoot for 85 right away, shoot for lower and keep kind of just cranking it down and cranking it down. After you've got your basal. In a situation where you're staying pretty stable most of the time without getting low. That's then you can start thinking about Pre-Bolus. And then and then the CGM can really help you with that, too. If I'm 120 and I haven't had food or insulin for hours, when I put in some insulin here, how soon before I started seeing a diagonal arrow is it 10 minutes 1520. Some people say a half an hour, everybody's numbers different. So once your basal is right, and you can trust the cause and effect that I've Bolus now and it took 15 minutes, let's say for my blood sugar to start going down. Within reason trust that that's probably your Pre-Bolus 15 minutes right when your blood sugar is in range. Now keep in mind if your blood sugar is higher, you'll be more insulin resistant that Pre-Bolus Time won't be the same but but for the for the sake of the conversation. Now you have your Basal rate. Now you know your Pre-Bolus time. Now you can start using insulin. And being a little more aggressive with it. I've put a Pre-Bolus in I'm 90 Diagonal down, I've started to eat my blood sugar shot up. Now here's where the CGM becomes incredibly helpful. So you've you've got your insulin and you've eaten, but you're going up. Are you going up? Like a sharp a sharp incline, right? Or is it what I call the prices right? You know, the prices might the the which is at the miner, the climber, the gates like yo lay he and he's got the pic in his hand. He's going back and forth. And it's it's this very gentle grade that goes on forever. And you watch it the whole time. God, he's gonna stop, he's gonna stop. He's going to stop. Oh, he'll definitely stop. There's no way he's gonna fall off the edge. It's not gonna happen through the whole thing. And it just keeps going. That's that CGM line that it tricks you. Because you keep thinking it's not on a crazy incline. I'm not shooting up. I'm just climbing it's going to stop in a minute. But no, it's not. So not most of the time. Most of the time, I find a gentle grade up means not You almost got the amount, right. And your Pre-Bolus deficit. Right, right. And your Pre-Bolus might have been not quite long enough, right? The sharp up is a complete. I just thought the curse but it's a complete cluster. Like you have not you didn't have nearly enough Pre-Bolus And you did not use nearly enough food. So there is nothing about your Bolus that even gave resistance to that carb impact at all. So you can even

more often with that arrow up more often it's a Pre-Bolus. Especially if you are using a ratio for your carbs and counting your carbs and whatnot. Most often, if you have a pretty significant quick, straight up or double up arrow, within 30 minutes, 45 minutes of a meal. There's a deficit there and or the deficit is more because you did not Pre-Bolus There wasn't time like that tug of war between the insulin that you said, you know, in a podcast before, there was not enough time to let insulin get the upper hand,

right. And I'll tell you that that exact situation, that scenario you're describing. That taught me how to over Bolus. So once the first time I put in insulin and her blood sugar started to shoot up, I just made the leap. I was like I missed big time. And I didn't just put in like another half unit. Like I crushed it, I was like I'm going to stop these errors. If I have to feed them later, I will but I'm not going to let this blood sugar go up like this. And so I realized a meal that I thought was going to take five units with no Pre-Bolus needed eight units. And so that taught me in the future when I don't have time to Pre-Bolus I'll just give eight units for the five unit meal because I can create that action of insulin and overpower this even without a Pre-Bolus if I use too much, it's a little more I call it like that's definitely more of a pro level tip kind of a situation I'm like you're you're more of a more of a diabetes ninja. Once you're doing stuff like that i i Hold that up with the same ideas after you've had a 30 too low and you start coming back up again and you Bolus like when you're 50 Diagonal up like you're a ninja at that point. You're just like, right

you're like yeah, I need a lot more because I know I ate 60 grams of carbon I really only needed like 50 and

start knowing how much insulin to Bolus to overcome not Pre-Bolus thing again, you've been at this a while but I learned that from the Dexcom like I never would have liked so you know when you see those arrows Flying up? Not it's not what was me time, right? It's what is happening. But what what could I do next time? Over bossing is an incredible tool. So an over

Bolus thing in the way that you're doing it is very I think we talked about this before probably is, it's actually what John Walsh from pumping insulin, he calls it a super Bolus, right, right. And he does it in a little bit more of a calculated way. He says, you know, you take the Bolus that suggested by your pump for the food that you're going to eat or the calculated, let's say, you said, Okay, she needs five units for this all the time. Well, today, there's no time to Pre-Bolus. And usually, you would have done a 20 minute Pre-Bolus For that five units. Okay, he says, You're then going to take the insulin and basal that's running behind that meal for two hours. And you're going to actually add it on to that five units, or whatever your pump is suggesting. So maybe if your basal is running at a unit an hour, that's two units of extra insulin, you're gonna pop that on top of the suggested Bolus. But then behind the scenes, and you probably do this a lot, too. With that heavier Bolus up front, you're like, I'm probably going to need to watch and do a Temp Basal decrease for a little bit after because I know that this is too much in the end result, right? We don't want to cause a low. He says to start by just taking the basal down to zero for about two hours. Yeah. And then evaluating I've got people use it and say, you know, I tried it. The Super Bowl is part of it works. But I don't need to turn my basal completely off. led to do a 50% basal instead of 100% off. Yes.

And that's where the Dexcom again comes in incredibly handy. You need it when you need it. You don't when you don't, right. And then I consider that idea trading Basal for Bolus, like there. There are times where I think, oh, Ardens you know, Basal rates. 1.4 an hour, I just Bolus a unit and a half. Listen, there's going to be a moment, right? There's a moment for everybody. And there's going to be a moment where you see the arrow up, put in the insulin, five seconds later, the arrow flattens out and you go, Oh, my God, I didn't need that insulin, right. That's when I'll trade the basal for the ball. So you

can always say cut it out the basal off. Do you know that? Do you know that if you don't have a CGM, you don't know don't know when that transition was happening. Right? If you had none, and you were very aggressive about just finger sticking, you're like, oh my gosh, you know, 20 minutes ago, it was here. And now it's like 50 points higher. I have to slam this with more insulin. Yep. Awesome. But if you're not willing to do finger sticks, then like every 20 minutes after that, to see where things are going. You never know when that horizontal is coming, or when a downtrend is coming, either.

Yep, I am right now texting Arden while you and I are talking. So what I say it has now been an hour and 12 minutes since she got her Bolus for her food. I got a little I didn't panic. But because you and I were talking and I could see what was happening. I shut off for the very tail end of her extended Bolus and her Temp Basal. Yep. And now she's 105 Diagonal up. I'm bolusing that, because I'm putting in the insulin that I bailed on from the extended Bolus and the Basal I should have trusted myself, right. And so instead, I'm putting it back again. And I will stop this diagonal up arrow around 115 120, she'll float there for a while, we'll come back down. I expect you to be at five by like an hour and 45 minutes from now.

And the interesting thing about that, too, is what you're saying in terms of her management. And I know her agency has been like in the 5% for a long keynote for a long time. But the bigger beyond that, and we had a whole we had a whole we did a whole long podcast about eumc. And kind of what that all means right? But I think bringing in to the fact here CGM translates into that CGM, because what we're really hoping for is more gentle rolling hills within our target, rather than these major rises and falls of a roller coaster. And if you start to analyze your data in CGM, you can actually start then to be able to say, Okay, I need to tighten things up here. I've got an awesome looking A1C, but I have a huge what's called standard deviation, which speaks to the variability between highs and lows, right. So you may have this awesome looking A1C. But if you're going up and down, and you look like a big jagged, you know, roller coaster or mountain range, that's not helpful. Your standard D deviation value should actually be low, which means the variance between the highs and lows are also more gentle, rolling,

rolling, rolling, right? And the way I found to say that to people is that if you were 350, and then 60, and then 350, and 60, all you're doing is tricking the A1C test if it comes back and tells you hey, you have an average A1C of seven, which you do when you average 60 and 350. Again, but you also have a you're also not living in a healthy way in any specific way. So don't let that number for you. And Jenny's right there is an episode called all about A1C that she and I did probably more than a year or so ago. Yeah. And I'll link it in the show notes, you can find it. But I have Arden's last five days. And her. Her let's see, her average blood sugar over the last five days has been 114. She has been in range 56% of the time, which probably seems low, except that her ranges from 70 to 120. That's another thing you need to be careful of when you look at these reports. If you have your high set at 300, and your low set at 60, and you tell me I'm in range 100% of the time Well, I'm sure sure you are. Yeah, I mean, good.

Standard deviation within that time and range,

right? What what is that and standard deviations? Just a simple mathematical idea that I didn't understand in school and still don't understand now. But it's a basic, right? It's it's an average, is it an average of maybe it's a mean, I don't know. See, I didn't pay attention to math. You know, it's funny, you were talking about Walsh earlier talking about like all these ideas about like, over bowl, his Super Bowl is, and I call it over bolusing. And when I think about all I think about is more like the word more just pops into my head more insulin and a half. He's over there, like with his college degree being like, what you want to do is for two hours, and this is I'm like more?

Right? But you've also figured it out. I mean, you're more is not a dangerous more. It's not a random more No, it's not a random you've figured it out in your you know, this is your diabetes may vary. You've figured it out in in Ardens diabetes, you know how much more to give, it's not like you're slamming in five more units you're like, she needs based on experience about a unit more, or she needs based on experience two units more based on what went in what has transpired up to this point.

So people who listen to the podcast know that if this wasn't a special episode called diabetes, pro tip, continuous glucose monitor, I would just call it Roger Moore. Because you have no idea how many times I hear from people they're like, could you just make the title something about what's in and I'm like, No, I can't that's not fun at all. I want to talk for a second about what happens when you get your brand new, shiny Dexcom on and it tells you your blood sugar's 90, but then you test with your meter and your meter says your blood sugar's 140. niggle I don't know which one of these things to believe. So I think it's important to note that a CGM is measuring interstitial fluid around your meter is measuring your blood.

Thank you for bringing that up. Yeah, both of them

have an FDA requirement of only being within 20% of range. So if if a meter says your blood sugar is 100, it could very easily be 80, or 120, or somewhere between 80 and 120. As people living with type one diabetes, and the 2000 z's, you're gonna have to accept this is pretty much the best we have right now. And not to make yourself mental. So imagine that your CGM tells you you're 100. But it's off by 20%. High. So you're really 120. And your meter says you're 140. But it's really off by 20%. Low. So you're really 120. They both agree the numbers you're seeing don't agree. You can not spend a ton of time being upset about that. No, you have to pick something and believe in it. And I know that's crazy. But I tell people all the time, there's somebody online, it's like look at my meter says this and my Dexcom says this, and I'm like you're holding a brand new Dexcom G six in your hand. And a meter that was made 12 years ago. And you're telling me I believe the meter and I always asked him the same thing. Why did you decide to believe the meter over the CGM? Is it because you had it longer? Because it's testing blood? And that seems like something that's more accurate to you like what is the random thought your brain has had that's made you decide that one of these is more accurate than the other one? Which do you I test sometimes when I don't when I'm

so really I mean blood glucose is the first line of glucose change it is first interstitial glucose follows blood glucose. And so with those random, you know, differences, most often I would say people on G five and G six, for the most part have pretty good accuracy finger stick to actual CGM, where I think a lot of discrepancy can honestly come in is from a finger stick value of let's say it's telling you 140. Right, and you're looking at your CGM, and it's 100. Well, as we kind of started out saying, it's not about the number on the CGM. It's about the trend. And like you do very often you're saying okay, now there's a trend going up, you know, you just bolused what you missed giving before because you started to see a trend up. Well, her fingerstick might actually be reflecting a higher glucose than what the CGM is showing right now because again, glucose changes first in your bloodstream screen. And so CGM is going to leg especially in those time periods of more significant glucose change such as after food or after or during exercise, that that can be a varying time. So finger stick 140, your CGM is trending up, or you've got an angled arrow heading up and it's telling you you're 102. And you're like, Huh, what do I do about this? The CGM just hasn't met yet the glucose value in the bloodstream, it will catch up, right? It will, it's just that it hasn't gotten there yet. Because really, if you think about the way that glucose sort of moves in a simplified form, it moves out of the bloodstream sort of has to move through insert interstitial fluid before it gets to the cells to get absorbed, essentially, I mean, that's simplified, but so your, your, your interstitial fluid is also always for the most part gonna leg, especially in special times, like food and movement.

And I'll tell you to and to circle back around to the idea of the quality of your meter. Arden's had an Omnipod forever, like since she was four, so she's going to be 15 Soon. Point is, that thing's been around a long time. It's got an old freestyle meter in it. They've always been kind of wonky. And now we're using the Contour. Next One, it's the little tiny meter that's going to start calling accurate on the market. Yep. So when Omnipod decided to switch over to dash, which should, you know, you might be listening to this, and dash might be a thing already, but it's about to happen. They're gonna offer you a free Contour Next One meter to come with it. So I've been using it for a few months to get my head around it. It's spectacular. Like what a great accurate meter. It's absolutely insane. Like I just compared to what was in that PDM. It was nuts. how much better it was? Well, and this brings

up for the people to who might still be using a G five, or a CGM. That requires calibration. What you calibrate with. Yeah, that really makes accuracy on the CGM hold better,

right? Right. And if you're calibrating with a Band Meter, say you have a G five, it still asks for calibration. And the G five says it's 90, but you've tested with a 10 year old meter, it's like it's not it's 150. What if you really are 90 and now you're telling the G five everything you think is wrong? You're 150. But the algorithms like that's not right, we're nine. And did you confuse it? And then it blows up?

Three, three, question marks for three hours. You're like, calm down,

and then you go this something wrong with a CGM? Actually, no, it was you, you put the wrong information. And so none of this technology is obviously Perfect, perfect. But again, I always like to say you're not boiling your urine to find out what your blood sugar is. So you're doing right, yeah, right. You're doing greatly. i All I can say for sure, as we as we kind of come up on the end here. And I'm gonna ask you to kind of sum up in a second. But what I can tell you is that, as I've said, before Arden's a once he has been between five, two and six, two for five solid years. And it's going to be a lot to do with the tools that you hear is talking about here on the podcast and how I've learned to implement them. But how I learned to implement them was the information coming back to me from ordinance glucose monitor. So if you have an opportunity to get one, and I know they're not covered by everybody's insurance, and they can be expensive, but if you can get one you absolutely in my opinion should do absolutely will just change your life. So Correct. Yeah.

I 100% agree. Yes.

Did we forget anything? Because at this point, people who listen, probably aren't surprised. But I don't pretty play on these with Jenny. She put on her headphones. She goes, what are we talking about? I'm like CGM. And she goes great. And then we just started talking. But But again, I like the way these conversations flow. So Did I forget anything? That is like wildly wrong?

I don't think so. I, I do think that if, I mean, this is just from an education standpoint, your own education with your CGM. If you really need some pointers, I mean, it's helpful to look or ask more of your care team. You know, if you do need some pointers, some some endos. And CDs are really awesome. Some don't know much more than just telling you how to slap it on. But look beyond I mean, because there is there's a wealth of of benefit to knowing. And some of it is self experiment, experimentation. In fact, I think a lot of it's self experimentation. But if you need some help with looking at things, I think searching out somebody can be helpful.

Yeah, yeah, somebody who can look at the graph and just make sense of it in a second. We've talked about before I can at this point, I can look at someone's three hour graph and go, is this where you're putting the insulin and they're like, how did you know I'm like, Yeah, because it should have been here. And it wasn't enough and this would have stopped that and like, it's pretty easy to see after you can see it right. It's like those, you know what it's like, it's like those posters that you look at it. You're like there's somebody tells you it's a tree and it's a sailboat and you stare at it long enough, it turns into a tree. I think that's what happens like after you look at it long enough. I don't People can get scared of the idea of data. I don't like the word because I think it I think it scares people off. Like, you need to understand the data. Well, that sounds scary to me. It does, right? Right, there's a little line on your thing. Okay, that line tries to go in a direction, you look and see where you put the hands on. And you see how harshly the line tried to go in that direction, you make a better decision next time.

You know, I think that actually brings in one point that we may have missed is that, especially Dexcom does allow you to use event markers. So if you are really wanting more, you know optimization, and you're the only one who can really look at your your lines and your info. Using the event markers. I know in G six at the at the bottom of your at least your screen on your on your phone app, you can just choose events, you can log things like food, or exercise or illness or even alcohol and like your your cycle or monthly and all that kind of stuff. It'll put little marks on your actual trend graph. And that way you can make more sense of the if you're again, the one that's really trying to look back for what what happened, why did it happen, you

don't have to remember that I ate lunch at 1130 You can just say food and maybe the amount of carbs and make a note about what the food was. Right? And that helps you when you look back. See again, that's well more way better thought out than I can ever be. But that makes a lot of sense. And that's why you're here. You're the you're the smart part of this conversation. I'm the chit chatty part of the conversation.

We're both important for reasons. Yeah,

I'm pretty sure that's true. Okay, I think you'd have to go in a couple of minutes, right? So I'm gonna let you go now and say goodbye. I want to thank smz 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 Gvoke glucagon find out more about Gvoke HypoPen at G Vogue glucagon.com forward slash juicebox you spell that Gvoke glucagon.com Ford slash Juicebox. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed 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 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two in Episode 1018 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025, we talked about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics. Scott brings useful information and presents indigestible weighs, 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 A1C down to a 5.6. In the past eight months, I've never met Scott. But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years, and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link. 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

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 CDE 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 revisitable. 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 Ascensia 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 Juicebox free meter while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke hypo pen. Find out more at Gvoke glucagon.com. Forward slash juicebox. Jenny Hello how are you? I'm good. How are you? Scott so good. Yeah. short episode going over the idea of bumping and nudging blood sugars, which is something we talk about on the podcast all the time. I'm a huge believer in the in the infuriating statement that you won't get high if you never get high. Sure, that's not as easy as it sounds. But that's how I think about it in my head. Right? So I want you to fight with a high blood sugar if I don't experience a high ledger. Of course, that's not always going to work. I'm not saying that. But I am saying that it's avoidable a lot of the time.

I think of it as bumping and nudging just bumping and nudging it could be bumping that term. I love that. But I love it right? Yeah, you can do it with insulin can also do it with food. You can also do it with a deficit of insulin, which you can create with a Temp Basal. We're going to talk about it all right now.

You can also do it with exercise.

Do you know I just I just interviewed somebody who you won't hear for six months. But a girl who has had type one diabetes since she was a little kid and she's like she was so compliant, like with whatever her mom asked. So she needed like celery all there for blood sugar was high. But if she wanted, but if she wanted a cookie, she would go exercise and then come back and say to her mother, I just ran around the house this many times. So went up and down the steps this many times I would like my cookie now. And this is back. This was back when she was doing oh gosh, the words just slipped out of my head. What was the old timey insulin, regular insulin regular and mph? That's what she was talking pH. So back then she would do a little exercise to get her cookie. But you know this by the way, this girl is delightful. You have to find the episode with her.

My, my mom would do the same thing with me. We're at my grandparents house, usually in the summertime for a couple of weeks. Usually at that time of the year. It was rainy, at least several days out of that time and I couldn't do anything outside. She would have me run around my grandmother's kitchen table and they had a pretty big dining room because it was a farmhouse. And I would literally my mom would be you need to run around. You need to move you need to move and I was like, okay, at that point. That's all move. You know, there'll

be a snack after this. I guess it's all right. So yeah, yes. Okay, so, so basically, we'll start with this if you have a glucose monitor. You can't think about the alarms. The way you're thinking about them right now you have to your low alarm, you should put wherever you think you need to know like, whatever it gives you enough time to react, I don't care what that is, that's up to you completely ours is at 70. Some people put theirs at 60. You know, at whatever, I don't care, it's the high alarm that I care about. Because you need to be able to react to a rising blood sugar quickly, you react to it quickly, you're able often to react to it with less insulin, under percent, right, it takes less insulin to stop a 120 Diagonal up than it does to stop a 150 or a 180, straight up or 202 hours out. You could have avoided the problem that you're having now 45 minutes ago, if you knew it was coming, right, right, right now people will say, but Scott, I don't want this thing to alarm all the time. And it's gonna bother me and my kids at school, and I hear all your complaints, put them away. And here's why. Eventually, if you listen to these podcasts long enough, these concepts will lead to a world where you don't really ever leave your 120 blood sugar. So you won't get a ton of alarms. And on the days when that happens, I don't know mute your phone, but don't make a bad decision to avoid a problem that I think is avoidable. And so I know I've said this a million times, but it belongs in this episode. And I know I talked about driving a lot. But when you're driving, and you find yourself just kind of drifting off of the road, you don't turn the wheel 90 degrees to the left to avoid the curb. It's this almost imperceivable turn of the wheel, you're just nudging it back the tiniest bit. Yeah, that's how you avoid swerving into the oncoming traffic, because you've only turned it a little bit. This is how you stay off the diabetes rollercoaster. It is that simple, right? So you stop a rise before it can happen. And you use such a small amount of insulin that the likelihood of being low after you've done that is mostly imperceivable. Right? How much? Does that make sense to me? Where should this be on the Mount Rushmore of diabetes thoughts?

I think it should be right there taught along with the early the early information of insulin use, it really should be, it should be it should be right there with when you're prescribed insulin. This is our target for high blood sugar should really in my professional opinion, it should be ratcheted down, we should not be being told that post meal blood sugars of 200 or 220 for kids is appropriate only because it's safe.

Right and safe. And as much as you're not going to have a seizure.

Correct? Correct. I mean, am I saying that you're aiming for you know, no rise at all? No, am I saying that you're aiming to to stay, you know, if you've been consistently rising to 250, and your alarm isn't set to 250, or 300, maybe you bring it down to 200 for a little bit, and then maybe you bring your high alarm down to 180, or you bring it down to 160. But as you do that, like you said, you're gonna see, it takes a lot less to address arise, then it does to correct a blood sugar that's already too high.

And in the beginning, this will take more of your effort. But as time goes on, it takes nothing. It really does. I know sometimes I'll explode a Bolus out on screen when I'm doing a talk, right? And when you blow it up like that, and show all the decisions that were made you think, Wow, this does look like a ton of effort, right? So I always have to start by telling people what you're viewing up here encompassed about three seconds of my thoughts spread out over five minutes. Right, right. You'll spend more time in initially then, then you will one day. And so it's the same with this idea. I know it feels like if you set it at 120 it's always going to be beeping, but one day it won't be and And wouldn't you rather be bothered even on a on a bad day on a quote unquote bad day wouldn't shouldn't be bothered? Wouldn't you like to be bothered five times to bump a 120 back down? That might take up 20 minutes of your overall day than to be stuck in a 300 blood sugar and everything that comes with it all day long, right? All right, little bits of effort. Little bits of insulin, way better way, way, way, way better to avoid the highs because you can't get high if you never get high. You can stop it from happening. Does it always work? It doesn't always work. But mainly, I will say this, Arden spikes about twice a day. And it's timing stuff where we don't have the ability to do what we're doing. But when I tell you aren't in spikes, I'm talking about 150 170 You know, and we get it right back again. So imagine if you had to 180s or to 160s in a day and the rest was between 120 and 70. That's where you get an A one. See it's in the fives, right?

Well for clarification to even about art and spikes, if not that you've waited until she's 170, to address it, but you've gotten the alert, the rise is happening, you've addressed it, you've probably taken a correction at like 120 or 130. Because you see the trend happening, she may still get to 151 70 before that insulin starts to working. But the curve down is probably more like an up down almost like a roller coaster. Right? But you're addressing it so that that ride down then is nice and smooth into the end versus staying way too high. And crashing from Bolus, Bolus, Bolus, Bolus, oh, no, I'm like 50.

And because I reacted sooner, I still am keeping mainly the balance of the insulin action, carb impact. I'm still keeping them pretty well balanced. I obviously missed a little bit in the carbs. Got ahead. But I got back in the game soon enough that I'm not going to create a crazy low later. And then you come in for like a nice landing afterwards, which I somebody just texted me the other day and says, Can you please like, tell me what that means. And I always like I think, just put your hand up high, and then dip it down and then bring it flat again. And like that's sort of like this. That's what you're trying to make happen. Right? You're trying to come in the end

of a roller coaster is what I explained. Yeah, kind of where you're the rush of that ride down and then you like roll into the station. Yeah, that's it exists nice and flat and smooth and perfectly

bringing in for a nice landing. Right? So okay, so, so sure you can bump in nudge that way, right. But what if I'm at the tail end, for example of meal Bolus, and I'm noticing I'm 110 151 100, I'm starting to drift down. But I'm so far past this Bolus that I'm now in that space where people do the thing, they can just go, I hope this stops. Right, right? Wouldn't that be nice of this that what I like in that situation is a Temp Basal decrease, decrease, right, take away some of the Basal rates. So now Jenny can see me which is a little unfair, but I'm holding both of my hands together palm the palm, and I'm pushing it them. basal is so important to think about like this on one side is the impact of your body and carbs. And on the other side is the impact of the insulin. And when you push at the same rate, no side wins, like I'm not going wildly one way or the other. Right. But all of a sudden, we get to a situation like I just described where, okay, the insulin is winning a little bit, right, the carbs that were there can't hold up the insulin that's left behind. So we start drifting towards a lower blood sugar, we'll just use your pump to tell it to use less insulin, take away a little bit of the force of that insulin has now maybe you'll catch it with a Temp Basal, and maybe you won't. But in certain situations, it's the best way to start. You know, I forever see people who are like, Oh, I'm heartbroken. I had to give my kid juice overnight. And you look and you see this 90 blood sugar that was just drifting down, that later, by the way, turned into a 180 because they put all this juice in. So you could have in that situation, if you really felt like you needed the juice bump with the juice, you don't have to drink the whole thing, drink enough to bring it back in for a nice landing. Or if you're far enough ahead of insulin impact. Try dialing back your your Basal and see if that doesn't catch it in your natural body functions don't kind of pull you back up again.

And if you're in evaluation time period as just a kind of an aside in the overnight, if you give that little nudge with juice comes up a little bit and it drifts down and you give a nudge again and it comes up and it drifts back down. That's basal, you're in basal only unless you have a correction from earlier that brought you down so much. That's still working. Basal only that's a good you've got too much Basal. There's too much there, up, down, up, down, up down and it never stays stable. You got too much.

The remastered diabetes Pro Tip series is sponsored by Ascensia 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 Juicebox free meter. When you use my link you're going to get the same accurate meter that my daughter carries contour next one.com forward slash Juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips 10 lancets, a lancing device control solution. And to carry case but most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen it fits well in your hand and features Second Chance sampling which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash Juicebox free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips you can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips 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 the back of people living with type one diabetes. Take for instance, their D box program touched by type one knows firsthand the intricacies of living with type one diabetes, and so their team has created a D box which is a starter kit that provides important resources and supportive materials to individuals with diabetes. They want you to thrive. The D box is completely free and available to newly diagnosed people. All you have to do is go to touched by type one.org. Go to the Programs tab and click on the box. While you're there. Check out all the other resources and programs available at touched by type one.org. Speaking of support, touched by type one.org is available in English and Spanish. Don't forget to find them on Facebook and Instagram too. You do not want to miss what touched by type one is doing. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. Gvoke hypo pan 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 Gvoke glucagon.com forward slash juicebox Gvoke shouldn't be used in patients with pheochromocytoma or insulinoma. Visit Gvoke glucagon.com/risk. I say a lot that if you find yourself when you find yourself boasting too often, your Basal is probably too low. If you find yourself out and doing to address in that situation too often with food, your Basal is likely too high. Right?

Right. And you want to stop nudging as much as you can.

We all want to go to sleep and nobody wants to drink juice in the middle of the night. And we're trying that's all the things we're trying to avoid right here. And I know a lot of it still sounds like oh, yeah, buddy, that. That sounds nice. But how do I accomplish this? I think that by now you're getting towards the end of this series. I think Jenny and I have laid it out pretty well, a couple of different ways here. So an important to remember. Because if you've ever spoken to me privately, if you've listened long enough, I will beat into your head over and over again. It's about timing and amount. It's about timing about even with basal. Even though you don't think of it the same way. Because basal doesn't all go in at the same time. If your Basal rate is too high, you have too much insulin and at the wrong time. So we've I've simplified diabetes down to like a handful of ideas that are sometimes so distilled, that even when I say them out loud, I go, does it just sound ridiculous to people when they hear it. But please trust me. At the end of this series, I'm going to go over all these ideas in simple sentences. It'll be a very short episode, you remember those sentences, apply what you've heard here. You're going to be on your way I you know, I can't promise but I swear I've seen it happen enough that I believe

a little print off sheets got,

oh, I don't want to give it away. Come back. I know.

Well, the full full ideas are really behind all of those little simple statements. So if you had just a little simple statement, you're like, I don't even know what that means.

And those reminders, I actually I use them too. So I've had times where I'm like what is happening? Because it's life, right? Like stuffs going on. You don't know like, why am I bolusing all the time. And I actually stopped myself one time and I remember standing in my kitchen thinking what would I tell someone if they asked me this? And I know that's ridiculous, but I was like, oh my god are basal needs to be increased. Boom. And there I was. I was like, Oh, that was so I should have listened to me. But like for days, I was like what's the problem here? So you're gonna you'll get those like simple ideas broken down into sentences that you can kind of repeat and keep in your head, you know that that'll should reignite the ideas that you heard in the podcast. Okay. So, to go over this again because in a different episode Do you need to think about how food affects your blood sugar? Sure, you need to think about how in some affects your blood sugar. Sure. But always to remember that you need to understand how the food affects the insulin so you can reverse engineer ideas. You're so used to thinking, I have this high blood sugar and I'm trying to force it down with insulin. Well, what if you have a low blood sugar and you're trying to force it up with food? I don't want to use too much. That starts us off on that roller coaster right we forget to believe that what we know is going to happen is going to happen we put in this food for low blood sugar, we shoot up now our insolence miss time, we eventually put in enough insulin it gets miss time with the food, the food now digest to your system. All the insolence left, you fly back down again, oh, my God, what do I do, I throw in more food than I wait and I get high. And then and then you start looking at the garage and thinking I just gonna pull the door down, start the car, put on my favorite album and go to sleep. But we don't need to do that. What we need to do is to bump and nudge with the food as well. And so this is crashing and nudging

with the food might actually be a little different. If you know and pay attention to in those, let's say the drops where you're going to nudge with some food. Why is it declining? Is it truly basal, like we talked about overnight, right? Where you meet need a lot less nudge, little incremental nudge versus you've got three units of iob. And you're dropping? Yeah. And the drop is actually happening a lot more precipitously, right? You're really like coming down? Well, that little nudge of three sips of juice. If that's not the time to like nudge, you need a little bit more aggressive nudge than that.

Yeah, I tell people all the time, if you see a 65 and it's really stable, and you want to try to check your basal law for half an hour to see if it comes back up right on. But if it's a 65 and dropping like a stone for the love of God drink a juice, eat a banana, shut your basal off, like like, you know, like you've really messed up somewhere so, but it's just not quite right. But the opposite idea that is not I'm gonna quote a mom that I spoke to. She said, Why did I always give the whole package of gummy bears? Why did I just automatically think because I opened the package. He had to eat all of the gummy bears. Why not two bears or three? Because 15 carbs? 15 minutes?

15 carbs? 15 minutes. Right?

Right. Bad advice you got from a doctor one time.

And it was again, it comes to the safety. Right? It comes to the safety piece of this is an easy rip off. Non in the moment. This is just please do this because it will at least alleviate the law. Right? You'll be safe.

It's jamming on the brakes 100 yards before you have to stop because you can't be 100% Certain you're gonna be able to stop but before you get 100 yards away because the doctor is not with you because they don't know the situation. Because they don't want you calling them on the phone every five minutes. Now I Bolus because I'm going to tell you when some people start explaining to me their bosses. I'm like, Look, I'm good at this. But that is hard to get straight in your head when someone's and you know, they're keeping something they're forgetting something. And so you're like, I can't make sense of this. Like show me a graph. Like when did you eat and sometimes they don't even know.

Right? I like that's the reason I like little tiny like the Jelly Belly jelly beans, they're a gram of carb a piece. Skittles are a gram of carb apiece, they're an easy way to nudge with food in a accounted way. Rather than like sips of juice where you're like, I don't know, I might have had a bigger SIP or a little or SIP or a whatever my SIP might be the whole container. I don't know.

I'm telling you again, Ninja like level of understanding, I can sometimes stick a straw on Arden's mouth from a Juicebox as she's drinking it. I just go and that's enough. And that's just something that comes with time, right? Like you're not going to figure that on day one. But the idea that it might not be all of it. And this and I alluded to earlier, it's gonna sound a little crass, but there are times when you just have to have the balls to wait. Like you can't just, you can't just over treat an 85 You know, what do you mean? Like I said it before, I've saw a woman online who told who once said that. That's a mom, and I'm sure she was scared out of her mind. I don't mean to make light of her. But she's like, I saved my kid's life last night with a Juicebox. And a kid was like 110 Diagonal down. I was like, wait a minute, you may very well have been on your way to the greatest night's sleep ever. You're never going to know right? And because this wasn't like what you were talking about. It wasn't like a big Bolus that was gone wrong. This was just like a drifting blood sugar. And I was like, Oh, you gotta wait the you know, you have to. And so let's talk about here like because we're gonna try to bump an agent in and out of an area. What is that area? And so, I mean, I'm sure to define your target. Yes. What is it you're going for? Right, like, I don't need Arden's blood sugar to be 85 constantly. I don't feel that way. But I don't like her blood sugar to be under 70. But I gotta tell you that if she drifts under 70 for a couple of minutes, I'm not running around looking for the glucagon, you don't even I'm like, let me see how I can just get this to kind of gradually come back up again. Same thing if she gets the 114. It said, Senegal, I really missed this. But you know what, now I'm only an hour and a half past this Bolus, I really do have to wait a second to see what's going on her or I have to decide I'm not going to look at this 140. And I may need to redress with food later. Right.

Right. Right. So absolutely. And you know, that also speaks then to the benefit of now we've got the CGM, right, because with a CGM, you can see more often what's happening that 140 hour and a half after eating, it might be a stable 140 You don't know whether the next three blips are going to start a downtrend or they're going to start an uptrend or they're just going to kind of stay stable. So you have to really have that same thing with your 70 before if she's laying on the couch watching a TV program at 70. Okay, yes, she's not out running a marathon. She's not gonna go to the amusement park and walk around for four hours. She's sitting on the couch. Yeah.

Even even when Arden is like incredibly active on a hot day playing softball, I still like a blood sugar right around 90. And so if I see 90 trying to get away from me, it's it could be just you know, you have a Gatorade with you take two splashes of Gatorade, then go back to the water, or, you know, have half of this Juicebox or are you hungry? You know, sometimes people are hungry. You don't think about it like that. Because you have diabetes, you always think about food as being this like surgical strike. But if you're playing you know, a sport, maybe it would be nice to take a bite of a banana every time you sat on the bench or something like that, right? Performance

energy is different than blood sugar, strategy energy. For athletes,

there's about 1000 different ways to think about bumping and nudging your blood sugar around so I want you to open your mind to it think differently. Try to really make sense of it. Jenny's got to go she's got a life. Okay, she's got she's got to work. And so I'm gonna let her go and say thank you. Absolutely. Always, always nice to me. I'll talk to you soon. I want to thank Ascensia 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 Gvoke glucagon find out more about Gvoke HypoPen at Gvoke glucagon.com. Forward slash juicebox. you spell that Gvoke glucagon.com. Forward slash juicebox. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com If you're interested in hiring Jenny, you can learn more about her at that link. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bumping naj 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 BGs in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two in Episode 1018 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 Weight Loss one 1023 Honeymoon 1024 female hormones and in Episode 1025, we talked about transitioning from MDI, to pumping. Before I go, I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult, and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning 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 A1C 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. 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

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 CDE 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 revisitable. 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 Ascensia 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 Juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke hypo pen. Find out more at Gvoke glucagon.com. Forward slash juicebox Hey everyone, Jennifer's back and we're here today to talk about the perfect Bolus. So that already sounds like a topic that everyone's gonna get upset about when they hear but I think but there's a lot of different ideas here. So Jennifer, what I was thinking was Bolus is differ depending on situation right? You might have a high blood sugar a low you might be falling, you might be rising, you might have a new site. There's a lot of exercise do you might Yes, keep going right? You may have just exercised, you might have your right

be ill you might have your period, you may be coming in to having your period that you know your dog might have eaten the other dog next door and like you're dealing

a little bit of anxiety going and there's different things your dog may have eaten your next door neighbor's dog Jennifer, Has that ever happened in your life? No, thankfully. Psychologists say that if you make up something like that, it comes from something I don't believe that because my view. My humor is so bizarre that I look back sometimes. And I think, but it was something really strange. I just said Does that have any real connection to my thoughts? And I've really looked closely because I've been worried in the past. But I don't think that's true for everybody.

Now I've got a chocolate lab and I don't think that that's even in there. Totally not in their nature. So anyway, no, it's never happened, thankfully.

So you people have already learned that chocolate labs are not carnivorous. At least towards other dogs.

What dogs know.

Oh my gosh, okay, yeah. So anyway, so I want to start with I mean, we're just gonna pick one right let's say your blood sugar's were you mean for debate, your basal are in check. They work? Well, you haven't eaten in a while. It's the perfect scenario, the one that they described you in the doctor's office, the first time you're diagnosed, right? Is your blood sugar's 95. And you're hungry. And you're thinking, what am I going to do? So ideally, we know at this point now from listening to the episodes, we have to figure out what our length of time for our Pre-Bolus is. Right? But how do we know how much to Pre-Bolus? And I think the answer always has to be, I can't tell you Jennifer can't tell you it's situational, but that you'll learn through trial and error. So but let's make this one general. Right. It's, it's a nice balanced meal. You've got some vegetables, some carbs. There's protein. It looks like it looks like a plate from a Superfriends episode that the government told you how to eat in the 70s. The food triangle let's call it a triangle. So So if you're a nice steady blood sugar if if my daughter was at 95, and I thought this was a pretty, you know, average meal, as far as what I expect, as far as impact back from it, I might put in all of the insulin, you know, in the beginning, but I also might look and say, Hey, there's bread in there a potato that might stretch out the action of the impact of the carbs over more time. So maybe I'll put in, I don't know, 50% or 60%, and stretch out over half hour an hour just to create, like we've talked about in the past that kind of blanket of insulin to cover the entire impact timeline of the carbs, I think that the thing to remember is, is that there can't be really a set idea for what that means, like maybe you'll figure out a meal eventually, and say it's 70% and 30%. Over an hour, you might get to that point at some point. And many people do

many people who have pretty consistent intake, or like the same things over and over. But the variables could be around that will sometimes change even near more standard figured out meal.

Yeah. And so I think so my first my first step, I'm telling you, any good Bolus, that one that has any chance of working, I think it's a nice simple way of saying it has to have a Pre-Bolus. Like you have to start Yes, you have to start getting the momentum of your blood sugar moving down, so that when the carbs start acting, they move up. So So that's to me, that's step one. Now, do you talk about or do you in your own life use combination of Bolus and basal in situations like this?

In some situations like this, perhaps more often, more often what I do and more often, what I teach is Pre-Bolus, based on some of the meal content, because some of that does, it does work together things like glycemic index. And also, as you brought in to begin with the where the blood sugar is starting, is it coming in standard at your target? Are you coming in, but it's already dipping down? Are you coming in and target but it's already drifting high. All of that is where you can also look at Bolus timing, and how much Pre-Bolus you may need. So you know, coming in at a blood sugar of 95 with a straight horizontal line the past hour, awesome, that looks great. But the minute you put food in that, that blood sugar line is going to start to change pretty quick after that, if there's not time for that insulin to talk first

to begin with, right, and I hear what you're saying too, about like understanding the glycemic load of different like foods, if you have something like you know, using Chinese foods, such a great example because it normally incorporates rice, which stays for a long time and hits you hard and usually some sugar that'll hit you fast. So if there's something sugary in there, you may need a real, you know, push of insulin in the beginning to combat that initial rise. But that initial rise could get beat up by that insulin very quickly. And now what's left over is the, you know, the rice that continues to work right. And so

good. So yeah, yeah, I was just gonna follow with yes, you could in that instance, then have the potential for meeting both Bolus and a basal. potential change. And that's also where we talk about basal. Most actors are like, whoa, basal shouldn't ever be used for food or covering anything. Well, we've learned very differently, especially with fat. Fat requires a huge amount of, of Basal change in the aftermath of eating your typical pizza or, you know, burger and french fries, or mac and cheese that's homemade, or whatever it might be. Oftentimes, you need 4050 60% of an increase in Basal for many hours after that meal, or you're gonna stay stuck high,

right? Or you could end up hitting it with so much insulin up front that you think you've avoided that and then three or four hours later, you start rising, and you think it's for no reason. Right? And it's still that fat is. So I like a in what I call car B situations, which is not a word, but in higher cars in

our, in our world, car B is absolutely a word.

So with the car be foods, there's a couple different ways I use a Temp Basal and we talked about it before, but in this situation, if I thought a meal was 10 units for sure, but I wanted it to be spread out more Arden's basal rate being 1.4 I might double Arden's basal for an hour and a half and catch two and a quarter units that way and then take some of that out of the of the Bolus. All right,

absolutely. Because you get a lingering effect from the basal and you get less upfront but you're still getting the whole Bolus you determined you need it.

Okay, same meal. Jenny, you rapidfire same meal, but I walk in the door from work, and my spouse says dinner's ready and it hits the table. I can't Pre-Bolus I didn't know this was going to happen, what do you do, and that's where I'd like you to lay out the idea of over bolusing for people here.

Yeah, and that's over bolusing. Essentially, that's a good super Bolus, as kind of we talked a little bit about before, that's a situation where 100% Unless that meal is like a plate of broccoli, right, in which you would never need a Super Bowl Pre-Bolus Maybe Pre-Bolus right, in your typical meal that we're saying we're having 100% of super Bolus would be beneficial, where you actually do take a load of insulin, that would be your Basal behind you added on to the suggested Bolus for what you're going to eat. And then you may actually knock off the Basal behind, so you don't go low later. But you've gotten the load of insulin, the push up front, right. The other option that many people do in that situation, too is they take the Bolus, and they may actually turn their basal up 100% for an hour.

Okay to also try to

spike, right, exactly, so that they're getting a Bolus there maybe not quite sure if the food in the Bolus, even though it happening at the same time is going to cause as much of a rise. But they're definitely saying I know I need a lot more because I wasn't able to give that 2030 minutes before this. Yeah.

And I think of over bolusing in two situations. So the one I don't have time to Pre-Bolus. So in my mind, the way it strikes me is I now need the insulin for the food for the high number I know is going to come because I didn't Pre-Bolus and some to stop the momentum or stop the arrow right? And so if I thought the meal was definitely six units, but I thought wow, there's no way this doesn't go to 250. I Bolus the six units. And I Bolus like I'm trying to bring down a 250 at the same time, right? That's like again, listen, we're calling these you know, we're calling these this series diabetes protests. So this is like ninja level stuff. Like don't don't try this on day one. But at some point, right. On day one, don't go I didn't Pre-Bolus I'm gonna double my bolt, please. Right. Yeah, right. Yeah, please don't. But as you're figuring things out, that's a great place to do, as you've heard in past episodes, is a very famous book called is it pumping insulin.

Pumping insulin is John Walsh. And he's the one who talks about sugar

Bolus and

Bolus. Yeah. Yeah, the other good you got you know, you call it something else. Yeah, right.

Call it. I call it over bolusing. But I don't know why.

No, I was gonna say the other. You know, the other concept that kind of comes in here that you'd sort of just alluded to is, where is the blood sugar going to likely be and that trajectory, you know, assuming that okay, I might be 95 right now, but if I haven't Pre-Bolus, I could easily be 250 In the next 30 to 60 minutes. Okay, you're taking that value. It's looking at the trajectory of where it will probably be and using that glucose value to add on to the current Bolus. So you're avoiding that really high blood sugar.

And what I say on the podcast, which people might remember is I just say you have to trust that what you know is going to happen is going to happen. That remastered diabetes Pro Tip series is sponsored by Ascensia 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 Juicebox free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash Juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen. It fits well in your hand and features Second Chance sampling which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one. Contour next one.com forward slash Juicebox free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips. You can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now through your insurance. Con toradex.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 just click on that to check that out ball for a cause their awareness campaigns and the annual conference that I've spoken at a number of years in a row. It's just amazing, just like 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. Gvoke 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 Gvoke glucagon.com forward slash juicebox Gvoke shouldn't be used in patients with pheochromocytoma or insulinoma. Visit Gvoke glucagon.com/risk. Right. So you can't just pretend this will be the time this doesn't happen. You know, oh, I'll get away with not Pre-Bolus thing today there's that doesn't make any sense. It might happen once in a while. But that's some random reason from something earlier. That's not you know, that's not

that's the I ran 10 miles and don't usually ever do that. And now look at that my blood sugar doesn't spike.

So now another place to use an over Bolus as a Pre-Bolus is a is a place where this the concept in my mind is the same the situation is different. What if I've been fighting with my blood sugar all day, and I just can't get it down. It's 200. But I know I'm going to eat an hour like it's dinnertime and an hour and I've been, you know pushing and pushing little Bolus as little Basal rates, I can't make this 200 move for whatever it may be. It's a sight not working well, whatever it is, in my mind, I Bolus the meal. I Bolus the number I over Bolus upfront and create a fall that I then catch with the food. So I reverse. We're going to talk about this in the next episode. But I reversed the way I think about I think most of the time we consider how does the food impact my blood sugar? How does the insulin impact my blood sugar? We don't often enough think about how does the food impact the insulin? Right. And that's, and we've talked, we talked about that in an earlier episode to where we put a little, you know, we put a little boy's blood sugar into a freefall and caught it by eating at the right time. So really, all we're talking about any of these situations is timing, right? It's the right amount. It's the right amount of insulin at the right time. And if your blood sugar's 300, and you have to eat an hour from now, well, the right amount of insulin is now and you know is now and you can't you can't just wait into your 15 Minute Pre-Bolus on the 300 blood sugar because you've lost already.

Right? Right. And you know something that that kind of goes along to with the concept that catching catching the potential drop while also sort of avoiding or taking care of a higher blood sugar. In pregnancy with the women that I work with. It's kind of similar, we actually at some point get to bolusing. That's like a split a split meal where you actually load the front of that meal time with the whole Bolus. Yeah, but you only actually eat about 70% of the food now. And you catch the drop about an hour later with the rest of the meal. Interesting. So what you get is not a spike, not going above those post meal ranges for pregnancy. But you also catch the drop on the back end and you never go low. Yeah,

that's very similar to how I handle days like Christmas or Thanksgiving, the idea that there's always going to be eating. So I Oh, I'm always Pre-Bolus in the next grazing opportunity, right like absolutely, boy that's interesting.

Do for holidays is I actually knowing and coming into a grazing time period, that's going to be a lot less than precise, a lot less. And a lot of little nibbles along the way behind any holiday where I know I'm going to be up the hours of nibbling and eating 25% increase in basal. And then again, I Bolus along the way. And depending on where glucose is. I might nudge that along the way too. Yep.

Okay, so now what happens if dinner is taking a little too long to make and my perfect 95 has turned into a 90 that turned into an ad that turned out 85 And now it's 75. And now, now someone's showing dinner's gonna be ready in five minutes. I know that for most people that makes them feel like well, I'm too low to Pre-Bolus. But no, you're not. And so you have to get some insulin moving. And you'll learn how much you can do over time. But in the in the interim, it's got to be some something right? You're just you're drifting low. I'm not even talking about for Dexcom years, I'm not even talking about diagnol down, I'm just this this blood sugar that just is kind of drifting down. Your Pre-Bolus still takes as long as it takes to eat to excuse me as long as it takes to work. So if you're 75 and drifting down, Pre-Bolus thing right now is not going to make you start crashing down. If that does happen, that was a coincidence. That's not you. Again, the insulin didn't just start magically working like that, right? science, the science didn't change. So you still need a Pre-Bolus. Now I get if it's a, it's a big meal, and you're like, Well, I can't put in eight units while I'm 75. diagonally down. You're right, you probably can't. But you could put in some 20 20% of it even. And we do this a lot while Arden's at school because we Pre-Bolus 20 minutes ahead of Arden's meal at school while she's still in a class. And I'm still Pre-Bolus If she's 85. So if I give an ardent gets a big Bolus at lunchtime, that while she's at school, much larger than most any other times in our life, 12 sometimes 13 units right for 145 pound kid. And so I might do a 0% upfront, and the balance over a half an hour. So it's all kind of getting squeezed in. But it's not all going to come on line and be active right away. It might be 20% up front, but you have to get some sort of that momentum happening again, on the on the action of your insulin, your insulin to be pulling down when the food goes in. Right. Okay.

And that's important. Even for kids, I think in what you're doing that is important, especially for little kids, where you're not quite sure. I know a lot of the people I parents I work with, but I don't know how much Billy is going to eat or Susie is a really slow eater or, you know, today, she might love spaghetti and she'll love it for the next three days. But then she hates it and I prepared it and I Bolus for it. And now what's going to happen, right? Yeah, for the most part, kids and teens will always eat as you said a percent. Let's say that you always know they're going to eat 10 grams of something, even if you have to change what it is they're going to eat something for you. Yes. So if you can Bolus for that little bit upfront, it's giving insulin again, more action before you put food

in. And one of the many, many reasons that Jenny is on the show is because if Jenny wasn't here, that would have been the next thing I would have said it's it's perfect. You, your parents have little kids, it's a perfect idea. Get something moving, even if it's a little bit, just get something moving, give yourself a fighting chance. And to Jenny's point, there is an amount of food if you look back at your kids meals, they always eat at least a little bit. And by the way, if they really flake out and don't or if, as in the case of the interview I did yesterday with a mother who said she was so excited. She put the insulin in, grab some like fast food and drove away and the kid fell asleep while they were driving away. Right? You know, okay, that might happen. It's happened to me, but still a little bit of juice, right? You only put a little bit in all you've done is Pre-Bolus a couple of sips of juice. You don't have to worry about the food. But the point is, is that the Pre-Bolus is always important. It's it's listen, if you're crashing down as the food's hitting the table and you're literally 50 and your blood sugar's falling. Okay? That's your Pre-Bolus. Right? Right. Okay, you're now pretty good.

Because there's already insulin that's causing the crash. Yes.

Something whether you meant for it or not, you have been Pre-Bolus by something, right? So good. So see that put the food in. And as soon as that stops, right, as soon as that down arrow goes away, it is time to get your insulin in. You absolutely cannot then say well, I don't know. I'm 60. And that seems dangerous. Now, what's dangerous is that you've put all that food in your body and it's going to start hitting you the other direction happened to us last night. And I had to Bolus I had to make a significant Bolus at a 75 Diagonal up blood sugar because I was like, Well, this is I know what's going to happen. Let me get let me stay ahead of it right.

And the hard thing about using CGM is now as wonderful 100% as they are the hard thing is that CGM do lag in times of quick change. Right, right. And so if you have been diagonally down you're waiting for you know, you want to Pre-Bolus But you're not quite sure, sure, go ahead and eat as, but as soon as you see that horizontal or a bit of a trend up. I guarantee your fingerstick is higher than the sij than the CGM is showing you you're already at a deficit of insulin. Yes,

yes, the deficits an important way to think of it and you end this says against something you'll learn over time. Like,

it says it like the first month of,

again, not on your first day, right? Yeah, I listened to all the episodes of the podcast really absorb everything, go through the pro tip stuff, and then say to yourself, I and then you have to see it right you have to recognize it. There is a way for CGM users, you have to be able to look, there's like a bend in the line. It's hard to put into words, right. But on the three hour graph on the Dexcom, the last three dots on the right side, tell a story about what's happening. And you will get to be able to glance at that at some point and say, Oh, this is heading down. This is heading up I can tell I know. And so it's not day one, and it might not be the first month. But if what most of you report back in your emails is anywhere close to true for most, somewhere in the three to six month range. This all just starts making sense in a way you put no imagine. Yeah. Early on in the podcast, I used to talk about it like in the matrix when Neo stopped the bullets. But that has become such an old reference at this point. I'm afraid right now there's like a 19 year old going the what what are we talking about? Now?

I'm old enough. I totally know at some point. At some

point, diabetes makes so much sense to you, the bullets aren't even moving, you can just walk in between them. And so you get there at some point, right? Okay. So I'm low, I'm high, I'm falling like in the end, I think you're hearing.

It's all about the right amount of insulin at the right time. Just like we've been saying over and over again, a new site is a good example of, I'm going to put this in here even though it doesn't sort of fit, but it does fit. And so if you put a new site on, and you find that your sites don't work as well, immediately, once you put them on, or you know, you just have a site that doesn't seem to be as reactive as you're accustomed to. You still have to do what you have to do. You might have to do it sooner, you might have to do it more aggressively. And I know you're gonna say but what happens when that site starts working suddenly? Well, then it does. But you can't not be aggressive when something like that is going on? Because then you that's how you end up at 300 all day long, staring at it wondering what to do next. Right. Right. Okay.

I think the biggest the biggest piece of that Pre-Bolus message is unfortunately, relearning. And it's a daily relearn in the beginning of starting to Pre-Bolus Wrap it in insulin is not rapid. Rapid is a bad word for it. It's a better word than our regular insulin used to be, which they called short acting. And I'd actually call that longer than short. I mean, rapid is not instantaneous rapid, as they tell you it is it takes a minimum of 15 to 20 minutes to really get moving.

Yes. If you don't leave this episode, and in general, this series, believing that understanding how insulin works in your body is the core of this entire thing. You were not paying attention. So go back and start again.

So you get a slap on the hand. Well,

I didn't go to Catholic school. But I mean, if I did, yeah. jellies, like I know what happens when I don't listen, someone hits me with a ruler. So now I guess the last piece of this right about this perfect Bolus thing, right is in my heart, it's about remaining fluid. Now, you know, a lot of people are going to tell you, you really have to count your carbs correctly, right, which is true. You can't use the wrong amount of insulin like you know, you can't have a 50 carb meal in front of you and only put in 30 carbs and then act like oh, I don't know why this didn't work. But you know, from listening for me and for a lot of people have been around type one for a while, like you just I don't think about it as much as carbs. I think about it as units. I look at a plate and I think that looks like eight units to me. But if I'm wrong, and I am frequently, for reasons that I don't care why, right? Like maybe it's a bad site, maybe I missed on my Pre-Bolus Maybe Arden sick, I don't care why but I miss, then I readdress immediately, right, based on my historical knowledge of how Arden acts, I know that if I see a double arrow up after a meal Bolus, I screwed something up pretty big. And I go more insulin. That's where you guys are starting to hear this. I'm starting to see you on online like talking to other people that people are just getting more insulin. I'm like, Yes, I know that's from the podcast. And so, but is she diagonal up well, then maybe I missed by a lot less so a little more insulin, or I'll try to bump it back down again or try to just try to stop the arrow but staying fluid is the rest of it. 100% staying fluid is our estimate. And I know that I heard someone say this the other day and I liked the way they put it that the idea of stacking insulin in a glucose monitor world is not quite accurate anymore. Like you this person kind of went a little farther and said you can't you can't really stack insulin. When you have a glucose ma Ron, because you seeing that you need more insulin. And I thought, Boy, that's a big idea. I agree with it, it totally in theory. But most of you are going to be taught when you're diagnosed don't stack and so on. And what they mean when they say that is don't put insulin in at one o'clock, and then put more in it, you know, 130, because you're gonna get low eventually. And if you're not using a glucose monitor, that very well may be true,

but Right, you can't follow it. But if

you can see your blood sugar, the direction and the speed it's moving in, you'd have to be incredibly insane to stack to the point where you'd cause some sort of a low that would make you capable of responding to it.

Right, that's where even you know, in the CGM, one that we talked about, I had mentioned using those event markers. And the event markers can be hugely beneficial now that they also show up right on your screen. So you can actually see, where did I put the insulin and you don't even have to go back to your pump to look at that. Or remember, when you took your injection, if you just mark it, you will know when those injections went in, you can follow the trend line and you see, okay, do I need more? I don't need very much more. I need a little bit more, a lot more. Right?

Yep, I've been this is gonna get away from this. And we'll stop in a second go to the next idea. But I've been talking to college students a lot through Instagram messaging. And if you just heard that and think, Oh, my God, that's me. You're adorable. It could be any number of you. But But, but but but this one person just had a long, protracted high blood sugar that wasn't coming down. So finally, I just said, Look, you you have to like, crush this number, and crank up your Basal, like do a Temp Basal rate for hours, like six hours, let's do 30% more and put in however much insulin you think is going to bring this down. And it took most of the afternoon, but they got there. And then just with that idea of oh my gosh, I don't have enough Basal insulin. The next day, here comes the 24 hour graph 130 blood sugar, because they're trying to live with not enough basal. So as much as as much as we're talking about the perfect Bolus here. Remember, you can't make the perfect Bolus if your Basal insulin is wrong. Correct, right, you'll never be able to. Because you'll always be replacing basal that doesn't exist. Or if your basal is too high, you'll be causing lows and thinking, Oh, this is the Bolus when actually

it might not end or if you are trying to really be aggressive with your bolusing than your bolusing and bolusing. And then finally, bolusing too much and that actually brings you back down, in which case then you might be eating, you're sending yourself back up, the Basal isn't enough in the background. So it becomes a roller coaster. As

infuriating as this is going to be and then we'll we'll end up this episode. But if you're Bezos right and you haven't had insulin or food for a few hours, your blood sugar is like at it's sitting right there. That's how you know you have your basal, right? And so when the stable right stable, and so and so if you stability at 140 a little more might have stability at 120 a little more you that's how you can learn to play with it, but I'm just telling you that if it's if it was you know, as intended, you know, by the heavens, then your blood sugar would be around 85 without food or insulin. It's not always going to be like that. I'm not saying that. But I'm saying if you're that far away from that number, you've got work to do on your Basal rates, right. Okay, so we're gonna wrap this one up, and then record the next one right away. Hold on a second. I want to thank Ascensia 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 Gvoke glucagon find out more about Gvoke HypoPen at G Vogue glucagon.com forward slash juicebox you spell that GVOKEGL You see a g o n.com? Ford slash Juicebox. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1000 And then three is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs. In Episode 1015, Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two, in Episode 1018 teen pregnancy 1019 explaining type 1020 glycemic index and load 1021 postpartum 1022, weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025, we talk about transitioning from MDI to pumping. Before I go, I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active took me already from a decent 6.5 A1C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years, and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link. 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

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 CDE 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 revisitable. 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 Ascensia 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 Juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org. And on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke hypo pen. Find out more at Gvoke glucagon.com. Forward slash juicebox. Hey everybody, this is Jenny from Integrated diabetes services. I understand a lot of you have been contacting Jenny privately, which I think is a fantastic idea for any and all of you who are interested. Jenny, of course has been doing the diabetes Pro Tip series with me. This was supposed to be the last episode. But I think unless Jenny has changed her mind, we are going to continue to add to this series throughout the year. Yes, excellent. Jenny. I'm very excited about that. And today's topic is. So you guys don't really understand how all this happened. I wrote down what I thought were the tenants of the podcast. And I sent them to Jenny. And she put them in a different order and made changes to them. And she's like, I think this is how that this will work. And I was like that's great. And then we were supposed to Oh, well. You know what I was thinking Jenny's? We were supposed to record? Basically a like a menstruation episode. But I think I but I think it fits really well into your idea for today, which is variable. So I think we're going to combine the two of them if that makes sense. You

agreed?

Excellent. Okay.

Why don't you tell people what

made you reach to me and, and suggest this

just the word variable brings in the whole topic of discussion, right? I mean, we're taught from the get go there are three main factors that really you know, you get educated about is impact on your overall blood sugar control, we've got an I kind of call them like the triangle of management of what you're told about to look for a fact. Exercise. The medicine you take in type one, of course, insulin Sometimes though, with the changes in some of the medicine now for type one use could be other medicines. And then you know, the third one is food. So we've got exercise, medicine and food and you know, if you contain all of those, you're going to have diabetes success, right? If you just learned about all those little pieces, when there are only three, so you're gonna do awesome. Well, that's like baloney. I mean, there's so many more factors to consider so many more variables or like icebergs, right? That can kind of come through the course of your day. I mean, some of them, you can sort of head off, you may know that they're coming if you know to look for them and that they could have impact on blood sugar. Again, the shortlist that I kind of came up with just to talk about today cuz I know we don't have like four hours to discuss everything. I think I came up with like 10 or 12 You know, variables that I could really think affect Most people, and that you really should consider. So, you know, I'm sure that you probably have some variables that you know, just with what you've seen with your own daughters management, right? Absolutely.

And, and to kind of tag on to what you were saying, I found myself this past Saturday at the dancing for diabetes touched by type one event standing in front of people telling them that insulin timing is the seed of the tree that is your management. And as long as you know, we can always go back to that as the base is the root, right? But then eventually, you know, that seed grows a trunk and the trunk grows, branches, and the branches grow leaves. And all of these different parts of the tree can affect your blood sugar and will sometimes, but you can't get caught in a problem. And staring at the leaf on the 77 branch and wondering what is that leaf doing to me right now, even though it is doing something to you, it's, I like to look back afterwards and say what happened there and try to figure it out. But in the moment, as we say, here on the podcast in the moment, it just means you need, you need to change just adjust, right, maybe that means more insulin maybe means less. The idea that Basal insulin is insulin to and we always forget about it, everyone wants to set their basal and then think about Bolus, which just doesn't work, you have to think about the timing of all of the insulin. And when one of these bazillions of variables comes into play, some of them being more constant in your life than others. They have requirements, and they require of you to, to resist, right? Like you can't just, you can't walk through a day when your premenstrual may be the same way you walk through a day when you're not. Right. And so go ahead, give me your first one, what's your first good one off your list?

So my first good one actually takes into account the three that I mentioned, right? Exercise, medicine, and food. Each of those seems like a simple like one topic blurb word, right? It's if I figure out the medicine, but you brought in a good factor, it's the dosing the timing, the consideration of the medication itself. And again, with more medications being added to the list of potential use, especially with type one, you bring in more variable there. And so with the dosing and the timing, it takes evaluation, so that that variable can be I guess, better known for you. Again, you know, we all have your diabetes may vary, right, we all have our n of one life with our insulin that we use, and we learn how to dose it, learn how to time it. So that's, you know, one and then the other two, exercise has a lot of variables to it. You know, you get the blanket statement from a doctor who says, Just take your pump off or just, you know, do a zero Basal if you're gonna go in exercise. The world of exercise is not that simple with diabetes, but if anything, there are a million variables within just the topic of exercise, if you consider you know, slow movement, like when I take my dog out for a 20 minute walk and he stops me pees in sniffs everything, my blood sugar could drop 50 points from just a dog sniffing, walk.

Sniffing walk not to be confused with the brisk walk.

Exactly. So I mean, you know, things like that, or, you know, going to like Disney World. To walk around all day, that slow, consistent movement, you wouldn't count as exercise not like going to the gym and huffing and puffing and sweating to death. But it's a variable that in my experience, I've found I need to reduce my Basal about 20% for the full extent of the time that I expect to be at like a Disney park or someplace similar.

Can I ask you a question about that? Yeah, we always say that and then we never sort of not not you and I just people in general, I always say like, you know, exercise can bring my blood sugar down. In I don't want to go too deep into it. But why? Well, I My question is, when my body starts moving, what does it do that makes my blood sugar fall? Is it using the insulin more effectively? Is it speeding up the like, that's what I want understand real quick. Those of you looking for a diabetes organization to support should check out dancing for diabetes. That's it, no big sell. I just think you should. Dancing for diabetes.com That's dancing the number four diabetes.com I was at their event. A couple of weekends ago. I heard Elizabeth talk about how she started the organization. Her words just made me so proud to be there and to be supporting what she was doing. And I think you would feel the same. Just check them out dancing for diabetes.com That's dancing the number four diabetes.com

Yeah, so the exercise piece, if you consider I like to refer to it exercises like Free insulin really, is some types of exercise again, you know, the low slow to moderate intense exercise, you're really looking those fuel cells, doors on them have, you know, little locks, right for the most part, we used to use insulin to unlock the door to get the glucose to enter, when we exercise, the body is sensitized to insulin, and those doors open freely, because your body wants to incorporate the glucose into the cells to get used and to energize the body to keep performing. So if you've got, and this comes into the first, you know, topic of medication and the timing, when you're looking at exercise, the timing of insulin is very, very important. And the dose and what you're coming into that active phase with on board, that's just it's huge. You know, so if you're looking at going into a five mile slow tempo run with five units of insulin on board from the Bolus that you just took, think again, yeah.

I just spoke to an adult woman this weekend, who still play soccer, and she said, you know, the advice she got from her doctor was to take her pump off, and she said, But then my blood sugar goes sky high, and I can't play. And I don't want to do that. And I didn't have much time to talk to her. But what I said was, I said in a very basic way, that everything I say on the podcast, works for activity, you have to wrap your brain around it. But in the end, if using the right amount of insulin at the right time and taking into account that this exercise is going to happen, that's it. And it's simple to say, well, you just turn your Basal back an hour before and during or something like that. And that may be the answer in there. But there's an answer in there. And that is, you have insulin needs. During the soccer game, you have less insulin needs. So don't give yourself the dog sniffing insulin when you're playing soccer. Right.

Exactly. Exactly. So yeah. And you know, so then we, you know, take into consideration the adjustment for exercise, but there is also exercise on the opposite side that may require more insulin. Yes, because of adrenaline, yes, things like you know, those who lift or do a lot of resistance training, or do HIIT workouts, you know, the high intensity interval training, where you've got a little cardio, but these really like short bursts of intense exercise in some of my first, I guess, personal informative about intense burst exercise for my blood sugar control was when I was starting to train for my first half Ironman and my training routine had some of the running as sprint Hill sprint, where I'd literally like fly up the hill and then sort of jog back down and fly up the hill. Well, you know, I adjusted, assuming that I'd have the similar response as other exercise where I would adjust the insulin and whatever, man I was high, like, you know, but adrenaline, you know, research adrenaline is kind of a component there to consider. The weight lifters that I work with, tend to find that they need to dose insulin before a heavy lifting session, they might need to take a unit of Bolus insulin, they may need to do a temporary Basal increase those kinds of things. So exercise isn't as simple take your pump off and go and exercise. That's,

that's the Do Not that's do not die advice. That's advice that won't kill you. It's definitely not going to help you. Right, right. Exactly. And the example that I use over and over again, in my talks in here is the idea of art and showing up for basketball at a great blood sugar and then running around which makes you think blood sugar would fall but then it would go up. And then we figured out that she was competitive and she wanted to win the basketball game. So her adrenaline spiked up.

And difference there you probably found from her game to her practices, yes. Which is very common for any athlete who is in a competitive anything. I mean, I found that with my running races, I could go out for my nice runs and for my training and have great management knew what I was doing some of my first five K's man, I was astounded at the rise in blood sugar as soon as I got in the car to head out.

Yeah, it

was like a drift off. It was like, for people who

play competitive sports or have been around it this, this might make sense to you. My son always echoes this back to me that is true. He said it's kind of impossible. They always tell you to practice like you play. And he said it's kind of impossible to do because when you're practicing, the game's not there. Like right like there's these the same intensity is not there. The same desire is not there. You can't you can't duplicate the feeling of feeling like you're going to lose or let someone down or lose your spot on the field or some something like that. He's like you can't you can't make that up in your head while you're practicing. So your your insulin needs will be different because your brain is thinking differently about what you're doing. Very, it's very interesting. Yeah, yeah.

So those are, you know, all even the time of day for exercise could make a very big difference for how you strategize adjustment. I know my morning adjustment for exercise is very different than my mid to late afternoon or evening exercise, very different just based on again, the sensitivity and all of that kind of stuff. So,

and Arden, as an example, closes her eyes to go to sleep and her blood sugar goes down. It happens almost instantaneously. So it's not a huge drop. But that girl goes to sleep and the I don't know what you would call it the day life. Right? The anxiety and knowing the use of Yeah, she relaxes. And when she relaxes, her body's not forcing her blood sugar up in the same way. And it starts to drift down. Yeah. Okay. All right, Jenny, let's on that list now.

So next one, again, of the three, the third one was the food, right? And we think okay, and we talked about this in one of our other, you know, just master carb counting, and you've got it like figured out, you've got it totally nailed, you'll be clear and beautiful post meal blood sugars, right? Well, again, I kind of it kind of takes into consideration, type, amount, combination of food, what went into the meal, you know, if you sit down and you eat, like, you know, a three cup jar of peanut, versus a three cup plate of white rice. Carbs are there in both pictures. The coverage of them, however, is very different. So those variables that kind of come in with food, we know now, thankfully, in the past, I would say five d, maybe even 10 years, we've become much more aware. And educating people a little bit better about it's not just carbs, it is the fat it is the potential protein. And with some of the I say newer, they're not technically new, they just have gotten a lot more media is things like the Paleo kind of diet or the keto diet, those kinds of past plans or, you know, eating habits, they require you to figure out the impact of the food in a different way than just carbohydrate.

I know I think I've said here before, but I was with person eating no carb at a meal. And we went into a restaurant sat down. Hi, Vicki, Vicki ate food. I feel like we sat there for a half an hour and talked, we got in the car, we're driving away. And she pulled out her PDM for her mommy blog and gave herself insulin. And I was like, What was that for it? She was the protein is gonna hit me soon. Let's look, that's amazing. I don't think she ate one car while we were where we were. So different ways to wrap your head around different things. And I haven't, you know, again, I just this is fresh in my head because I just got back from a talk. But there's a slide that goes up that says all carbs are not created equal. But you have to you have to fly, right? You have to believe that 10 unit, you know, 10 units away, I cannot talk about grams, 10 grams of rice and 10 grams of watermelon or grapes are not going to impact you in the same way or for the same amount of time. And if you don't know that, then you'll struggle. You know, you can't, you can't just you can't just count your cars, put your insulin and eat your food and go away. If it worked like that. Well, then diabetes would be easier. And this pocket probably wouldn't eat this podcast.

Oh, that's exactly right. Well, and then the other factors, you know, that will kind of, I'll touch on as we sort of go on here. But factors of food impact, you may get many of your common things figured out, as I think I said in one of the previous ones, you know, if you figure out the 2025 most common foods, meals, things that you eat, that's like 80% of your management, if you kind of nail those, figure them out from the protein, carb fat impact, awesome. But then we bring in all of these other potential variables, like you mentioned, initially, you know, the menstrual cycle for women, well, you may have all those wonderful things figured out. And then in comes the three to seven days before your period is supposed to start. And if you haven't been told that there is an impact on blood sugar, and you just think that, gosh, it must be my insulin or it's a bad site or something crazy is going on. You get really annoyed and confused. And for women that could happen every single month that you're getting annoyed and confused. And unless you start to track things. You'll remain annoyed and I

try so hard to tell people I don't want you to. I don't want you to completely forget about the possibility that your insulin went bad or that your infusion site suddenly stopped working. But if your blood sugar was at all day, and then all of a sudden it jumps to 150 and it won't move. It's probably not your insulin, you know, but you see so many people that hyper focus on the physical things, they think they can see that they that they can they can believe might be the reason, right? And you have to be able to kind of look back a little bit and say, okay, it doesn't make any sense that my blood sugar was doing doing what I expected it to do. Suddenly didn't, why am I thinking the pumps at fault? Like, why am I thinking the insulin is at fault that insulin has been working for a day and a half, you know, or that vial has been working for two weeks, or whatever it ends up being? You really sometimes just have to think it's probably the stuff I can't see. And then I think, and then I always think too, and then don't spend too much time on it, to bring it down. Yeah. And here's a great variable, say your cannulas loose and you're leaking. And you're not getting as much insulin as you believe when you push the button. Still, in the end? The answer is, you're not getting enough insulin. The reason is mechanical. But the idea is still the same. If you were getting enough insulin, your blood sugar wouldn't be that high. Correct, right?

Absolutely. And when we take into consideration, you know, cycle changes, if you start to track things as a woman, and you do have a cycle, and you're not on birth control that completely, you know, cuts your cycle off entirely, and you just don't have it anymore. If you're having a cycle, start to track things, because that's a good way to figure out some of that variability that a woman will have has nothing to do with the male at all diabetes management strategy. So if you're a woman listening, and you're within the time period of potentially having a cycle, and you're not postmenopausal, or anything, start to track your cycles and evaluate usually, for most people, they see a rise prior to their cycle starting, as soon as their cycle starts usually needs dip back down, up until about ovulation for women can be anywhere between day 11. And day, like 18, give or take. That could be another rise in hormones, it's usually shorter, it's only about two or three days. And then things kind of drift back down again, typically before that three to, let's say, five days before your period starts again. So we have this continual roller coaster of hormones through the course of a month. And if nobody's kind of queued you in to pay attention to it. You may just feel like there are variables that you just don't know what's happening,

right? It just seems random. If you don't, it seems random if you're not aware that that's an impact. And by the way, they're fantastic. I happen to know, trackers like different apps you can get for your phone to track your period with it's it was only uncomfortable period tracker, there you go. And it was only uncomfortable for me like the third time I asked her and can I see the app that tracks your period real quick. You know, she said she was like, Okay, take it. But it really is spectacular. And in the end again. You need more insulin, you need less insulin, do you need the regular amount of insulin, you know, once you recognize that it's happening, and you don't spend a day and a half wringing your hands wondering what's going on and you just stay fluid and do what it asks, then then then it's not a burden anymore. It's just I need more insulin, but our brains get stuck. You know, you and I talked about this before we started recording. But Arden's looping now and I'm seeing with her basal, that how much more Basal insulin the loop can use. And I thought back to when I used you know, I had Ardens Basal before the loop set up at like 1.4 An hour and to double it to 2.8 to me seem like all the insulin in the world. And now I'm seeing the loop do it too, sometimes four or five, six units, and not for a full hour. But it's still it's, I realized I was stuck in the number the idea of the number and that can happen to you too, when you're when your period pushes up your insulin needs. And you think that's crazy. Let you know on most days, I use 20 units all day between basal and Bolus 40 is gonna kill me. Well, it's not that day, because your needs are

different. She needed it. Right. Right. Okay. Absolutely. Absolutely. And that I think you bring into, you know, you lightly touched on, like the site or the pump or you know, those as being variables, but they certainly are, I mean, you have to know when to definitely address it as a potential site issue. You know, if you're in the time period of, let's say, your month or you're a man and you shouldn't have hormone issues, and you've got you've been floating along beautiful for, you know, weeks and weeks and weeks. And now all of a sudden, you've got this like, high blood sugar, you know, you're usually up to like 140 Maybe after your breakfast and now you're at like, 300 Clearly that's not normal if another variable isn't there, right. So you know, you address things you say I'm high let's address the high but why is it happening as well? Could it be the site check your site, you know, those kinds of things? Could it be the insulin think about, you know, if it's a brand new vial, probably not. But if it's a vial, that's good And close to that like, end of life like it's almost empty or you've, you know, you don't use very much insulin, so you're getting to kind of that 30 ish days, especially this time of the year and through like fall, where if you keep your open vial of insulin out of the refrigerator, temperature changes will effect insulin. So it's really an important piece to consider, maybe you just need to change the insulin out. So those as you know, potential site issues, the other side issues would be the site itself, have you used this site over and over and over and over and finally, it's gotten to the point of just you can't use me anymore?

When you switch to a new site, expect that it's possible that you need less insulin than you needed prior on the old site? Because maybe that sites working better and and for all my talk about don't beat yourself up about it's probably the pump it's probably the pump once you decide it's your it's your site, it's you know, it's the pump. And nobody bails on a pump site faster than me once I believe it's the site, you know, I'm like, Okay, off gone. And that's that, you know, and you if you're newer to this, by the way, this all seems I try to bring this up once a while talking about things on the podcast is an exploded view, right? Like you're really stretching things out to see in your regular life. It's not going to take the last five minutes at Jenny and I talked about this for you to make that decision. You know, you've heard me say before, like about CGM people, like how do you know how you can trust your CGM? Like you can tell. They're like, What do you mean? Like sometimes it's 30 Points off, which by the way, you know, 30 Points off a 10 year old meter. I don't know why we're believed in the meter before we believe in the CGM, but neither here nor there. My point is, is that if you have some experience with this for a while, you know what's real, and what's a ghost, you know, and you can you can look and say to yourself, alright, this is clearly the site. This is going, you can look at your CGM and say, I don't think it's possible my blood sugar has been at three for six hours, maybe I ought to use my meter to see if that's right. And those decisions become very easy over time. The remastered diabetes Pro Tip series is sponsored by Ascensia 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 Juicebox free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash Juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen, it fits well in your hand and features Second Chance sampling, which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash Juicebox free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips you can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now through your insurance. Contour next one.com forward slash Juicebox free meet her go get yourself a free starter kit. while supplies last US residents only touched by type one has the back of people living with type one diabetes. Take for instance, their D box program touched by type one knows firsthand the intricacies of living with type one diabetes, and so their team has created a D box which is a starter kit that provides important resources and supportive materials to individuals with diabetes. They want you to thrive. The D box is completely free and available to newly diagnosed people. All you have to do is go to touched by type one.org. Go to the Programs tab and click on the box. While you're there. Check out all the other resources and programs available at touched by type one.org. Speaking of support, touched by type one.org is available in English and Spanish. Don't forget to find them on Facebook and Instagram too. You do not want to miss what touched by type one is doing. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it Je voc hypo pan 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 Gvoke glucagon.com forward slash juicebox Gvoke shouldn't be used in patients with pheochromocytoma or insulinoma visit je voc glucagon.com/risk.

You know another one that this time of the year in consideration of like insulin and viability and all that stuff. Another one that a lot of people don't realize, is this time of the year could for many people bring in the variable of allergy.

Okay, how so? Right? Just because because that's almost an infection. It's

caused it Yeah, cause it's kind of like that histamine reaction in the body, which causes an inflammatory response. You know, that's the reason you get all Flemmi and, you know, bergerie eyed and like, whatever is coming out and

trying desperately to push out that dust

push out the nastiness, right. I mean, unfortunately, my husband has nasty allergies in this time of the year. He's just like, full of sneezing and like runny eyes, and you know, that kind of stuff. And it stinks. But when you consider diabetes, insulin needs with this as a stressor on the body, we talk about stress as a variable to allergies could be a stress variable. And so your insulin needs may very well go up in this time of the year. Because of that type of you know, setting. Now, if you use some medications to help deal with the allergies, it's always important as a medication kind of component or variable, check the label or ask the doctor, make sure any of those medications that you may take for, you know, an allergy won't necessarily have impact on blood sugar, some of them have a steroid base to them. And steroids, as we know, will usually raise blood sugars as well. So you could have kind of double impact and medication impacting as well as the allergy itself impacting

Do you have pain on your list?

Pain would be another stressor within that like, kind of body sort of Yeah, I think it's something that

people don't think about. But I've seen it happen so many times that you can't not trust I saw Arden get hit in the knee with a softball once. And her blood sugar immediately started going up and stayed up. State her insulin needs remained high for days while the pain in her knee subsided, and it was a significant pain. And so let me ask if I have a headache, would that push up my blood sugar?

It could if it's a it's a bad enough headache, especially those who may have like migraine issues absolutely could be a variable. Sometimes too, you know with that as as effect. Sometimes if you notice the rise in blood sugar, you take medication to offset the pain itself. If the pain isn't felt anymore, blood sugar's should or could very well come down. And so you do have to be kind of cautious with the adjustment in insulin. If you're doing something to cover the pain, you may find that correcting the high blood sugar drives it down more than you expected, because you're not feeling the pain anymore. So

funny. My next question was going to be to you say I'm in a road rage situation. And because I'm all dialed into my diabetes, and I've got a Dexcom I see my blood sugar goes from 80 to 140. I don't want to Bolus right away right because my Basal because that that burst of adrenaline is going to go away quickly and then my Basal is going to my basal is going to crush that number again, most likely,

most likely I mean in basal is never meant to essentially bring blood sugar down. But once the stressor is gone like that a quick impact kind of thing. Typically, your blood sugar should start kind of coming back down. And if it doesn't, it just means obviously that you are thinking about it and continuing to like dwell on the problem.

Right you have extra road rage is extra road rage

Exactly. Go home and you tell every neighbor about what happened on the way home and you know, you continue to perpetuate the issue

and go ahead and Bolus Ford

Bolus. Exactly. Yes, exactly is

a quick burst of adrenaline the same as a lollipop. In that it does it does hit you but that it can't sustain the rise.

Is that a similar idea?

It kind of similar idea of kind of a good way to

you know, something, you know, doctors used to and I I'm sort of against the idea of talking about free foods. I don't I don't really think there's free foods in general. But But I have seen it with Arden and I've always wondered is the fact that like she put a lollipop in her mouth and her blood sugar went up a little bit and came down is that because a lollipop is a quick hit that goes away? Is it a free food or is it because I've got the balance of her insulin so wrong that it's able to handle carbs I haven't. Like I used to think about that when she was younger. Like am I really like did that really not have an impact or are, you know how we talked about if, you know, I was explaining to people this week and I said, Look, you have to Pre-Bolus You can't be scared of it like insulin works the way it works, it does not work the minute you put it into your body, if you Pre-Bolus and two minutes later, your blood sugar starts falling. The Pre-Bolus did not magically start working. You probably already Yes, you were falling already or you did something hours ago that is impacting now that you're unaware of. And I always wondered about that. Like when we'd give art and like little bits of candy Mia jet, was I just premature? Like, was I just holding up a low that was coming anyway,

could be the factor. And that's also it kind of brings up a good point. Well, it's not really a variable, but it might be if you consider it lows, when you treat a low we recommend treating with simple sugar, right? When you treat with simple sugar, that simple sugar is really its potential impact should last an hour to 90 minutes. And thus the age old recommendation. If you have a low blood sugar, treat it it comes back up if you're not going to be eating a meal or a snack within the next two hours. Treat or follow up that carb sugar with a snack that includes protein. And the reason was to sustain the blood sugar then because that quick glucose like you just said it goes in it does its job it gets things up, but eventually the Basal that's there that's supposed to be right. overpower sugar, it will overpay there's not enough laughs really, if it's working the way that it's supposed to. So yeah, absolutely adrenaline and a lollipop.

So the numbers not really the power without the when it's just a simple sugar. You have to give it a protein or a fat to actually add the, the weight to that number that so that

something slower digesting you know, if you consider something like you know, quinoa or like a piece of sprouted grain bread or you know something longer sustaining. It's got the carbs, probably more than the lollipop does. But you're gonna get the rise. It's going to be a lot slower, but it's also going to be a lot more sustained. Jenna, you're

not from where you live. Are you? Like Were you born where you live? Like Jenny's like a Midwest girl. Are you from the Midwest? And still you said instill you said quinoa as an example of that was really interesting. That took me by surprise. I was like, Oh, look at fancy Jenny must have been born somewhere else then moves where she lives.

I'm just you know, I am a dietitian.

Oh, okay. See?

I know the fatty foods I guess I should know about right.

I haven't I haven't read your bio in a while. Don't worry. I just I usually do it before the episodes when I'm putting the episodes together. You keen? Well, I got me by surprise. If this was a regular episode, I would totally title this episode. Kenalog. Just so you know. It's funny, so many people. So many people came up to me this weekend and said, Can you put any more effort into making the titles match what the episodes are about? That was like No, probably not just listen, you'll figure

you can title it the variable of Qianlong that.

I'm sorry, yeah, get you off track what's next on your list?

The weather. As we consider temperature changes. I've got you know, so many people. And I noticed myself I've got a really good friend who notices as soon as March hits. And you know, here in the Midwest, March may or may not be warmer than the winter has been. But she's like, as soon as markets, it's like a switch in her body goes off. And it's like, it's spring, hey, let's dial down the insulin needs. And she literally has about a 20% decrease in her Basal needs. From March all the way through, like, you know, October ish, when it starts getting a little bit cooler out

is that an across the board rule. For the most part, the

warmer the weather, the more and the more time you might spend in the actual warmth of the warm weather. You know what, what does warm weather do, it increases the like, your body needs to cool itself off. And so your vessels come closer to the surface of the skin so you can cool yourself by sweating a little bit more that like increase in in the vascular nature of the underlying tissue brings vessels closer to insulin and you absorb faster

plus and this isn't physical but physical in in terms of inside of your body but you probably become more active when it gets warmer to write.

Absolutely do more things I know myself I you know here and my husband talks about it all the time. He hates the winter weather and everything and he's like let's just move someplace much warmer all the time. So we can always be outside and quite honestly, if that was the case, I probably would have lower insulin needs throughout the whole year because warm weather comes I'm consistently at the park with my boys and go and doing my normal exercise. I mean, I don't even consider that exercise. That's just part of our normal daily when it's nice outside. So yes, we become more active when it's nice enough to be active more often outside. So I

think what Jenny saying is if you're thinking of relocating to a warmer place, and you feel like you can't afford it, don't forget to deduct your savings, insulin, right? There you go. You might be able to afford more rent, because if you just move somewhere warmer, all the diabetics are gonna live in California now.

Right, right. And the opposite of that, you know, the cold weather, you stay inside more oftentimes, cold weather means you're eating a little bit harder your food, you know, to kind of sustain and backup or kind of plump up almost, you eat more like stews and things that might be a little bit more protein and fat laden, just heavier meals in general. I mean, nobody eats well, maybe some people do. But nobody eats like a rockin hot chili, dinner in the middle of July summer.

Food certain times, now I get that you're more sedentary in the in the wintertime and

more sedentary. Exactly. You may get your exercise, but you may be shorter, you know, the, though it's not as light outside anymore in the wintertime. So all of those kinds of things as far as a time of the year allergies, whether cold, warm, they can all be a variable. So I have

a variable for you. Is it possible? It's more of a question that you may be able to tell me to shut up. But do some of our bodies react differently to cannulas than others? Like like this? This gives it possible that because you're because that cannula goes in, right. And it's seen as a foreign body immediately. Do some people see a third day on an insulin pump less effective, but some people can make it longer or shorter because of that?

Okay. Yes, absolutely. And I think that's part of the reason, you know, knee pod, especially did their 72 hour or up to 80 hours of you know, exploration, essentially three days Omnipod because the studies have actually shown that longer than three days with a sight, it starts to impact the absorption at the site. So if you think of the consistent drip, drip, drip, drip, drip, and then these big boluses I mean, if you don't use a lot of insulin might be two units for every Bolus. If you are some of the team guys that I work with who are eating, you know, 100 plus grams of carbs per meal and the ratio is a one to three. You've got huge 20 unit Bolus going into a site and that site gets it gets saturated. It can only absorb for so long, so some of it may not necessarily be cannula. Some of it may be how long and how much is going in at the site. For the people that are sensitive to different cannulas though. It could be the angle some people do much much better with the angled type of cannula. Other people do much better with the 90 degree cannula. I myself found no issue with Omnipod at all. I mean, I was a longtime user before I started looping about a year and a half ago. But once I started looping with my Medtronic pump, I actually found the angle cannulas were horrible for my skin. They did not work. And I found the 90 degree plastic cannula also wasn't something that my system seemed to really like. Whereas the steel cannula that goes in in a 90 degree angle, it's kind of like a thumb tap. You just pop it right in. That's awesome. It is like my go to set now. Fabulous.

He just t slim have steel and plastic. They do because I see people a lot talk about the

people who struggle on the T slim move to the steel cannula that sometimes helps.

Yep. The one for T Slim is called True steel and the one for Medtronic is called the shore T. Okay. They're both steel. They both they work. Lovely. I would say for most people that I've encountered who have that cannula kind of issue. Yes. And you know, as a variable, those may be things to evaluate and say, I know it's not the darn insulin, I can give an injection with the same bottle of insulin and my blood sugar moves the way that it's supposed to. Let's change the site. It's not necessarily the site. It could be the cannula, we changed the cannula. Magically, things look better. Sometimes we even need to go down in the insulin needs because you're responding better. So

I would like to say at this point that when you buy a pump, you're going to get instructions from the pump company about approved sites to use. Keep in mind that the pump company had to get the pump through the FDA process. And every site they wanted to test took more time. And that took away time from them getting it to market for you. So had they decide had they had the luxury of more time they may have tested more sites and the FDA may have said hey this data Use that you can use it here to. I'm now not saying anything else about that. Other than you should consider that. Correct. That's all.

Yes. And even some of those approved FDA sites. Don't work for some people

at all. Yes. Just because they're approved doesn't make them good for you. Doesn't make them good for you, because they're not approved doesn't make them not good for you always, always take into account the photograph on my blog that Chris Freeman, the Olympic skier allowed me to use of him wearing his pump on his pectoral. And I believe the man has the same body fat makeup of this metal microphone that's in front of me. So yeah, I think

as well, even though they don't technically have, they've got pectoral muscles, they're just hidden underneath a breast

I love when someone shares like a cleavage picture with their pump on them. And I show it to my daughter and she's like, Never, never. And I'm like, Okay, I'm just saying this lady says works really great. Get away from me.

Again, all those variables to definitely consider. I mean, we're talking about location here, I clearly had location for a different reason being a variable. Go ahead location, being like travel. Travel is a variable. If you notice, changes in your blood sugar. When you are flying or traveling long distance, we usually find that over two hours of sedentary travel will usually require more insulin because of the sedentary nature and the potential bit of stress that travel brings in

weight. On a three hour flight. We always have to Bolus art and two hours into a three hour flight. I never thought of it before, but it's constantly that

yep, yep. So I personally have found that I use about a 20% Basal increase. When I fly I get to the airport, I turn the Temp Basal on so that by the time we get on the plane, it's already like circulating at a higher level. I continuing until we get the notice of dissent. And then I cancel it. And that works really well. For me I do the same thing on long travel I'm when we lived in DC, and we would drive back to the Midwest to visit family. That's a long drive lots of sedentary sitting in a car, the stress of driving on the road and everything I would need a Temp Basal increase for that. So travel in and of itself can be a variable for those on tube pump. The variable could be the pressurization in flight. Many people find and there's actually some really good I guess, blogs on what people found with a tube pump in flight. So the recommendation now is to disconnect before ascent. Check the tubing once you're at cruising altitude check if there are any bubbles, purge them out with a priming Bolus and then reconnect. Same thing for descent disconnect once you land look at the tube and clear the bubbles if there are any, some people have noticed that they get a bit of insulin Bolus that won't show up in the pump. Because of pressurization of the pump and the reservoir and everything. Some people find that they've got this huge air bubble in their tubing. And so if they didn't look at it, they would get a huge missed amount of potential basal or Bolus the next time they're pump pumps out.

And that's something with the change of level elevation.

Yeah, it has to do with the pressure pressurization within, you know, the cabin and unfortunately, there's not a lot of it. In fact, there's nothing that I've seen in any of the tube pump companies that they talk about doing that, but it's something that we know is common to happen. So on Omnipod, obviously there is no tubing, I've had a random couple of people who've noticed that in flight, they have these lows, having not bolused having not done anything different having sat at the airport for like an hour or two before their flight took off. Again, no Bolus, is there anything and they are low through the course of the flight. So potentially, I guess it could happen even without the tubing component there. I mean, the pods still have a reservoir. But I've really primarily heard it with tube pumps.

I always wonder about you. Some people get like, like, we all most people have the same reaction, right? Nervous upset adrenaline, blood sugar goes up, but you do see sometimes, like people have the complete opposite reaction that you expect from them. And it's that's their norm, right? Or, like, here's one, how come when Arden has a head cold, it's like she doesn't have diabetes anymore. And other people say when I'm sick, my blood sugar goes through the roof aren't get sick or blood sugar goes to 80 and sits there for days. It's faster, right? And it's just so the other variability that we haven't spoken about yet is you? Right, right. So yeah, your response to all of these things. So You know, the variables may treat you differently than other things.

Similarly, I have my friend, who I have done races with in the past not recently, but she actually has a considerable drop in her blood sugar once she gets to the race day, okay, that's it. She doesn't have that adrenaline spike, she has the opposite. I mean, there's adrenaline there, but whatever reason it's causing her to drop.

And so for Jenny's friend, the the point here is, don't say, Well, I heard on a podcast that you know, when adrenaline hits your blood sugar goes up, and everybody online says it, but mind goes down. Don't Don't bang your head against the wall. Just accept that. That's what happens to you and address it accordingly. Correct.

Exactly. Yes, exactly. The other travel one was altitude. Many people don't consider altitude. And if you are someone who goes to Colorado skiing or somewhere fancy in Europe, and you go skiing, or whatever you do, you could notice that going to altitude, I noticed that when my husband and I took a trip to Peru, and we hiked the Inca Trail, which is we got to Cusco and we were like, oh my god, can we just sleep the like the altitude was like crazy, we felt like we had never exercised before. And my insulin needs go up about 30% for about 24 to 36 hours, once I get to altitude, and then they come back down. It's like my body just needs this like adjustment period. And then it kind of comes back, you know, to my normal. But that's a pretty common one to consider.

And that is incredibly common. And even though it is incredibly common. There are three people that I know of right now listening to this that are thinking AI it's the complete opposite of what happens to them. I correspond with people who live in Colorado and are afraid they're going to die because their insulin just crushes them they use the tiniest bit and their blood sugar's falling constantly they don't know why pumps injected doesn't matter. They just the the elevation that altitude just it Wrexham So yeah, that's their that's their normal, you know,

that's their normal, right? Absolutely. So, you know, all those, I guess, all those things to consider. You know, they're all there are lots and lots and lots of variables. What else is on my list? I have

Jamie prepared for you people, I hope you appreciate that I

did just because I was like, gosh, there's so many of them, I need to like make sure I get the primary ones that I appreciate to people about considering, you know, a variable I know we've talked about previously, when we're talking about like being bold with insulin is high blood sugar itself, like extreme high blood sugar can be a variable in how you expect your body to respond to insulin. Typically, when blood sugars are higher than about like that 250 mark, which, huh? You know, they recommend testing ketones anytime you're higher than 252. Right. So along with that comes the consideration. So you've got it all like squared away, you know, your Basal, you know, your sensitivity to boluses to correct blood sugars, or carb ratio is all dialed in, and you feel like things are working and, wham, you're high now. And you take your correction, and you're like, Well, that looks like I put water in my body. And it did literally nothing. Sugar. So we've got this like, like this toxic state, almost like they actually call it glucose toxicity that comes into play when you've got extreme high blood sugars, where you'll need more insulin than your sensitivity factor would normally

cover. And that's what people commonly say, I'm insulin resistant, when I'm high. That's the That's the common way that people talk about it. So if you have that feeling in your head, this is what Jenny's talking about. Now, from my very non scientific perspective. I learned years ago, and we've been talking about here forever, that bringing a high blood sugar down and coming in for that landing that you're hoping for and not a crash, right? You have to in my opinion, it's a mix of basal and Bolus. Jack, you don't just if you're thinking in my mind, if you're thinking it's two units to get this 300 back to 100. I like to find a good portion of that insulin from basal and I don't know why that makes more of a difference, but it certainly does. So

it's also a I call it as let's say a safer way to also manage potentially because if you've got a Temp Basal increase going along with a part of a Bolus that you've used to address that higher blood sugar, the Basal can be canceled, right you can always bail on Okay, once you see the movement that you want, you can bail on the Temp Basal whereas if you've taken your rage Bolus in your like, it's telling me all you need to units man I'm gonna nail it. I'm gonna get it down with like eight units and you like nail Well, once it's there, you can't get rid of that eight units. It's

you know, whereas you just Pre-Bolus For your next meal, you better eat it at the right time.

That's exactly right. So, you know, if you do some of it as Bolus, like you said, and some of it is this Temp Basal insulin, you can cancel that term, you may need to cover a little bit, but at least you're going to drift down better without a huge crash. And

also, you can also cancel it and go back to it, which I found myself doing before, right? You're, you know, 300, it's now it's 280 is 250. And then you're like, oh, my gosh, is two hours down, I'm shutting the basal off, then all of a sudden to 20 levels out and like, Oh, should left the basal on, and you put it back on again. But at least you're in control of it to a degree, right. And you didn't just put in this giant like, you know, mallet full of insulin that you can't stop. It's already hit you. It's hit you and you're done with it. Yeah, I want to say too, and this maybe doesn't fit here. But when you find yourself in those situations, I think it's incredibly valuable that when you cause that fall that that the sent in blood sugar, and you have to eat some food to stop it at some point. I know everybody thinks of that as like some failure. But there's so much to learn from watching the food going and watching how it affects your blood sugar on the CGM, that that that experience of stopping a drop like that will inform a lot of what you do in the future. Because just like you can see, oh, wow, I was 152 hours down. So I ate this. And I came in at at that knowledge. And I can't really explain to you how in the moment right now, how in this example, but it will inform your understanding your greater understanding in a way that will help you in the future. It's absolutely very neat to see how the food affects the insulin.

Actually. So awesome. Yesterday, I talked to somebody who she works very hard, you know, with strategy management, we knew something was kind of going on in the evening for her. So we said, well, let's do like an evening basal test, let's see what's happening truly behind dinner without the dinner, you know, being there. So she did this awesome basal test, we saw the drift happen that we kind of assumed was from basal, we, you know, could counter it, but she ended up having to treat the drift down. And she didn't want to eat at 10 o'clock at night. So she just treated the low. She had three glucose tablets to treat it. And she thought, you know, all we're getting out of this is the Basal testes. So we know where to change things. Yeah, you know what? So we could actually get the evaluation of what the Caribbean takes she did right? How much of a rise did she get with it from it, because there was no other food, there was nothing I mean, the only other food she had in our system was from lunchtime at noon, at 10 o'clock at night, there is no impact of that whatsoever. She had no exercise, we treated the low it came up, we saw how much she could use it pointed out, she's like, Wow, we got like more done than I thought we got done, she was so excited that she could actually see. And it was simple sugar, right. So she didn't treat with something that had the fat or the protein that would have later potential impact that you couldn't figure out, it was just glucose tablet.

Not so there's so much to learn. If you just step back a little, and widen your vision, and you know, and you have to get rid of that I failed or this is a mistake or a problem feeling. It's just data coming back, like look at it and really accept what it is instead of being upset with yourself. Because you can't because I said it this you know, I say it a lot. But this weekend, I was really pointed with a pretty large group I said, every time something goes the way you don't want it to go. And you don't use that as a as a moment to collect the data and make decisions and, and and further your understanding. You wasted that moment. And you're going to have to have it again now because you didn't pay attention to what happened. It's just like I mean, what's the saying Right? Something about history doomed to repeat it right? I don't know the exact thing. Right? All of you who know it now are repeating it in your head in your car. But that's the idea. The idea is it's happening. Learn from it. Don't just wring your hands and go I can't believe that happen. That sucks. I bet at this you know, right? This isn't fair at all. That's true, but isn't gonna help you the next time. So right cool. Jenny keep got anything else. I mean, we're right. Yeah, I

had two other one was something that I think is not addressed. Usually not addressed at all. Unfortunately, health factors, I guess, that we don't really want people you know, doing really, it's things like smoking. Okay, if you're a smoker, I'm sorry. But you know what smoking can have impact on on on blood sugar and some of the research that's out there that can actually show that smoking can impact by causing some insulin, because King is it's suggesting an inflammatory response in the lungs might make sense. So could have impact blood sugar wise. The other one would be drugs. Drugs can have impact potentially on your diabetes management. To, you know, depending on the kind of drug that you're using,

you're telling me that if I'm sitting at home really trying to figure out my insulin problems, and I'm not taking into account my heroin addiction, I make I'm leaving something out that's important to think about. Absolutely. Which which might be, which might be reasonable. Like, I think that people compartmentalize their thoughts sometimes. And you really sometimes don't see where the impact is actually coming.

Yeah. And as a variable, you may not be considering all of the things you could be doing for your diabetes management. If you are utilizing a drug, and it's, it's really your main like focus, right? Because diabetes isn't going to be a focus.

Are you gonna say drinking next, because I have one I want to ask about, okay, I'd say drinking.

Yep, alcohol itself, drinking, it's big one that I discussed with, you know, my teens and my college. Because it comes into the picture it does. Learning how to do it safely, is an important thing, because the impact of the alcohol itself, you may have your fantasies, sugar, you know, juice sweetened beverage, the alcohol in it, however, is going to have impact later on your blood sugar. So what we find is that hours later, if you've had enough alcohol, it could cause a drop in your blood sugar.

And and not for nothing. But when you're really loaded, you're probably not doing your diabetes, math as well as you probably could be. So is it fair to say maybe have a buddy with you explain to them, like, you don't just need a sober driver, you might need a sober basal tester to somebody. These things just made me think of her because I just did an interview with somebody who's like clinically depressed and has type one. And to watch the cycle of how it hit this person over and over again, was just like, it's crushing, you know, to see, but for them to have to live with. So now I'm thinking, if I'm on a depression medication, is that affecting my blood sugar? Is it making my blood sugar higher? Giving me anxiety more, that it's higher and making me feel more anxious about you having to use extra insulin in What about just the, the, the physiological, and maybe you don't know, but experience of being depressed? Like Does that have an impact on you?

It's, well, depression is a stress, right? So it could be it could go various ways. If the depression isn't being managed with, you know, assistance, whether it's counseling, or use counseling, and medication or whatever it might be, you know, that in effect could be enough of a stress that it is bringing your blood sugar levels up. It depression can also mean that you're just, you're just not eating. So it could very well maybe bring insulin needs down, because you're just literally not taking in anything through the course of the day. Now, some of the some of the medications, some of the oral medications, will make you feel so much better, which is purpose, right? That's the purpose. But some of them also increase appetite. If it increases appetite enough, and you're not cognizant that that's what's kind of happening and kind of rein that in, you could have weight gain that could impact your insulin sensitivity.

I'm going to add a thought to this, because I had a conversation with somebody online, who told me something I never considered. So this person was overweight. And so their eating was more than they wanted it to be. And so when they counted their carbs, and when to give themselves insulin, they wouldn't give themselves all the insulin they needed, because it reminded them that they were eating more than they wanted to be eating. And I know that's a real interest, you have to wrap your head around it for a second, but they were disappointed in themselves for eating that much. And one of the ways they pretended that it wasn't going on was to use an amount of insulin that a more normal meal would have. Yeah. So there's a lot of things I wrote, you know, as we started this conversation today, I wrote down life because the variable really is life. Right? Like it's your living, and there are different things happening to you. And whether you're, you know, addicted to drugs, or you're depressed, or you just don't have your basal, right? Or what are all the things that Jenny's brought up here today. Really, it's just it's you're alive, and you have diabetes. And so they're going to be variables. Are there any more on your list if you're looking over? The other one

was kids growth cycles,

oh, growth hormone.

And I think you know, I mean, that is a it's a broad topic. So I bring it up as a variable. It may need full nother discussion potentially, but it is it's and people act. You know, we're the last kid. Lots of ages. I mean, little younger than two is my youngest person, and kind of up until like seven days is my oldest and but the key Kids have these variables of growth that just drive parents crazy. Because become, you know, we've got things smoothed out and beautiful and one of the biggest things I tell people is the needs will change. We'll get them figured out, they'll probably look like they're going along pretty nice and that oh, you know, little Johnny is going to burn up, you know, a half an inch. And so for the next couple of nights, they may get these like, like you said, Arden goes to bed and her blood sugar, kind of like drops off in a growth spurt. Many kids go to bed, as soon as their head hits the pillow pillow and they're snoozing, man, it's like a rocket ship to the moon blast off blood sugar. That

is the worst part about growth hormone and children is that it happens while you're trying to sleep. That really I have to give Arden her Bolus really quickly. This one's gonna be easy, though. Because Arden's doing the loop right now at carbs. Taco. That's it. Wait, wait, hold on, hold on. Time, 10 minutes from now. At carbs Taco Time, change time to 10 minutes from now, that isn't going to make sense to you guys yet. But it will one day when Jenny and I talked about that and and Katie De Simone comes back on and tells me all the things I did wrong while I was setting up my art and sleep. And how I could have been how I could have avoided them.

Yes, I can. That's great. Because that was like my last little tidbit of a variable, which is a total different discussion. I'm glad you're gonna have it with Katie, but you should discuss with her the looping variable. Because these all have different if you are using a looping pump.

Oh, Jenny, this is going to come out before I talked to Katie. And so I'll just tell you now and then you guys can all hear it now and then hear me talk about later with Katie. Every every thought I had trying to set up the loop was wrong. Like, like, like you don't I mean, up, down left, right. Like everything. If you asked me, you know, yes, though, I'd say yes. And you'd like oh, no, you know, I sent Jenny attacks. I'm like, I'm seeing this. Should I move this up? She go, no, no doubt, I'm gonna How do I get that wrong? It's just it's so all of us. Right now, everybody who's listening. If you're being bold, if you're following along with this podcast, obviously, it works fantastic. And there's no you don't need to change. But if you go to looping at any point in your life, or into a closed loop system, the variables, the settings that allow the loop to think are counter intuitive to what we're all doing, when we're not looping. But I am putting myself through this so that I can explain it to you all better. Because if you guys want to move to a closed loop in this future, I think that's not a bad idea. And I want to make sure you understand how to transition from being bold with insulin to being I don't know, bold with

blue, or how to maybe let loop Be bold with itself.

Yeah, there's a way but trust me, I still only understand that about 65%. But by the time I'm done talking to Katie, and by the way, now that Jenny has been kind enough to say that she's going to continue coming on like this. I don't think we'll be putting them out like three at a time, but maybe once a month, or as often as Jenny can do it. And trust me, we're gonna get to talking about that as well. So thank you so much for doing this. Thank you, wherever you are right now, I imagine you applauding for Jenny, just a slow, deliberate and lovely clapping. That's how I feel every time she's on. Hey, how about that great news. Jenny is going to keep coming back on the show. The diabetes Pro Tip series is going to go on into the future non stop pro tips just for you guys for listening to the Juicebox Podcast. I want to thank Ascensia 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 Gvoke glucagon find out more about Gvoke HypoPen at G Vogue glucagon.com Ford slash juicebox you spell that Gvoke glucagon.com. Forward slash juicebox I hope you enjoyed this episode. Now listen, there's 26 episodes in this series, you might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001 all about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs in Episode 1015, Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two in Episode 1018 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and an episode 1025 We talked about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics. Scott brings useful information and presents it in digestible ways. Learning 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 A1C 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.

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 CDE 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 revisitable. 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 health care plan or becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by Ascensia 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 Juicebox free meter while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke HypoPen Find out more at Gvoke glucagon.com forward slash juicebox Hello everyone and welcome to episode 237 of the Juicebox Podcast. Today's episode you know by the title is with your favorite guest Jenny Smith, Jenny and I are here today to add an 11th entry into my diabetes Pro Tip series. Please don't let the fact that this is the 11th episode in this series make you think Basal rate testing probably not that important. If it was they would have moved it up sooner. Not even close. Having your Basal insulin correct is the core of everything you're doing with insulin. You can't trust that your Bolus was right or wrong. You can't understand why you got low or why you got high. When your Basal insulin isn't correct. Everything you see coming back to you from your blood sugar experiences from your glucose monitors from your meter testing. None of it is actionable. None of it is valuable. If your Basal isn't right. Every time I speak with someone privately, we start with Basal insulin doesn't matter if you're pumping or injecting, and most people's Basal insulin is significantly incorrect. If you're seeing blood sugars that you don't understand, it's easy to see a low blood sugar and think that means less basal. But that's not always the case. At the end of this episode, I believe you're going to have a firmer grasp of what Basal insulin is, how to make adjustments to it and why it's so important. You really need to listen to this one. This is where it all starts. A funny thing happened the other day, I felt like we did such a great job of outlining everything that everyone would need to know. And I was so comfortable with it that I started supporting the podcast episodes with like social media posts like hey, don't forget how important your Basal insulin is. And the the amount of notes that I got that were like, Hey, you didn't do an episode specifically about setting up your Basal rates. And I was like I didn't I felt like we covered it all is what we talked it up. But okay, if you want it like so let's add one that's about setting up your Basal testing and getting it right. And I was like alright, well we'll we'll definitely do that if the people are asking for a journey than we have to deliver. That's right. That's what I'm

that's what we're thinking so alveolus so,

so I wanted I would like to do that. Now, here's how I imagined this. And I'm recording already. So this will probably all end up in the opposite. I'm assuming there's a super like specific way because I remember being taught at like, you know, in the doctor's office, like very specific don't eat food for this much time like makes you feel like this whole thing and this is what your Basal rate is going to be Now, there are times when I think that's antiquated. And as much as if you have a CGM, you may be able to figure out your basal more quickly. But I'll cover that when we get to my less technical way of doing it. But I really do want to start with what is the accepted medical process for figuring out what your Basal insulin should be? Check out dancing for diabetes at dancing for diabetes.com. That's dancing the number four diabetes.com. You can also find them on Facebook and Instagram. Fantastic organization, you should check them out. At the very least get involved if you like what you say. What is the accepted medical process for figuring out what your Basal insulin should go crazy, Jenny, because I feel like you're gonna get to talk a lot.

Well, I mean, the accepted medical way to do it can also vary. You know, I've heard, I've heard a lot of different but I've also heard heard enough similarities that you, I guess, our medical way to do it within integrated when we start working with somebody brand new. That's a first and foremost question, Have you verified that your Basal is are working well, and Basal evaluation can also be done using injected Basal insulin as well, not in the same way or as extensively as a pumped Basal rate, right. But you can evaluate to see whether or not your Basal injected insulin is working pretty solidly to Okay. So both of them can be looked at. As far as pumping, we always start with an overnight evaluation. And the reason for doing overnight testing first is one majority of people, unless you're a shift worker, or overnight truck driver or something, most people are sleeping in that overnight time period, there's no eating, no exercising, there's no food going in anyway, it's like one of the easiest times of day to actually get a Basal test in. Okay. The biggest thing heading into any basal test is that there isn't any food that's going to be impacting in that basal time period. And there's no lingering impact of your Bolus. So for an overnight test, we aim to say, have your dinner in Bolus by 6pm. Because by 10pm, when most people are going to bed, give or take depending on if you're a little kid or an adult or whatever, by 10pm that Bolus itself and 99% of that food impact should be gone by 10pm in out kind of the bell curve of effect, right? So from 10pm overnight and into your normal waking time, then we get a true look at what is basal doing to hold things steady. Now the other variables since we had an episode about variables to write I did that comes into play with testing. You know, if you are in those couple of days before your period is starting, if you have a nasty cold if you have a lot of exercise because of training or practice or something, you don't want a Basal Taff on an overnight when any of those pieces are. Right, you

know what I wonder, too, is I'm starting to believe that there's a different Basal rate that my daughter needs depending on our site. So I think there's a leg Basal rate for her and I think there's a belly Basal rate for

that's actually funny I used when I use my upper bought for my knee pads. Prior to looping with a Medtronic pump. I noticed that on my butt, I need about 10% More Basal insulin. And so I set up a Basal profile that I call but

I could definitely say but yeah,

I called it but and I had it 10% higher than my standard tested Basal rate, right that ran on my other normal sites, which seemed to work the same. So you're not crazy in thinking that it could be the case and it's something I bring up with people too, especially those use Omnipod, which can you can wear it in a lot of different places compared to conventional tube pumps, right. So overnight, the goal of Basal testing then is to have fair stability, and not like this entirely flatline. But the goal is to not have more variance than about 20 to 30 points up or down from where your fingerstick value at 10pm is. And the goal at 10pm. Once that Bolus from dinner and the dinner food is pretty much gone. 10pm your blood sugar you're aiming for it to be somewhere between 80 and 250. I know that looks like a broad range right here. thinking, oh gosh, if it was like 150, I'd totally correct that at bedtime, because I don't want to sit at night all night at bedtime, you know, 150, you let it lie, you don't touch it, you don't take corrective, you just let it sit. So if you go to bed at 188, you leave it alone. Because the basals job is to not correct that the Basal job is to hold you pretty steady. If you're not going to have more than a 20 to 30 point variance up or down from that. That means all night long, you shouldn't really go more than like a little bit above 200. Or maybe down to like the 150s if you started at like 188.

And if you wish that then you imagine that the Basal is pretty steady, correct. Okay, correct.

If you accomplish that with little variance, but not a lot, and you wake up, let's say at 169, awesome, your Basal, we would hold it, check marked off in our box of records as stable tested. It's good. Let's move on to the next testing period. Now, let's say your basal does show that it's not right. Let's say that 10pm 188 blood sugar, but by 1am, you're starting to see a drift up. That's significant. And by two or three o'clock, you're like 50 or 60 points higher than you went to bed at. Absolutely, there's something wrong. Now, where do you adjust? That's the next big question. People are like, Well, I was high at two o'clock. So I changed my basal at two o'clock, so that it wouldn't be high anymore. That's actually it's kind of missing the boat, right? Because where you really want to adjust the Basal is about one to two hours prior to the drift to being too high or too low starts. Okay. So if you're too high by 2am, you probably need a Basal adjustment, at least by 1am. Or maybe midnight, that's higher, so that you don't have the drift up in the next two hours. Yeah.

And that's and for people listening that get confused by that. If you think about Pre-Bolus, and you put insulin in, it doesn't begin working for a certain amount of time either does Basal insulin, and you're using much less of it. So to get a real impact from it could take some time for to build up its efficacy, I guess, right? And then be able to hold you stable.

Okay, correct. Yep. So that's circulating insulin level, that's a great description, it needs some time to bump up or bumped down to the rate that's going to be then effective an hour to two hours from now at that rate.

It's the same reason, same reason why when we tell somebody if your blood sugar is super stable at 70, and it's been like that for hours, and you haven't had any food or you know, insulin, and you want to try to bring it up by doing a temp down, you can but if your blood sugar's falling at 70 Shutting off, your Basal is not going to do anything to affect what's happening right now. Now, you'll make your blood sugar high, two hours later, right after your seizure.

Right. Exactly. Right. Yeah. Or after you had, you know, 30 grams of a Juicebox or whatever. Yes, exactly. Yeah. So it seems same thing, you know, if you're drifting down, you adjust the Basal down a little bit, still in the same timeframe, one to two hours prior to that drift starting, so that you don't get too low, later. Now by how much? I mean, again, this is where it does vary a bit. But usually, you know, if the drift up is somewhere between like, if the like 30 to maybe 60 points higher or lower than you want to be within that time period, and adjustment by point 05 to the Basal rate, could be enough to make a change so that you're not drifting up or down. If it's more significant drift, and you're really rising like 100 points, you started at 188. And by 2am, you're at 280. That's, that's a pretty big change. And again, we would probably adjust the Basal at least by point one, maybe even point one, five. Depending,

you know, what's interesting is that I know this isn't like any kind of hard and fast rule, or it is and I've found it by mistake, but I talked to a lot of people with kids, you know, younger children. And it seems to me that the rule of thumb is point one per 10 pounds of body weight with kids. I don't know if I don't know if that ends up working, is it for adults or not? But the more people I talked to, the more I see, like that's what makes sense. And I don't know if it's an anomaly for me. But when you have somebody on a phone call with you, which you know, telling telling you something about themselves. And it's like, you know, I'm doing this and it's not working and blah, blah, blah, and you need somewhere to start like it doesn't you don't even you need somewhere to start. And I always ask like, well, how much do they weigh? And most the time it bears out but then recently I spoke to somebody, it wasn't even close. It didn't matter. The weight was unimportant. That child just did not use the insulin the same way. Right Think of basal in a completely odd way. I think of it like volume, right, like on a on a stereo. And I just think if you can't hear it, or if the basal is not working, turn it up. And if it's too loud, turn it down. And because Arden's using, you know, a Dexcom, G six, I, I just turn it up until she gets where I wanted to be, and then I dial it back a little bit. Is that a bad thing? Am I doing that wrong? Is that is that irresponsible? Which by the way, in the last 10 years has become a word again, I don't know if you know that. You're irresponsible. There was time grammar people would be like, That's not a word. You can't say that. And all of a sudden, it's been come acceptable, and like the last half a decade or so. So now I feel comfortable to speak improperly again. So you're responsible? Is it irresponsible?

irresponsible? Well, I actually use that word with my six and a half year old all the time. So I guess I've been using it more appropriately now. And I thought, yeah, that is irresponsible to do that. Do not do that. You know? So yeah. Anyway, I don't think I don't think that that's irresponsible. I mean, you're doing again, and again, in the topic of basal specific adjustment. If you're talking about temporary basal adjustment, you we do that a lot to dial it up to dial it back to kind of you know, and that's also the concept of looping, right, is that the system works according to what it sees happening to the blood sugar and the insulin that's active in the food that's active, and it may dial things up, and it may dial things back. So that's, I mean, definitely not irresponsible. When we're talking about setting true basal though, we really want to make sure that we set the the basal rate itself in the profile the right way, and you can dial it up, you know, if you want to be truly bold with insulin, you may want to dial it up a little bit more than you think you may need do another Basal test. And then if it doesn't work quite well, because now you're ending up lower than you wanted. Great. Just dial it back a little bit in the adjustment that you made. But at least it'll be a better picture. You know, overall, and you can always test over and over again. Most people hate basal testing, myself included. Well, listen,

that's I remember getting the sheet of paper handed to me when Arden was two. And they're like, the first thing we're gonna want to do is basal tests. And I looked at the sheet, I'm like, Well, I'm not doing any of this. But okay. And you know, looking back, it really should have done it, you know, especially back then when there was no CGM, and you know, none of that stuff, and I really shouldn't have done it. But, you know, no food being digested, you know, no act of insulin, like how am I going to get like a little kid not to eat for five or six hours? And I did eventually figure out that overnight was the place to begin. And you can, to some degree, infer the daytime from the nighttime meaning, meaning, you know, if it takes a unit an hour overnight, you're probably not five units an hour during the day, you're probably somewhere near that unit. Right. Right. And it could be I mean, it could be significant i right now, Arden is more like a unit overnight and more like two units during the day. Right. So in, but that also will go back and forth. It just changes. I will say this, because you you alluded to it earlier, and you were just talking about the idea of Basal testing, like I know a lot of you don't want your blood sugar to be 180 or 200 overnight. But for this test, maybe that's what has to be, I'm really coming to realize that an incredibly flat line one that's 85 for 24 hours a day is really not reasonable. It's doable, right? And sometimes you'll get it and maybe you'll get it for days in a row if you're really dialed in. But you can't be upset if a blood sugar goes to 160 for 45 minutes and comes back again. It just my blood sugar goes to 160. Like if I sit down there to play two pancakes today, my blood sugar is going to be 160 Probably for a couple of hours now. Different situation right? And I don't have the other impacts of type one diabetes like people with type one, two, and I get wanting to limit it. But everything we've talked about on this podcast for the last number of years, I've seen it intersect with art and becoming an adult. And so do I think you can keep a 90 blood sugar forever if your kid hasn't hit puberty yet? I bet you can. Right? I think it's super easy. I think that when you get At to puberty, I don't think you should beat yourself up if that doesn't happen. And and I can still do it most times you don't I mean, like, don't get me wrong. But I don't know, like, it's, it doesn't seem as important to me it almost seems like a video game. Now when I step back and I watched people online do it, for instance. And they're like, look at this graph. And I'm like, that's amazing. And then there's part of me that wants to say, show it to me 10 days in a row, and then I'll get excited, right? Like, don't just show me one in the middle of May and go, Hey, look what I did here. And that's why, you know, on my blog, I tried to put things up that are like, look a little wrong, everything went today, or didn't say once he's still under sick, you know? I don't know, I just, I want you guys to realize that we don't want spikes. When we get them we want to bring them back down again. But if they happen, you cannot run around like you've lost some, you know, Game of the attached to your mortality somehow. You know, if your blood sugar's always 200 Yes, but you know if it jumps once or twice, come on, like ease up a little bit. Okay, right. So how reasonable is it that once I basal test, I'm actually going to know what my Basal rates are. That remastered diabetes Pro Tip series is sponsored by Ascensia 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 Juicebox free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash Juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and 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.com forward slash juicebox free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips, you can use my link and save time and money buying your contour next products from the convenience of your home, it's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now, through your insurance. Contour next one.com forward slash Juicebox for a meter go get yourself a free starter kit. while supplies last US residents only touched by type one has a wide array of resources and programs for people living with type one diabetes. When you visit touched by type one.org. Go up to the top of the page where it says programs there you're going to see all of the terrific things that touched by type one is doing and I mean, it's a lot type one, it's school, the D box program golfing for diabetes dancing for diabetes, which is a terrific program. 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 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. Gvoke 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 vo glucagon.com forward slash juicebox Gvoke shouldn't be used in patients with pheochromocytoma or insulinoma visit Gvoke glucagon.com/risk. The other times I basal fast and then I don't have any better of an answer.

There might be especially if like I said before, if you're doing some basal testing and there are variables at play that you didn't really think to pay attention to in that time period. Then absolutely though that basal test could be not very purposeful it could be kind of null and void. And this is something I encounter a lot with women and something I bring up when I work with them to begin with in a in a first visit. is one, you said you've done basal testing, but two, or you know your cycle impact if you have one, and two did basal test in that sweet spot of like two to maybe three weeks whether women are on birth control or not, they're sort of like this two to three weeks of sweet kind of play of management without significant hormone impact. And that's where Basal testing needs to happen. It needs to happen without the impact of the pre cycle, or ovulation hormones kind of coming into play. So if you haven't basal tested in those sweet spots up completely wrong, what's happening and what your basal needs are. Once you do have that sweet spot, put into play, then auger. And this is an important piece that a lot of people ask about too, is great. So then I need to test and these other times, well, that really, you know, what we find is that women mostly need like a 25 to maybe 40% increase in a hormone specific time period of the month. If you know that what you can do is use a Temp Basal, see how well this is work. And what you can do because the time periods during the day that your Basal goes up or down, physiologically those times will remain pretty stable. Those shouldn't need to change, it may be that you just need 25% More between 6am and 10pm. Right. Okay, so you can plug that into a Basal profile, set it and turn it on or enable it when you need to. But those time periods of the day, they stay pretty stable. Once you've designated Oh, my Basal needs go up at 2am up, they shift down again at 8am. They're pretty stable until four or 5pm, they might go up or down again. Another piece for Basal testing is that most most people, again, your diabetes may vary. But most people will have about four will most people have one valley and one peak to their Basal during the day. So let's say they start midnight at point six, it might go up to point eight by two or 3am. Maybe it goes down around 8am 9am to like point six again, and then through the day it stays kind of lower, and then it may shift back up into the evening time. Okay, so you kind of had one dip in one rise through the course of a 24 hour time period. Again, that's most people, not everyone. Most people also have about three to five Basal rates through the course of the day or basal time periods. So, you know, Midnight Until 6am 6am Until 4pm 4pm to 9pm 9pm to midnight, those time blocks. Most people have about three to five different segments of rate need through the course of a day,

you have to stay flexible too. You can't just say to yourself, look, I've set this Basal rate, it starts at 3pm and ends at 7pm. It always works. And then Thursday comes in at five o'clock your blood sugar starts to drift up, and it won't stop drifting up. You can't lock yourself into that doesn't make sense because my basal always works. It's not working now. And the reasons you know, we talked about this throughout the years of the podcast, but the reasons are almost unimportant in the moment. The truth is your blood sugar. Yeah, yeah, right. You need more insulin, use more insulin. And and I've come to start, I've begun to start saying privately that that the diabetes, your blood sugar, it's requiring more of you. So give it to it. You know, it's telling you something your blood sugar going up is your body's saying, Hey, I don't have enough insulin. Don't like wanna hear why just believe it. You know what I mean? Like, there's no reason to, I don't know, if you came up to an intersection. And there was a cop standing there with his hand up and says don't go around the corner. There's a guy with a gun there, just believe the cop and don't go around the corner. There's no reason for you to peek your head around the building. Oh my god, there is a guy shooting there, like just take his word for it and walk around the block. And so move away. So when your diabetes is telling you, hey, I don't have enough insulin, just believe it and give it more insulin. I got this beautiful note this morning from someone who said they were listening to the last episode. And she said, I think she called it like a bat in the head moment where she was just like, oh my god, I'm an idiot. Why am I not using more insulin like like, you know, running around all day looking at her blood sugar going, what's wrong? What's wrong? What's wrong? What's wrong? And she said, we must have said something on the podcast. And she just was like, oh, but sometimes that that happens like because you get so narrow focused on the things that are supposed to be happening, that you can't break away from them for a second and look at actually what's going on. You know, listen, people this is good life advice, too. If you're fighting with a spouse or a girlfriend, and you're saying to yourself, I have the best intentions here. Why is she upset? It doesn't matter. She is you know, so you're doing something wrong. Forget figuring out what it is. You're wrong. Stop or That's it. Yeah, I've given you a number of ways to think about this. Now, when your blood sugar is going up, give yourself more insulin. As a matter of fact, Jenny, my next t shirt is going to say, more insulin. That's the next t shirt. I'm going to print if I can ever figure out how to one. Absolutely. Jenny deserves a t shirt. All right. Everybody's always like telling me it's so easy to print t shirts. How can you not figure it out? It's like, I'm very busy. Leave me alone. But I'm trying. Anyway.

Yeah, I think that's also a really good point, Scott, because if this is where you could also say, is it a trend now? Like you said, 5pm, my blood sugar is going up. I don't know why I don't have any active food. I don't have any active insulin, it shouldn't be going up. I felt like things were pretty good up until today. Great. Well, you know what, tomorrow if it's happening again, the next day, if it's happening again, something shifted? Why? Again, don't play with the why I mean, you can go back and evaluate and look at some things and whatever. But in the moment, you say, You know what, it looks like my blood sugar is starting to go up by 435 o'clock every day. And I'm high by six o'clock, and I keep adjusting and correcting. Don't do that. Right? Adjust it, make an adjustment and go forward. And then you know, what, if it shifts back down? Great. If a couple of days, you're ending up low, then you shifted back down again. Yeah. See,

you're you're highlighting something that I've never understood when people say to me how many days till I think it's a trend, and I should change. And I'm always like, good, what, like by the time you by the time you suss it out three days later, it might go back again, now you've given away three days, your blood sugar at that level, get just learn. Don't ask your wife, are you really going to wear those pants, like she doesn't like it when you say that to her right leg, Sue, so stop and don't don't do it again, like, my blood sugar went up at five o'clock, I did something about it. Tomorrow, it went up at five o'clock, I did something about it. The next day, I'm not even let us get to five o'clock, right? I'm just gonna decide, I'm going to expect that what I know is going to happen is going to happen. And I'm gonna deal with it ahead of time. And if it happens to not go that way, well, then I can dial it back again, right? But it's so much easier to ramp up your insulin and bring it back than it is to

sooner than later. Where many times doctors will say hey, you know, follow a trend over the course of a week. Well, that's five to seven days, then that you have chunked out higher or potentially lower than you want blood sugars, because you're trying to find a trend. I mean, in pregnancy with the women that I work with, we say two days of a trend, we're making an adjustment. And you know what if we need to dial it back again, for whatever reason, we will but we're not leaving things travel higher or lower. For more than that time period, we will adjust and then we'll adjust again,

and for all of you who have ever said to me, yeah, I'm going to handle that the next time I go to my doctor three months from now you make my brain hurt when you say things like that. Okay, just please do not wait three months to address something even. I just yesterday, had a person who won a giveaway that I did with dancing for diabetes, and they you know, we had a phone call together. And this person, this is great. A person in their 60s who decided to get a CGM and a pump and you know, is very excited for themselves. And then she said, you don't have a doctor's appointment July, is it? No, no, don't wait till July. I said write an email right now. Hey, Doc, guess what, I'm getting a Dexcom G six, and I'm getting Omnipod. Go ahead and send those prescriptions in for me, I want to do that right now. And when we get I'm excited to come to you in July, and I'm gonna bring my new stuff with me, you can show me how to do all of it. And I said, and if you never make it there to show or maybe you figure it out on YouTube or somewhere, whatever. And you know, and you know, but or maybe they'll send a trainer to your house. I think that is the appropriate thing to say right? And but but I was like don't wait till July. So because a July is six weeks from now, six weeks from now you're going to tell the doctor what you want. They're gonna wait a week because people don't do things right away for you. They're gonna send in their prescriptions for you, then you're not gonna get this pump for six months. If you do that, like start today. Go right now. Be proactive.

Yes, with technology the way that it is and electronic medical records and things like my chart and things that you can send back and forth. There is no reason to not communicate between with a doctor and you know what if you don't get a response from them within 24 hours, you call the office and you ask to talk to their nurse, then you say this needs to get to the doctor needs to be signed, it needs to be taken care of.

Arden's endocrinologist and I have been adjusting her Synthroid Arden is taking Synthroid and site ml now and we've been making we've been making adjustments by email. But But what's taking and it's still taking a long time to get it straight. I imagine if I only made the adjustment every three months when I saw Arden would be like a puddle on the ground. When Arden doesn't have enough Synthroid. She can't pick her head up off of the ground. She just slumps over and she's like her her blood pressure Blood pressure gets incredibly low. And she looks like she's dying the whole time. And so once she has more Synthroid, she sits right back up again. It's, it's literally like grabbing a marionette bytestrings When When she has not centered, but if I had to only make adjustments to her medication quarterly, it might take us two years to get it right. And we might never because she's growing and gaining weight throughout that time.

And think of her education in this time period to what would she be getting out of her classes and the ability to perform and any athletics that she likes to do and the enjoyment of fun with friends and everything? I mean, that puts a major cramp in any age, whether you're a child or an adult trying to perform in work or whatever. Yes, I mean, any adjustment it needs to be addressed in the here and now not waiting three months to say, Oh, well, Doctor, you can see my see as such. Hi. I've been having a lot higher blood sugar's I didn't know what to do. But I knew I had an appointment. So I waited until I came to that. Yeah.

All right. standing out front of your house, and you had your garden hose in your hand, and your porch caught on fire. Would you stand there with the hose saying, Oh, the fire company will be here soon. I don't need to squirt the hose at this porch. Why would I do that? The fireman is coming. He's a professional. I'll let him handle it. Just hold the hose. I get started with my hose. Right? Yeah, why don't I just see what I can get accomplished here. All right. So bringing this all back to your Basal insulin, because no one thinks about their Basal insulin with nearly the importance that it is I spent the first 10 minutes of a conversation the other day explained to a person what it was. And after I explained it, I had to explain it again. And so and you can still hear people go so that's the level mere like people on MDR they're like so and I get it like they're newly diagnosed maybe sometimes or they never got a firm explanation. But we treat Basal insulin. Like it's not important. And it's everything. It's it's so much more important like it can we say it all the time. Everything starts at basal. basal is not right. Nothing else works coming off of it.

Well, and so many people think that Basal job is to bring blood sugar down. Right? So many people I mean, people I've worked with who've had diabetes long term who've come in and you know, I look at their records to begin with and they're confused and annoyed that their Basal insulin isn't letting them wake up at a target blood sugar. I just stay high all night long. Well, you're starting the night high. So something I mean, time chunks of the day. Usually where you are now it's because the hours ahead of that something isn't right. Yeah, it's not the here and now it's the what happened before this that got you here. So let's look No I wanted my basal should is here, here and here. And it should be bringing me down. No, that's not basal job. basal job is to hold just steady. If you didn't eat all day long, you shouldn't have much variance.

diabetes is like a time travel movie. I've come to think of it this way. Right? Like it whatever is happening to you in the moment when the cameras pointed at you has nothing to do with what's in the frame with you. It's not a it's not a murder mystery. It's not somebody stabbing you and going, Oh, this is what's happening right now. It's the guy in Act One set something down on a table and an act 325 years later that thing is how come you blah, blah, blah, blah, blah. There are things in the past. There's decisions you're making right now with your diabetes that are going to affect you in three hours, or six hours. And it's not now so much like it's interesting to how people overreact to the idea of Pre-Bolus Sing originally. Because when their blood sugars are out of whack when they're really first starting to get things together and they're jumping up and down. They're so reactive to everything they see I did something and then this happened. And I always tell people if you Pre-Bolus and two minutes later your blood sugar starts dropping that has nothing to do with the Pre-Bolus Nothing. That's why when you know when you guys hear me say Arden's blood sugar was at five and I Pre-Bolus there because she was stably at five for three hours, the Pre-Bolus isn't going to start working right away. I only needed her to get to lunch 10 minutes later.

The only reason it would start working right away is if you physically had that cannula in a vessel, right? It was literally going right into the vein popping into her bloodstream.

Right? So in normal situations, which Jenny's bringing up probably because she knows we actually had a pump probably Nick a vein in art and one and for two days I could we couldn't get her blood sugar to go above like 50 Most of the time until we finally just changed your sight and everything went back to normal but that was anyway that had never happened before that was crazy. For the I'm texting Jenny like you should have seen the texted Jenny I sounded like you guys sound when you email me. I was like, I don't know what's happening.

Better so much.

I wasn't with her. I was in Florida doing dancing for diabetes. My wife's at home going seriously. This is what's happening when you leave and I was like, I don't know how to explain any of this. I said I've looped in the genuine gotta figure it out, you know, but, but anyway, yes, the point is, is that timing of your basal, just as important as the amount of your basal. And to Jenny's point, for those of you who are thinking that basal is in charge of bringing your blood sugar down, it's not, it's in charge of keeping your blood sugar stable. And I say all the time, it's a stupid thing. But do it with me here. Unless you're driving, hold your hands together in front of you, like, you know, in like the classic, you know, prayer prayer session, right? Imagine your body function and, you know, sugar on one side, and your and your and your basal on the other side, and they're both pushing each other towards the center. And when nobody wins, right, when your hands don't move to the left or your right, that's a good Basal rate. When you start moving towards body function, then your Basal is too high. And when your body function starts pushing you away, then your Basal is too low, you're trying to just give the Basal enough strength to fight off the background things that are happening in your body. If I right, right, and when you eat, you know, a reasonably normal meal, that basal should also, you know, help with your Bolus, but don't expect that if you're going to eat like an entire pizza, that your point six Basal rate is going to be okay. Because it's not. And then so that's, that's another thing. So once you get done Basal testing and figuring out your Basal for all your normal times when you're just standing around being you amazing you that's one thing, what about your Basal insulin while you're eating? And those tests have to happen in real life, while you're eating? You have to say to yourself, when I eat a salad with a burger, my blood sugar tries to go up. I wonder what would happen if I did increase my Basal rate during that? And you know, I mean, for those you've been listening for a long time or after that, or right, right, maybe it's pizza doesn't hit me for 90 minutes after I've eaten it, you know, or any other thing like french fries, or had French fries the other night and must have made her high like four hours after she you know. So

it's that's just understanding again, that's why we also start with the overnight test it because if you can wake up in target, you are not fighting being too low from excessive insulin dropping you and you're not fighting being too high and having to correct and add insulin in a time that you're most people are insulin insensitive in the morning, right? Yeah. So we talked about things like adding fat in Yes, your background basal, if you know it's solid and set to begin with, then you know how to play with that temporary basal feature to accommodate for long term impacts like fat fat causes, essentially a stress factor, it releases triglycerides into the bloodstream, which causes insulin resistance in the aftermath, it can last as long as 10 hours after eating high fat. Yeah, so most people need a Basal increase, it's like fat almost causes your Basal insulin dose to be reduced by 50%. So if you're running at a rate of 1.0, overnight, and you have this big ol awesome like cheese, meat lovers pizza at night, you go to bed thinking man, I nailed that Bolus, I'm going to bed beautiful. I'm like a 103. I'm going to sit here all night, it's going to look awesome. At two o'clock in the morning, you're at 300. And you're like, What the heck, you know, where did this, it's that usually fat starts to impact by about three hours, you get this leg drift, and then you get stuck high. And you nail it with insulin and you nail it with insulin and you nail it again. And then finally you might start drift down. By the time you wake up the next morning, you could have fought it ahead of time by using a temporary rate adjustment. If you know your basal to begin with is that well, you can increase using temporary basal and offset the impact of that fat.

I wonder if I can explain what's in my head correctly. Because when your blood sugar gets elevated, imagine it's 250 coming off of the pizza and you think oh, a unit brings me from 250 to 100. So I'll put it in a unit. That's great. But what Jenny just told you was you're at 150% need for your basal. So the unit really just keeps replacing the basal you don't have. So you put the unit in, replaces the basal keeps you stable at 250. But you still haven't addressed the number. And so then you wait an hour and I can't believe that didn't do anything and you put it in another unit. It doesn't do it again, because you're still just replacing the basal. You need a yak up your Basal rate and Bolus for the number. And remember that turning up the basal at midnight doesn't make doesn't mean it's going to start working really maybe until one or two o'clock in the morning. So what So in the end, let me get very close to the microphone. What you need. And I don't want to oversimplify diabetes is more insulin. That's what you need. You do not have enough insulin. It's just you need that T shirt. I'm telling you right now, I can't do this podcast forever. People are more insulin if your blood sugar is high. Hey, if your blood sugar is low, guess what? Let me just go at it right now. less insulin. There you go. It's not difficult, right? It's difficult to imagine the whole thing which is Let this podcast episodes about like, we're talking through a number of different scenarios where your Basal rate means something. But I think that I think that's it at the beginning here, Jenny explained a more clinical way to do Basal testing. I think if you have a CGM, I tell people who are speaking privately and they're like, how do I figure out you know, how much more basal to use? I just go well, you know, if it's a kid, and they're like, at point three, I'm like, well turn 2.4 and see what happens. And I was like, no, they started getting low, put it the point three, five, you know, and it has, because your kids blood sugar's sitting at 200. You know, like, with point, you know, point three going in every hour, point four is not going to make them nothing, it just doesn't stand to any reason. Common sense and diabetes is, you know, just like I tell people all the time, one of the best pieces of technology for managing someone with diabetes is text messaging, it is a Absolutely, like pivotal way in how often I deal with our blood sugar. If you don't, if text messaging is a is a diabetes tool, and it the same way, right? Just trying things is the diabetes tool, like give it a shot and see what happens? You know, point four, okay, now, let's see what happens. Not enough stuff,

even for little kids, you know, even the incremental of the smaller rate, you know, the point 05, or the point 025. You know, all of that is an option. It's not an Omnipod, but it is an option on the tandem and the Medtronic pumps. So that is an option to get smaller, incremental adjustments, depending also on what your sensitivity kind of seems to be. I think the only thing that we didn't really is like the daytime testing, honestly, you know, daytime means that if you really want to know what's happening behind the meal, to make sure that the basal is doing its job, the meal can't be there, right. So if you wanted to look at morning time, you'd really have to, for adults, you can skip a meal, because you can deal with that. You can just you can slug it out until lunchtime, and go ahead and eat your lunch and just see what happens in the morning when you wake up. You know fasting blood sugar, you let it sit, you don't Bolus you don't take caffeine, you don't eat anything. You can have water, herbal tea, or whatever. Don't go for a 10 mile run either. Look at what happens for little kids. I usually say You know what, if you can get them to sleep in a little bit longer, maybe on a weekend, at least you're gonna get an idea behind what their normal breakfast time is in that morning time to see did the basal carry them pretty well, or what I had one mother I worked with, not too long ago. She's like, he woke up and he just started playing with his Legos right away. He played with his Legos for a long period didn't even care about eating breakfast. I'm like, awesome. Yeah, that was a basal test. I was like, there was nothing. There was no food, no Bolus, he was sitting and playing with Legos. Fabulous. We've got information.

That's cool. That's x. Yeah, whatever you can do, just just but do it. Because you need to know. In the end, if you've ever spoken to me privately, what I'll tell you is, in a perfect world, if your basal is right, your blood sugar is going to be 90, it's going to be 85 or 90. Now, I don't expect it to always be that. But that's your goal. And if that's your goal, then it's when you're at 150. It's not correct. And also, when you're bouncing all over the place. If you're one of those people who right now is struggling and your blood sugar flies all over. You may turn your basal up and get a low blood sugar and think oh my gosh, that's because I turned my basal up. But again, it might have be about the Bolus you use before. So, you know, there's one thing I say all the time. That I think is how you start your Basal rates. First thing you have to do is find a level, just find a stability point, it doesn't really almost matter where it is just get your blood sugar to sit still. And if you have to nudge with food, to do it or not with insulin to do it, it's fine, but get stable somewhere and start over even when things go crazy here. I'll say that to Kelly, I'll be like listen, I said we're out like everything's out of whack. Like we got to find a stable point so we can start over again. And you know, you just can't. I don't know. It's like It's like trying to catch a. It's like trying to catch a ball. You mean like you gotta wait till it lands. Anyway. All right. Um, do you feel like we've covered it? I think for the most part yeah, I think we have to. I appreciate everyone who reached out and asked about a more specific episode about basal testing. This was it. I hope you liked it. Goodbye, Jenny. Hi. I want to thank Ascensia 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 Gvoke glucagon, find out more about Gvoke HypoPen at GE Vogue glucagon.com forward slash juicebox you spell that Gvoke glucagon.com. Forward slash juicebox. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed you're starting over episode 1001 all about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two in Episode 1018 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and an episode 1025 We 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 insulin so that is active as the carbs become active took me already from a decent 6.5 A1C 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. 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. 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 has 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.

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 CDE 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 revisitable. 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 Ascensia 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 Juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org. And on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke HypoPen Find out more at Gvoke glucagon.com. Forward slash Juicebox. Podcast I liked your idea, a lot of beginning ideas around blood sugar management with exercise because I hear from people constantly and I always think that my answer to them is incomplete. Because it's one of those things that I think I just know how to do. And I don't know why I know how to do it or why it works sometimes. You know, I everyone who listens to those at Arden played really competitive softball for years and years and years. And that that means at this part of the country, that means being outside in incredible heat. weekend after weekend, sometimes from 8am to 5pm playing 234 softball games, right? And I strive for a nice blood sugar around 90 Or I don't change my goals because of what she's doing. Right. And I also am not much of a pre planner, but I do I have spoken to people who are like, look, you know, I'm an adult, I'm gonna go to the gym at five o'clock after work, I need my blood sugar not to fall at five o'clock when I start working out or later sooner. And how do I do that? And I have to tell you, I know it's around Basal insulin and pre, you know, basically like setting Bezos up ahead of time or afterwards to catch lows and stuff. But I'm so reactive. I don't think about it that way. So how do you talk to people about it?

Yeah, you don't really have a I mean, as you've done for a long time, you're sort of like, you're surfing the wave of what's happening for art and and you're managing very well doing that, because you've intuitively learned how she reacts to things for the most part, right. But to teach people in a general sense, I think one, you said it correctly. I think it's around basal. Well, you're you're right in that it's around insulin. Most people,

my son, my son just well. I'm recording.

So the the insulin is really a big piece and a lot of people again, they focus on a number when they're going into exercise, but they're not focused on what's what's the causative to that number, what's affecting that number and where it may directionally go. So we talked about, you know, your person here example wise, who's going to exercise every day at 5pm. Well, for them, that's kind of a nice timeframe of the day because the goal there in a simplified way, would be no active insulin on board, so no Bolus insulin, you know, and they let's say as an adult, they only eat lunch at noon or one o'clock technic by five o'clock that Bolus should for them. most part unless they're looping, that should be gone. Right? And it would mean then, you know, aiming to either not have an afternoon snack or in which there's no Bolus that would be writing into the exercise. And then the Basal component, there is a lot of debate about should I adjust my Basal for exercise? When should I do it? How much should I do it by, and that's where it comes to be an individual nature of adjustment, because it takes you have to take into consideration the intensity and the duration of the planned activity. You know, if this example, you know, guy is gonna go for an hour and a half spin class, high low, it's sort of a high intensity interval sort of workout. And if he's only going in on basal, he could shut his basal down, not off, but lower his basal incrementally enough, well, before he actually starts moving, so that he shouldn't technically need much of any food at all, to continue that, let's say 90 minute spin class, for example. Yeah, adjustment to basal. Most people feel like they have an idea, I turned it off, you know, I turned it down, or I turned it off 30 minutes before, and I still went low, or I continued, I was low by the end, and then I continued to be low. The problem is that as we've talked before, circulating insulin level isn't lower or higher, until about 60 minutes post adjustment. And when you're really aiming to get into a specific target. For beginning exercise, your circulating insulin level should be low enough by that point, because this is kind of propelled intense, intense action of the insulin on a Basal level that you have now circulating. If you're normally at a 1.0 unit per hour Basal rate, and you knock it down by 50%. That 50% reduction should be started at least 90 minutes, if not two hours prior to when you jump on that spin bike.

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So this gentleman, you know, he should really reduce his Basal by 3pm. And he should reduce it for the intensity and the duration, at least by 50%. Again, these are kind of starting places and you'll find what adjustment works specific to you. But it's a good starting place. Now if he was just going to go for a walk for 60 minutes at a moderate pace enough to kind of bring up his heart rate a little bit but not crazy. Maybe his adjustment is a 25% Basal reduction, but it still needs to be taken back by at least 90 minutes to two hours before he takes that walk. Right?

It reminds me of a number of things. One there was I forget what it was called. Gosh, there was a thing that happened in there. And I can't think of what the name of the website is. It's gone now. Manny Hernandez website that's not to diabetes. Yeah, they used to do that thing every year where they kind of challenged you to get out and do exercise, right and check your blood sugar and see where it would fall.

So it was in November for the diabetes month diabetes Awareness. Yeah, check your blood sugar. Now walk or do something fun for 15 minutes of movement and check again,

right and people would see that their blood sugars would come down. And so it's the same idea except with lower lower numbers and tighter tolerances for exercise your blood sugar is going to fall or try to fall because of this exercise. What can you do prior to that, to not to keep the fall from happening. And I think that what ends up happening is there's two false narratives. Well, there's a false narrative that and a problem that people build around exercise and I think about going to sleep too with diabetes. The false narrative is if I make my blood sugar this high, that when it drops, it won't get dangerously low correct. If you're thinking that you are completely missing the point right the point should be that your blood sugar doesn't need to drop like that. Let's find let's find a way to live where it's not dropping out of nowhere correct and so but I see how that's the fix right? Like I see how that's what occurs to people I dropped 50 points. So you know let's start 50 points high points ever want to be right because the guy stuck a pencil in his pocket and then he broke out of the bank so the pencil cause the bank robbery like just the Falls not the the falls the falls. god what am I trying to say? Like like the fall is

it can be offset. If you think ahead about how insulin works,

it doesn't have to happen. And so you shouldn't be planning to stop the fall, you should be planning for a fall to never happen to begin with.

Correct or minimal enough that you really are not in danger because of the drop, right? I mean, exercise can even you know, even people who do plan ahead might see something like a 10 or 20 point change in blood sugar during or by the end of their exercise session. That's nothing, you know, if you're starting with a blood sugar of 110, and you drop 10 points, great, right at 100. Now, awesome. It's nothing, you know,

my expectation isn't that you can set your blood sugar at 89. While you're, you know, running a marathon, it's never going to move, but there are things at play while you're running, that you don't think about the you know, the anaerobic style of exercise is trying to bring your blood sugar down, but you've changed your Basal rate, which is trying to bring bring your blood sugar up. Also, maybe you have adrenaline, which is trying to bring your blood sugar up. So even people who have that stability, they don't 100% know why they have it. Like they don't really understand all the pieces that are affecting this number moving or not moving. Right. It's interesting that the other thing that you said, that feels problematic to me, because I hear so many people, like, every time I speak to someone, I'll tell him the same thing. Look, just start Pre-Bolus Sing and your agency is gonna go down like a point. And then they inevitably say, Well, I can't really remember to do that. And I'm like, alright, well, then your blood sugar's gonna go anyway, what do you want from me, you have to Pre-Bolus Like, this is how this is what you're gonna see, this exercise thing really is no different. They're still Pre-Bolus thing, they're just Pre-Bolus thing with their pre Bazeley. But with it with a with a reverse adjustments that have a more positive adjustment. And so I wonder how many people fall into that category? When they say, Look, I know, I'm going to be at the gym at five. But how in God's name, do I think about it at 330? You know, in that situation.

And so some of the strategies in pumps today, you know, there are alarms or reminders that you can set, you know, even in the PDM for Omnipod. You can set up alerts and reminders for things, I used to have one set up for reminding me to Pre-Bolus, so that I had enough time between that and actually starting to eat my dinner. I also had a reminder to check my blood sugar at bedtime. Not that I needed the reminder. But it was there in case I had a really hectic night. And I did forget before I like climbed into bed, right? So for things like a reminder, if you are pretty strategic about popping in your exercise every day at 5pm. Why not just set an alert or reminder in your pump to go off or even on your phone. If your pump doesn't do it or you don't want to set it there, put it in your phone and call it exercise adjustment or whatever you know. So it is that physical visual reminder. You have to turn the alert off. Oh, why did I set the alert? Oh, that's right. Exercise at five o'clock just

just two days ago, someone said my child will let does not seem to be remembering to Pre-Bolus at school. And I said oh yeah, Artem was terrible at that. And she said, Well, what did you do? I said, I just set up an alarm on her phone for when I wanted her to Pre-Bolus it would go off and it would pop up and say Pre-Bolus. And then she you know, send me a text and be like, you want to do this now. And we built on that. And that was years ago. And last year. She says to me, I don't need the Pre-Bolus alarm anymore. And I said oh yeah, okay, no problem. And sure enough, like it just, it happened so many times that now it's just it's muscle, like brushing our teeth. Exactly. It's just memory. Right? Yeah. So that's, that's what you guys are gonna have to do. Whether this is about, you know, an adult for exercise a kid for exercise, or a kid playing a sport. You can't just, I mean, it sucks, right? That you can't just get up and run out the door and go do it. But it's going to take a little bit of pre planning and if your health or your you know, your you know, if that means that much to you, that's what you're gonna have to do. Like,

I do think it helps. It's important. I mean, with that statement, you can't can't just get up and run out the door. Well, you know, what, what if you ended up sleeping in because the alarms didn't go off the right way. And you had planned to get to your kids softball tournament at 9am. And oh my gosh, it's like eight o'clock, and we're like running out the door with like, food in our hand and we're running and trying to get there. It just didn't happen to be able to plan. Well, in that instance. I mean, there are strategic management, you know, ideas. You couldn't adjust the basal, there was no way to do it. Right. So in that circumstance, then food becomes your offset to potential changes in blood sugar. You know, have you got up late to go for your normal six mile run first thing in the morning, and you always like to eat ahead of time, then the strategy may very well be okay. Maybe you don't Bolus if you're going to eat and head out the door in the next 30 to 60 minutes and you're going to take a six mile run depending on how long that takes you. You may be able to Take 25% of the recommended Bolus, you may be able to take none of the recommended Bolus. And strategically then manage blood sugar. Well, because you're feeding the activity you're feeding, to avoid a drop in blood sugar, but you're not stacking insulin into a time that it's just going to get active.

It seems I'm smiling so much, because this is like the next level of thinking about all this about the manipulation of the insulin. When Arden would run off the field, like and I'd have her I know what her blood sugar was. And she if she ran off, I'd might say to her, Hey, water, you know, drink water now. And then maybe watch and then if I saw her blood sugar kind of dipping down the next time she came off the field, I'd say switch to the sports drink. And then you know, she'd switch to a sports drink. And then I'd be like, switch back the water. You know, and it only happens a couple of times, maybe it maybe never to be perfectly honest with it. She's played softball games where blood sugar's never moved, you've got her Basal, right, your prep right going in, or like you said, you ate the right things before playing. And these things are sitting nice and stable in your stomach and kind of holding, you know, holding the pressure back of of the activity, trying to make your blood sugar lower. But you can reverse engineer all of these ideas, like use food instead of like, you know, I say it here. Uh, you know, a lot. And I don't know how clear it is because it's sometimes not 100% clear in my head. But we don't we always just think about how the insulin impacts the number your blood sugar, but we never think about how food impacts the insulin or how food impacts the number. There's so many different pieces to this. It's all not just a one way street, like all these things are affecting all these different things. And if you pick the right one, it can manipulate something you never thought was manipulatable. And it is you know, and also

understanding your variables and how they affect you maybe at certain times of the day is a piece of it as well. I mean, I can tell you from my from my management, I guess toolbox. I've figured out that my morning runs, I can get up, I can Bolus for about 40 to 50% of the normal recommended Bolus, as long as I'm heading out the door within the next 30 to 60 minutes, that partial Bolus for what I ate will help me keep my blood sugar nice and stable throughout. Now, in the afternoon, if I did that my blood sugar within 1520 minutes would take it would entirely take I would need. I just know my sensitivity at times of day. And so again, on an individual level. Some of the things you know that we're talking about there a beginning piece there where to start, if you've had no strategy whatsoever, these are places to start with what you can try to, you know, I guess implement, but you're going to find that things need to be adjusted personally for yourself. I raced a strategy knowing my like training run strategy, my race day strategy is completely different. With the adrenaline of everything getting going on a race day morning. I mean, and I'm not a competitive like Pro Runner.

Not out there being like I'm gonna kill all these people here.

four minute mile or something. No, I'm just I'm out there, but it's a race day. And so I Bolus 100% For my breakfast on a race day morning. And if I don't my blood sugar is 300 by the time I start the race.

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If I don't my blood sugar is 300 by the time I start the race. And again, it's experience it's experience of figuring it out. It kind of goes into the difference of what type of sport or what type of athlete Are you? Are you a an aerobic exerciser? Or are you more the weight, kind of the heavy lifter kind of you know, anaerobic because those adjustments are different as well. strategy there for many of the lifters that I work with, they find a need depending on their lifting plan, they find a need to potentially Bolus to avoid a rise in blood sugar during a lifting session off at the potential rise that they see is slower with a Temp Basal increase. And again, in their standpoint, that Temp Basal increase needs to be started about an hour before they actually get to their lifting session, or it doesn't help enough and they get a major rise. So I think the biggest thing with exercise adjustment is what has happened. What have you seen? What is your problem? Right? Because if you start with the data that you've got, and you look at and you say okay, I just did this way totally didn't cut it. This did not work. Okay. Adjust Yeah, look at your data and adjust and make you know, is it a timing component isn't an amount component. What do you need to change?

It's funny because I see a through line from this to correcting a low. So when you know when people when people's blood sugars get low and they they eat because they need to then this you know uncertainty just allows them to they do nothing and their blood sugars come like crashing like back up again. Right now you're you've just crashed down now you're flying back up. I say all the time. Like you'll know you're like a ninja when you're bolusing you know, after you've eaten for a low like, you know your blood sugar is going down to 40 or shaking or out of your mind. You're eating all the food. He stopped for a second go, okay. I'm okay now. I just ate 70 carbs worth of food. What do I do now? Well, the answer is I Bolus now that you know how much I don't know you figure that out. But that's what I did. I mean, I the first time I did it with my daughter, I'm like I can I'm so scared. Boom 350 blood sugar. Then next time I was like, Okay, well maybe like for half of it and half of it didn't work. And so eventually I could just I kind of eyeballed it was usually about three quarters of the carbs, like right and like when you stopped and really thought about it, you know, sure that 2025 carbs stopped the fall and got your level, the other 50 were just your body gonna eat more, eat more, eat more, eat more, right? If you could have stopped yourself after 25 or 30 carbs, you would have been okay. Right? You wouldn't need to Bolus but you know, you can't stop yourself in that situation. And so it's happening. Now you got to do the next thing that makes sense. It's all really just about I hate I hate to i feel like i oversimplify sometimes. But all we're talking about in the last 10 minutes, all you really heard was right amount of insulin at the right time. You know, which is obviously overly simplified. But that's all we're talking about. The right amount might mean and I get scared too when people hear it right amount that they that they think of on the positive or more like actually, the right amount might be less, it could be less basal, right? It could be not bolusing at all. eating a banana going out the door for a run and thinking you know, this banana is usually three units but I know if I didn't Bolus for this my blood sugar is going to going to go up about 80 points because bananas don't hit me that hard for some reason. And when I go out for a run, I fall 60 points so boom, I'm gonna eat the banana. I'm gonna go and that's countered it. Yeah, there's all different ways to get in that fight. I have a couple of notes the other well, please, you know, please,

oh, I was gonna say kind of on this kind of on the same note there from the standpoint of not having enough time to adjust prior to, let's say, for a Basal adjustment truly Another component is you may actually have to, you may have to eat food to curb a potential drop. If you know the drop is coming, and you've only got 20 minutes before you're going to head out the door to go and exercise, you may have to have 10 or 15 grams of carb in order to stop a potential drop from happening. And that it's a, it's a hard thing to consider when you're also for the most part as an adult, especially considering exercise as a piece of like a weight management tool. Right? And if you're feeling like, Well, gosh, every time I exercise, I have to go and eat like three granola bars. That's like, what's my purpose? What's the point of this? Right, I'm exercising, but I'm not seeing any changes here? Well, again, some strategic planning can help. But if there's no ability to adjust anything ahead of time, because there's not enough time, you may actually have to quote unquote, eat something. And my my recommendation and most of the athletes that I work with, if it's that the circumstance, simplify the carbs that you're eating, that an eat peanut butter, jelly sandwich, or a pro bar that's, you know, like 300 calories, your body right, before you get started moving needs, the simplest form of carb you can get, it needs to get into the system to effect quickly and stop a potential drop. Because usually aerobic exercise drops happen within about the first 20 minutes or it gets started within about the first 20 minutes. So simpler, the carbs are one, you're not getting fat and protein calories. So you don't have this load of excess. And if you use something simple, like the sport drinks, you know, whether it's Gatorade, Powerade, vitamin water, or whatever it is, make sure it's got some carbs in it, and have about, you know, eight ounces, which is almost 15 grams of carbs. That's a simple amount your body is going to use it easily is going to help to stop an initial drop, you may need to bring it along and sip it along the way, as well. But at least it's getting used up. And it's not something that's packing away calories. I

have a question. And I don't know the answer to it. So which just as an indication to you guys, and sometimes I ask questions I know the answer to just so you can hear the answer. But in this situation, I don't know the answer to this question. So your body when you work out uses up food as fuel, but that we're accustomed to putting that fruit in us and letting it be used up as a buoy for our blood sugar. So I don't know what my question is. But if I eat a banana, and I sit down, like because my blood sugar is 60 I eat a banana I sit down to expect this to bring my blood sugar back up to 130. And it does. But if I eat that same banana at 60, well, I'm doing something that's causing my body. So is are my muscles stealing the banana that I need for the sugar? Does it still go in the blood? And I use it and I get it any? Do I get both benefits? Or do I only get one

depends where you are sort of in the exercise in early exercise, your body would get the benefit of the banana would actually bring your blood sugar up because your muscles now are resting, you've stopped you're eating the banana you haven't been exercising for very long. So it should technically bring your blood sugar up maybe not as much as if you were just sitting and not doing anything and eating the banana and not taking insulin for it. But the longer amount of time you've been moving, the more primed your muscles are to grab glucose and bring it into for for their benefit. Right because they're trying to retain they're trying to energize essentially. And this is a really hard concept. I'm glad question wise you brought it up. Because athletes, endurance athletes, especially those who are doing long distance of anything triathletes, long distance cyclists, even kids or adults who are in long term like competition on a weekend like four or five like you said, you know, Arden might be have been in softball from 8am until 5pm. That's a long day of movement of asking your muscles to do something. And most people are like, Ah, I've got my Basal dialed in. I totally I rocked it my blood sugar was nice and stable. But man, I felt like I couldn't move. My I just slogged through this whole four hour marathon and I didn't I my blood sugar was great, but I didn't feel the greatest. What's the problem? The problem is that you've been thinking about yourself as diabetes person with diabetes, right? You have to first think about yourself as an athlete. Athletes whether you have diabetes or not, you need energy of whatever source you're choosing to use, you know, even ketogenic endurance athletes use some form of fuel during long distance To maintain and be able to perform, and you know, people who aren't ketogenic, you need a carb source, and you need it put in strategically over that endurance time, so that you can fuel your muscles, you can give it what is needed, so the muscles can keep doing what you're asking them to do. Now, from a diabetes standpoint, what you're putting into fuel your muscles also has to work well with blood or peace, right? They have to kind of balance each other out. But first and foremost, as an athlete, you have to think what are my muscles need to perform the way that I want them to perform,

you're doing two different, very different things. But they're both working out of the same pool of food, basically. So

yeah, and thus with it, insulin adjustment might be very different. I mean, when I in training long distance like half marathon marathon, my training runs and the actual event, it's surprising, most people who've kind of dialed things in will find that their Basal insulin adjustment doesn't go down a lot. For my marathons, I only reduce my Basal by 10%. And this was conventional pumping, right, I only adjusted my Basal down by 10% for the duration of time of the run, because what I expected then was the rest of the basal to be able to encourage the food that I was taking into fuel along the way into my working muscle because insulin has to be there to propel some of that in the activity helps with the rest of it, it opens the doors on the muscle cells and lets the food end. So if I reduce my basal too much and fueled along the way, I had these jumps in blood sugar that I didn't need. Whereas if I just kept my basal a little bit lower, and I feel strategically, you know, every 20 minutes putting in a little bit of something along the course of time and hydration. Again, blood sugar stayed nice, but I also had energy to keep moving.

I I should say that at the the other side of Arden's long tournament days. You know no problems like you just said with the blood sugars throughout the tournament into the evening, their regular bolusing at dinnertime. But around late evening, 910 o'clock going into falling asleep time, all the food was free at that point, like she could eat without insulin like yes, and by the end when she goes to sleep. I know people see like one way or the other usually Arden's eyes closed blood sugar falls person, like So if something's not right with her insulin, when she goes to sleep, her blood sugar tries to go down. And so even if you gave her a juice at midnight, and turned her basal off, that still couldn't catch a low after a full day of activity, you had to give her something to eat. That was substantial that would really stick with her in her system while she was sleeping. And even in the morning, even in the morning waking up like getting through the night, okay, and I've done it well, and I've done it poorly. And poorly would be like, you know, three juice boxes to get through the night and a banana or something like that. I would call that poorly. And I've done it well where I've gotten her through with like a you know, something at the end of the day that stuck with her overnight some tamping down with basal, stuff like that. But even that next morning, when she woke up, her blood sugars were like, terrific. They were low, you needed the be of the mind, you know, whatever the base amount of insulin was for the meal, like, you know, sometimes you're like, This is two units. And the next day you're like, oh, how come it was more like four today? Whatever the most minor amount was, but always the day after a softball tournament is all you need, her insulin needs were very low. But that was, gosh, if that didn't kick in nine hours after she got done playing and lasted probably for nine hours after that. It's really it's really.

And that's what we call a Gary actually has coined the term don't like Homer Simpson, don't go dough is do do a delayed onset. Hypoglycemia essentially is what that is, right. And it is again, this is where visually looking and seeing, you know, it was about nine to 10 hours later that she started having a drop in insulin need and it lasted for another good, let's say 10 hours. That's experience. You looked at her data and you said over and over, this is what I see. So that's kind of where you have to go back and you have to look and see. Well gosh, after I have like a three hour run in the afternoon or you know a four hour softball tournament in the morning. I ended up being low from dinnertime all the way through the next morning. If that's the case, you can set temp adjustments down again in basal at a strategic time. So you don't end up having to do a Juicebox and a basal off for a certain amount of time because really there you're missing the boat, right? No, no, that was your treating now when ahead of time had the basal been adjusted down and off the tree It shouldn't have been needed or less of it,

right? Yes. Yeah. No, I made sure to characterize it that way. Like, in the beginning, like, I didn't do a good job of it all. And you were just the whole evening was just like here, stay alive, eat this here, Stay Alive eat this, Hey, why don't we just, you know, shut your Basal off for a while and see if that helps. That's all 911 stuff like, that's not that's not like, Oh, I'm really doing a great job. You know, later, later, a great job was knowing that after dinner throughout the evening, she needed less basal, and that she should eat something reasonably substantial, like a little before bed, like that kind of stuff. But my gosh, the first couple times, you know, I did it once in a hotel room, where my God, it was just embarrassing. You're banging into things. You don't know where anything is. And it's dark, you know? And I'm just like, what is happening? And then, you know, her alarm goes off. She's like, we have another game. And I'm like, Yeah, that's great. Because I've been up all night, you know? And then the next day, all the parents are like, all the parents like, you look tired. I'm like, Uh huh. Yeah, you guys are all drinking all night, I was up trying to fix this blood sugar thing. Not that all parents at sporting events are drunk, but most of them are. And I'm not a drinker. So I wasn't involved to begin with. But they all were like they come down in the morning like all hungover and I they must have thought I was just like, quietly privately drinking by myself, because I looked worse than they did some days. But no, but there's just so much. So. So

kind of on the same on the same note not to interrupt but the aftermath sometimes to of exercise can happen right after the lower needs and insulin can be for several hours after weightlifters to may have that rise during but then the impact of lifting and their muscles sort of building repairing restructuring. And the insulin sensitive sensitization that they get from working their muscles out, can have impact into, you know, for six, eight hours after where they actually need less insulin now.

Yeah. I had that. I had that on my notes, like, what does muscle breakdown and rebuild, do? And what you know what to dehydration. I'm reminded about this again the other day, because I said this to a person. And it was like no one had ever said it to them their whole life. And they're like, you know, sometimes my insulin doesn't work as well. In the morning. I was like, you know, have you tried waking up and just banging down the glass of water? And they said no, why? And I said, Well, insulin doesn't get through your cells as well, if the cells are dehydrated, because then the insulin can't travel through. You know, I'm like Senate. And as I'm saying, and I'm like, God, you've never heard this before. You know, like three years with diabetes. Like I had never heard that before. It's like, I just Okay, that sounds great. I'll try that. When Arden's at school. Whenever her blood sugar gets sticky, the first thing I say to her is like, hey, drink some water. Let's see if you know, we can find a simple, you know, answer to this question. So it's kind of

like things just move slowly through your system. It's like your blood gets when you're dehydrated, your blood gets like sludge, or like molasses in winter, essentially, it doesn't move, nothing moves through the system very well. Nutrients don't get where they're supposed to go. Everything that's traveling there is slow. Whereas when you're well hydrated, and everything is nice and plump with water, it can move fast. It's like a freely flowing river. Right? Okay,

that so so I have to stay hydrated when I'm being active no matter what. But it is also helping me get a smooth baseline for what I expect out of my insulin. And then at least what I see one way or the other, I know is real. And not because I'm dehydrated, and or something. What does heat? How does heat impact blood sugars? Because, you know, people in the warm weather states always report problems with their blood sugars. As soon as the as the summer comes, but I'm wondering if you hit yourself up when you're working out too. Is that similar or no?

Um, you know, that's a good question about the workout. I guess I never thought about it that way. It's probably pretty similar. In exercise, of course, your muscles are just uptaking glucose more efficiently. The doors are opening even with less insulin being there. They're just opening more efficiently exercises like free insulin, really. I mean, unfortunately, we can't live on exercise. We still have to use insulin, but it does help. But in the in the case of overall warmth. If you think about when you're warm, your vessels move closer to the surface of the skin or right and you sweat and you that's a cooling effect, right. It's your body's sort of ways so that you're you don't overheat. Well, when that happens, get more circulating. You get more circulation around the actual insulin pump. or injected sight. So you allow that insulin to get absorbed faster, I guess is the easiest, most simple way to say it. So in warm weather or when warm weather comes, many people do see, in fact, a friend of mine, once April hits, she's always like, my Basal just need to go down, it's warmer outside, I know that I need an adjustment, nothing else has changed, my weight hasn't changed my infant, my food hasn't changed, I am just outside more, it's warmer, she needs less insulin, and then it might go up again in fall and or winter. And exercise, obviously that heats you, you get a lot faster circulation, I mean, that's the benefit to your heart, your you know, circulatory system is exercise does your heart good, makes it pump harder. So with that, and the fact that you're getting warmer, you just get a faster circulation of insulin essentially.

And we haven't really said this here either, but you have type one diabetes, or the person we're talking about does exercise is very important to you. So this is a piece you have to figure out, you can't just say, I can't figure out exercise you you need exercise, you know, everyone does, but you know, people with diabetes needed maybe a little extra because you're trying to keep your body healthy. While it's trying to while it's trying to, you know, it's trying to beat you up, you need to you need to take away as much power from that as you possibly can.

And as a weight management strategy, sort of in the same realm of it needs to be something that happens everyday and many people with diabetes are really struggling and really trying to keep a healthy weight. If you can strategically plan your exercise in the aftermath of a meal. As I said before, you could potentially use less insulin then because you're planning the exercise in a timeframe of after insulin has been injected, insulin is going to work better, you're also going to enable your body to burn more of that fuel off. Right, right. So it's a good strategy to just all

around eat and then workout,

eat and then workout. Again, ability to reduce the amount of insulin again, prevention of lows, but also just burning calories and not having to take as much insulin

doing what you what you wanted to what you what you intended to do. When you when you decided to get up and go exercise. I want to look real very quickly to because Chris Rutan was on the podcast and we talked a lot about we talked a lot about this kind of stuff, too. And I just want to be able to tell people what episode that was. Be nice if I could figure it out. I am the guy with the podcast you would think I would know but

Well, there are so many of them. Well,

that we are getting to that spot, aren't we? I can't figure out what should people are like what episode on my I don't know anymore. Let's see where's all right, I'll have to figure it out and plug it in. Jenny's got her own life. She's got to get back though. I will figure it out. And you'll hear it edited. And right here. Chris Rutan was on episode 201. Jenny, is there any anything else that you think we should talk about here?

We could probably go on and on with more like advanced stuff. But overall, I think those are the good basics to start with.

Yeah, I think this is what we're looking for basic. And we'll we'll hit more advanced things in another episode. Let this all set. Cool. All right. Well, thank you very much. Thank you. I want to thank Ascensia 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 Gvoke glucagon, find out more about Gvoke HypoPen at Gvoke glucagon.com. Ford slash juicebox. you spell that Gvoke glucagon.com Ford slash juicebox. 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 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 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 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two in Episode 1018 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and an episode 1025 We talk about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with this and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning 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 A1C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link.

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 CDE 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 revisitable. 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 Ascensia 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 Juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke hypo pen, find out more at Gvoke glucagon.com forward slash juicebox a half an hour before you and I started recording this someone sent me a message on Instagram and said how do I deal with fat and protein overnight because I was bawling all night with my kid. So I texted them back and I said hey, great timing. Can you see my recording calendar from where you're at? And hold tight? Because the answers coming? This is another one that Jenny proposed that I'm really interested in. And I don't know how much help I'm gonna make. Why don't we start with what I know? Because it's so little. So forever seriously. So for everyone who listens to the podcast and knows that I'm just sort of fluid with insulin Right? Like more. More need equals more insulin. And so because of that, I don't usually stop and think about whether that means it's protein or fat or what it is just if Arden's blood sugar seems to require insulin, I give it more. I'm assuming I'm been handling fat and protein rises for ever.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Those are going to be defining diabetes things we're going to do after we stop recording this journey. Okay, awesome. All right. We're gonna we did well with this, I think, yeah, I want to thank Ascensia 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 Gvoke glucagon, find out more about Gvoke HypoPen at G Vogue glucagon.com Ford slash juicebox you spell that Gvoke glucagon.com. Forward slash juicebox. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and lo BGs. In episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two in Episode 1018 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025 We talk about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with this and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics. Scott brings useful information and presents it in digestible ways. Learning that Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so it is active as the carbs become active. Took me already From a decent 6.5 A one seat down to a 5.6. In the past eight months, I've never met Scott. But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Jennie Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link.

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 CDE 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 revisitable. 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 Ascensia 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 Juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke hypo pen. Find out more at Gvoke glucagon.com. Forward slash juicebox. J Let's do a big Sick Day episode. And so I'd like to try if we can to get through sort of a regular sick day like you know, little beyond the sniffles the the flu a stomach virus, an injury like a broken bone or something I might have to take, you know, steroid for and then an actual surgery and have you where do I want to start? You've had a surgery pretty recently, haven't you?

I've had multiple surgeries. I've had a week surgeries I've had I've been out surgeries. I don't like surgeries. But I've had them. Yes.

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

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

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

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

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

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

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

Let's say a little higher would be like 180 ish. Yeah,

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

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

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

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

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

And find out ahead of time what her favorite soft or cold things are, so you can have them ready.

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

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

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

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

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

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

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

secondary issue. Yeah.

They think of it that way.

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

just seems like a lot, again, which is a lot.

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

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

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

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

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

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

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

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

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

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

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

they're not going to offer you an Omnipod, if you know,

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

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

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

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

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

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

Okay, that's also the benefit of having a

medical alert. Look at Jenny is wearing her bracelet, don't you? Oh, it's

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

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

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

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

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

are we sharing where your tattoo is? Or no,

it's on my leg. Okay.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

they do. It's called diabetic tossin. Diabetic tussen. That's what it's called.

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

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

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

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

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

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

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

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

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

That's a great idea.

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

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

So a Jumanji situation when giant vines and lions are going through your living room and you really need to get out. You want to be able to grab this bag. Correct and at least have it packed somewhere and no, it doesn't have to be hanging by the back door chasing you through the kitchen. We're very mean in that movie. Hey. I know Robin Williams and now now people are like Robin Williams wasn't in that movie. That was the rock. How did you confuse those things? And who is Robin Williams but there's been two Jumanji movies so young people please leave me alone. I want to close As by saying that as we were talking, I was proudly struck by how much of what is normally spoken about on the podcast translates very well to this idea of sick days. That, you know, obviously, there's heightened scenarios, but that the tools you use really aren't much different. You might use different ones in different times than normal, but, but it's not like. And the reason I say this is because when people are trying to figure things like this out, I oftentimes see them believing that there's some extra special knowledge that they don't have about diabetes that applies only to the day you're sick. And I still think that one of your greatest diabetes tools is common sense. And so I think that, you know, we obviously broke things down a lot more granularly here, but it's still the tools. It's the Pro Tip series, you know, applied slightly differently. So right, um, I thought this was really terrific. I appreciate you doing this. And we talked so long that I can't ask you to define Lada so I'll do that next time. Okay, so that you can go I will say thank you. You're welcome. I want to thank Ascensia 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, Gvoke glucagon, find out more about Gvoke HypoPen at G Vogue glucagon.com Ford slash juicebox. you spell that Gvoke glucagon.com. Forward slash juicebox. If you're living with diabetes, or the caregiver of someone who is and you're looking for an online community of supportive people who understand, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, there are over 41,000 active members and we add 300 new members every week. There is a conversation happening right now that would interest you, inform you or give you the opportunity to share something that you've learned Juicebox Podcast, type one diabetes on Facebook, and it's not just for type ones, any kind of diabetes, any way you're connected to it. You are invited to join this absolutely free and welcoming community. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two in Episode 1018 teen pregnancy 1019 teen explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025 We talked about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son on how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning that Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active, took me already from a decent 6.5 A1C down to a 5.6. In the past eight months, I've never met Scott. But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link.

You

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 CDE 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 revisitable. 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 Ascensia 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 Juicebox free meter while supplies last US residents only. This show is sponsored today by the glucagon that my daughter carries Gvoke hypo pen. Find out more at Gvoke glucagon.com forward slash Juicebox. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. Hello, everybody. Welcome to Episode 301 of the Juicebox Podcast. Today in a pro tip episode Jenny and I will talk about glucagon emergency Lowe's, just you know how they manage that kind of a scenario? And what happens if you need glucagon? And how do you use it? That kind of stuff? It's not a bummer. Don't worry, Jenny and I laughed more during this one than most of them. So we're gonna go over how to use the glucagon. What glucagon is, what is it do the three different kinds that we could think of there on the market? Pretty much. It's a nuts the bolts glucagon extravaganza talking about low blood sugar somewhere else you're going to talk about people having seizures, and hearing them laugh at the same time. I mean, who else is putting out diabetes content laughing about a seizure? It's not funny, by the way, it's just the situation was fine. You'll see when you get to it, don't get upset. I liked your idea, a lot of doing a pro tips for glucagon. And I was wondering if we couldn't meld it together with like emergency situation ideas as well. You know what I mean? So I just I realized, well, we'll talk about what we're talking about it. I don't know how to start this. Honestly. I can tell you that. We buy glucagon religiously. I always have some when it expires, we always get more. We've never used it. We've had opportunity to use it twice when Arden was little and both times opted to try glucose gel instead. Which worked. Here's the best place to tell the story, I guess. And I'm sure I've said it here before, so I'll encapsulate a little bit. But, you know, when Arden was really newly diagnosed, she was probably like two and a half years old. And thinking back now knowing everything that I know, she's probably honeymooning still, right. And I had no one ever spoke those words to me ever. I didn't know that was a thing back then. And we got kind of ahead of ourselves one day and Kelly was getting ready to leave on a business trip. She was gonna go overseas. And it was like, six or seven hours before her car was going to come to take her to the airport and she's like, Hey, I need another piece of luggage. Like let's go to the mall and you know, a little piece of luggage looks like alright, so we get over to the mall and it's a Sunday. And we're hungry while we're there. So we grabbed you know, the worst thing in the world like mall food, Chinese food, just not just more food, more Chinese food. And I was just like, boom, I counted my carbs. And I was like, pull up my insulin and the needle, bang, go ahead and eat. I figured this out. And she ate the food we ate, we bought the bag, we went home. It was super little. So she fell asleep in the ride home during the ride home only like 15 minute ride. And I carried her into the house and put her in her crib. My wife's packing and my son's watching the football game and everyone's living their life. And all of a sudden, it sounded like there was a wild animal trapped in the house. Right there was like this grunting and grunting and grunting. And you know, it's like anytime, like, I'm just like, what is that, and I start moving through the house towards the sound that's coming from Arden's room, and I get into her room and look in the crib, and she is having a seizure, you know, and I was just like, I did not 100% know what to do. So I picked her up, and I went through the house to where Kelly was. And we had just this kind of little area rug. And I said, I'm like Arden's having a seizure. And so I put her on the floor, and I got out the glucagon. So the red box, you know, that

has changed

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

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

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

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

is just one of those things

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

up. It's stored in your liver, right?

Glycogen is stored in both liver and muscle cells.

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

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

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

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

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

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

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

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

Like you were fine, right?

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

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

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

And that is mess around drinking, right?

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

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

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

Yeah. It's not a multitasker.

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

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

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

Right? I feel like that's a very important point.

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

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

Correct. Exactly. So that's one I think one in that like emergency time of potential Oh, get the glucagon out.

Try some other stuff first.

Obviously even calling you know, emergency services. Obviously, if you're with somebody you really don't know what to do. Call 911.

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

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

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

No, it I, I understand that it's glucagon.

So glucagon makes your body make more glucagon,

glucagon injected makes your liver release glycogen and transition it into glucose.

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

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

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

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

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

all the way and it's a good size. No, yeah, it's

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

right into the bot. Yep. I mean, yes, that's the easiest place.

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

Gosh, I don't remember the name of the company. It's back shimmy is the name though? Of the

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

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

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

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

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

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

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

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

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

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

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

do any of that extra stuff? That's really awesome. Yeah.

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

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

Yeah, you might be maybe

tackling them and holding them out. Exactly. But you hold

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

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

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

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

how long did it last after you ate like after you brought your blood sugar back did it last?

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

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

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

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

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

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

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

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

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

to say to yourself, I really just need half of this Juicebox.

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

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

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

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

got diabetes got.

If we're measuring fair, I think I win, you know, like, so anyway. Do you feel like we did a good job here? I do too. All right. Cool. So I will so let me say goodbye let you get back to your business. I want to thank Ascensia diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free Contour. Next One. starter kit at contour next one.com forward slash 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 Gvoke glucagon, find out more about Gvoke HypoPen at G Vogue glucagon.com forward slash juicebox you spell that GVOKEGLUC A G o n.com. Forward slash Juicebox. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years, and she works at integrated diabetes.com If you're interested in hiring Jenny, you can learn more about her at that link. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed or starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two in Episode 1018 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and an episode 1025 We talk about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with this and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active. Took me already from a decent 6.5 A1C 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.

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 CDE 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 revisitable. 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 Ascensia 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 Juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org. And on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke hypo pen, find out more at Gvoke glucagon.com. Forward slash juicebox. So Jenny, this whole time we're going to talk today. I think we're gonna just talk about this one email that I got.

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

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

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

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

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

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

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

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

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

sharing services still exist. So you might just be getting a person taking a message, right? Correct.

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

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

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

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

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

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

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

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

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

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

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

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

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

Take your busted pump. There's a

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

So Jenny just brought something up. Interesting.

Okay, so I kind of I kind of sugarcoat that in a way like that. They don't know.

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

up because you've also come in for help. For something else, respect what they

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

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

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

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

Yeah, exactly. One second, I gotta tell ya. The remastered diabetes Pro Tip series is sponsored by Ascensia 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 Juicebox free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash Juicebox free Meet her head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen, it fits well on your hand, and features Second Chance sampling, which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash Juicebox free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips, you can use my link and save time and money buying your contour next products from the convenience of your home, it's completely possible that you will pay less out of pocket in cash for your contour strips 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 touch by type one is doing and I mean it's a lot type one it's school, the D box program golfing for diabetes dancing for diabetes, which is a terrific program, you just click on that to check that out. Both are caused their awareness campaigns and the annual conference that I've spoken at a number of years in a row. It's just amazing, just like touch by type one touched by type one.org or find them on Facebook and Instagram. links in the show notes links at juicebox podcast.com To touch by type one and the other great sponsors that are supporting the remastering of the diabetes protip series touched by type one.org. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. Gvoke 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 Gvoke glucagon.com forward slash juicebox Gvoke shouldn't be used in patients with pheochromocytoma or insulinoma visit Gvoke glucagon.com/risk. One second, I gotta tell you something

else you follow fallen asleep in class because she's so tired from studying so late last night.

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

we always we always talk at the time that she's into lunch. Yes. And you're always texting her do this or did you do this or today?

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

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

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

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

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

I think I can explain it right. Yeah, I

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

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

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

Yeah. Not fun,

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

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

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

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

do your part. I'll do mine. How's that? So

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

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

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

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

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

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

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

their loss because they don't have diabetes, right? And then they start

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

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

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

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

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

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

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

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

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

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

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

bar, and this guy passed out and

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

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

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

I really do. Yeah, 100%. Jenny, we've done it again, I really believe that this is a good episode.

It's a good episode, a really great awesome that you're, Miss Misty, decided that it was a really good topic, because

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

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

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

planters war that I treated this way 40 years ago. Now my

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

year. So it's harder to do that than other years really?

100% right. There's a lot going on. There's a lot

of illness going on.

So I'm gonna tell Jenny, a really gossipy story that you guys don't get to hear so goodbye. Bye bye. I want to thank Ascensia 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 Gvoke glucagon, find out more about Gvoke HypoPen at GE Vogue glucagon.com Ford slash juicebox you spell that Gvoke glucagon.com Ford slash Juicebox. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs. In Episode 1015, Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two, in Episode 1018 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022, weight loss 1023 Honeymoon 1020 for female hormones, and in Episode 1025, we talk about transitioning from MDI to pumping. Before I go, I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active took me already from a decent 6.5 A1C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link.

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 CDE 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 revisitable. 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 Ascensia 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 Juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke hypo pen. Find out more at Gvoke glucagon.com. Forward slash juicebox Hello, everyone. Welcome to Episode 311 of the Juicebox Podcast. Today's episode is a pro tip. So you know that means it's not just me today and a guest it's me and Jenny Smith. Today Jenny and I are going to talk about long term health as it relates to type one diabetes. This one's a little less pro tippy and a little more conversational. The information rises to the level of pro tip. But the style of conversation is more like Jenny and I got together as friends. And I said, Hey, tell me your thoughts about this. And then we chatted about it a little more laid back a little more conversational. But the information is definitely something you want to have in your tool belt. And that's why this episode is part of the diabetes Pro Tip series that begins back on episode 210.

What are we doing today?

We are going to do a protip episode that you suggested and prevention of long term complications you said and you said What does optimizing glucose long term do for keeping things healthy? So I feel like what you meant by that is low less variability not low but in you know, lower than what a lot of people go for less variability, lower standard deviation, how is that going to help you throughout a lifetime? And so I feel like between that, and some other safety ideas that I'd like to bring into the conversation. I think we're going to have a good a good talk here. So I guess first, why don't we talk about a little bit through time, right? Where does everybody? Am I everybody? I mean doctors, where do they get the information that they put on their patients? You know, I'd like to see you have an A1C of x. Does that come from the American diabetes Association? Did they set the tone who sets the tone for what we should be shooting for? For somebody does it

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

So less than 160, less than 160.

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

So, um, is what I'm hearing good, good for the

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

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

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

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

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

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

Exactly. It's like your job to herd all of the million cats in your yard with no fences, right?

What if I just didn't let the cats in? How would that be?

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

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

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

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

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

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

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

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

And blood sugar Oh, sorry. Sorry to interrupt. Go ahead.

No good blood sugar.

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

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

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

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

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

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

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

Yes. And so everything you just said, is about using the right amount of the right time. Hi, Nick. Yeah, it's timing. It's all timing. Like I, again, I that I figured it out. I mean, we should all be able to figure it out. Right? Really, I know myself, trust me. It's there's not a lot like I'm not, you know, I'm not over here. Figuring out the Pythagorean theory after or a theorem, whatever it's called. I don't know, after I get off the podcast. Yeah, I just don't think I think there's so much fear in now that we forget later. And you know, what we're talking about right now is long term health. And so, let me jump to I can't quote it. I don't have it in front of me. I don't know where it came from. But I think everyone's fairly aware of this article that came out in the last six months that tried to say that lower a one sees aren't necessarily an indicator of health. And that did you see that one they started talking about like, you can have a one seat like this here. It'll be fun. if it tried to give the impression to me that the way I saw it was someone trying to say, Look, I know a lot of you are using this technology to do better, but you really shouldn't do that. Like it's not necessary. And I thought, well, how do you know? You don't even mean? Like, like, I thought the same thing. I thought when I saw vaping the first time I was like, I have no interest in that. But if I did, I wouldn't do it. Because I don't want to be the one to find out 10 years from now what happens? Because no one knows, you know, right? So is there any in your mind? If you're safely at, if you're in the fives, and you're A1C and look, you know what I'm going to do here, I'm going to actually pull up an email. To make my point, hold on one second, it's going to take me a second to find it. I apologize for that. But I got this email this morning from a person I know who listens a lot. And when she emailed I thought, wow, this is gonna work right into what Jenny and I are talking about today. It's crazy. And it's from Laura. And this note from Laura mimics many, many, many, many notes that I get. Scott, I achieved a 5.4 a one see, first time I've ever been under 6.4. But my doctor freaked out at the number of lows. And she's asking, what's an acceptable amount of time under 70? Like, how many times can I dip under 70? And you know, and so I there's first of all, it's it's a two step thing, right? Everybody who goes to any kind of a doctor who's more like the lady in the crowd, who's thrown her arms around y'all and don't talk about it like this, when they get their blood sugar down, and they find a way to keep it stable, and it starts impacting their variability and it starts impacting their agency, the doctors flip out, they make this assumption that they have all these crazy lows, and it's throwing them off. So I know what I'm okay with. But what where do you stand in your personal life? I guess like how often do you find yourself under 70? Do you think?

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

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

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

so When I gave the explanation of a Pre-Bolus this week, this weekend, I used something that had happened an hour before because my wife was at home with Arden. And I said actually my wife did a great job this morning with breakfast. About an hour ago Arden's blood sugar was 70 and it was time for lunch. Now Arden is at school, and I think 70 is a great blood sugar right before a meal. Arden's blood sugar was able to stay at that level for a number of reasons. But those reasons are evident to us as they play out, because we can see her blood sugar in real time with the Dexcom G six continuous glucose monitor. Not only can Arden see her blood sugar right there on her iPhone, but I can see it here at home on my phone as well. Because of that knowledge and seeing the stability that had existed within Arden's blood sugar for the hours prior to lunch, we were able to make a good Pre-Bolus and give her a nice launch into her mealtime. Now that our later Arden's blood sugar is 132. The data that comes back from the Dexcom G six continuous glucose monitor is life altering with type one diabetes, but being able to see it remotely, that takes life altering to another level. So if you'd like to know what your blood sugar is, the speed and direction it's moving, and find those things out without a finger stick. The Dexcom G six is something you should check out. I have a link you can use dexcom.com forward slash Juicebox. There are links also right here in your podcast player notes and at juicebox podcast.com. But I think you should check out the Dexcom Arden's results are hers and yours may vary. But I'm telling you right now Dexcom is a game changer. Now moving from continuous glucose monitoring to insulin pumping. I'd like to talk about the AMI pod. Until you first I have just as much affinity and love for the AMI pod as I do for Dexcom Arden has been wearing the AMI pod tubeless insulin pump since she was four years old, she'll be turning 16 In just a couple of months. The Omnipod brings so much freedom along with the ability to pump your insulin right no injections all day long. No slow acting insulin and fast acting insulin let the Omnipod take care of your background Basal insulin for you. It does that put your insulin in the pump, you get your Basal insulin from the pump. And when it's time to Bolus for a meal or to crack the high, same insulin, same pump, no tubing, right so not an infusion site on your body somewhere that's attached to this plastic tubing that runs through your clothing out to a controller that has to clip to your belt. You know whether you're an adult or a little kid, you're not looking to have something clipped to you. Here's what you can do. Go to my Omnipod.com forward slash juicebox. There you can ask Omnipod to send you an absolutely free, no obligation demo of the Omnipod. It'll come directly to your house. You can try it on and see what you think for yourself. You can see the difference between wearing a shirt and not having tubing running down your sleeve. Every time I've worn a demo pod. What I thought first was, it's amazing how quickly I forget that it's there. This is super important. This is something you have to do every day. You don't want it to be constantly bugging you. Check it out my Omnipod.com forward slash Juicebox with the links in your show notes. Were the ones you'll find it Juicebox Podcast icon, an absolutely free no obligation demo can be in your mailbox before you know it. Actually, my wife did a great job this morning. With breakfast. She made a Pre-Bolus at like 83. Right. And it was a big kind of breakfast. And Arden drifted down drifted down and she actually hit like 63 for like a split second and came back up. So imagine this 63 probably happened 30 minutes after my wife pushed the button right? And probably 10 minutes after she had already started eating. So if you want to say she missed I guess you can. But it's funny. Had she been at 68 Everyone would have been like That's amazing. But 63 is a number that somehow gotten in somebody's head. So I'm like so she hit 63 one revolution of the CGM and right back again, and I said if she didn't have a CGM, you never even would have known that that happened, right? She's She just wasn't dizzy. Nothing happened like that. I can see it because I'm looking at it that this same person in the crowd, this person who's you know, you know, from a property from a different era with diabetes, you know, fell just shy of, you know, back of the hand on the forehead. Oh, Scarlet, what happened? I've got the vapors, you know what I mean? Like that kind of thing. And I was just like, I looked over second. I was like, You got us like I was thinking to myself, like, just stop, like, don't like the look at the rest of these people. These people are enthralled, they're excited. These are people who are half an hour after they put their insulin in or running around with their blood sugar's 250? And Are you really telling me that that's what you want to say is okay for them. Because when I speak to them privately, when they come up to me as I'm trying to walk around you guys, we're all delightful. But people would come up and be like, hey, look, this is my, you know, my 23 year old son's CGM, the kids like 403 100 all the time. Like, are you telling me it's not worth trying to do better for this kid. And so I think sometimes, both in the community, in people's minds, in doctors minds, in some older doctors minds, there's just more of that idea. And we talked about all the time, like, it's better not to like, like, I don't want you to have a seizure. Like that's it, like when I say don't die advice, like, that's what they're trying to say that I don't want you to have a seizure. I don't want anybody to have a seizure, either. But I don't want your blood sugar to be 300 all day. You know, it just it's, it's not okay. Because we say these nice things out loud, and other people who are maybe well meaning but don't have good information. They're like, Oh, you know, I want you to be safe, blah, blah, blah. But those people you're talking to online, or whatever your whatever that person's ability to get to people is, you don't get to see those people 20 years later, you don't know what's happening to them. And so I'd rather take a bet on what I'm saying being good for them 20 years later, than what I hear some of those other people saying, I think that if you're going to if you're going to roll the dice one way, you ought to roll the dice and try to be healthy, not hope. I hope that your body's the one impenetrable thing that diabetes can't find its way through. Yeah, you know, right.

Right. Well, and there's also the safety of bringing those high numbers down to, right. I mean, it's like, you don't want to end up going from an average of 280, which means you're drifting well above 300, and not quite into the low two hundreds to average a 280. Right? So you're not gonna say, Okay, today we're at, you know, an average of 280. And tomorrow, you're gonna be averaging 100, right? That goes, well, that would be a pie in the sky one, it's not actually healthy. She drops you that fast, drop that fast. I mean, you will have significant changes in your body. And you know, I remember when I came home from the hospital for two to three weeks after I was released from the hospital. And I think I started with an A1C in the twelves, when I was first diagnosed, and my blood sugar was coming down and coming down. My vision changed so much, that my mom had to read me my homework in order for me to answer and she had to write things down. Because my vision was so blurred, I couldn't actually see well enough to read what I needed to get my homework done. Right. So and that was gradual. So again, you can imagine bringing a really high blood sugar down that's been consistently stable high, yeah, it will be problematic.

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

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

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

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

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

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

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

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

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

absolutely.

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

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

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

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

yeah, I also want to say that, I think

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

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

do now. And until I have like

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

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

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

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

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

Yeah. Because you're you would have been fighting with that all day. Otherwise, right?

Correct. And my post breakfast would have been orange. I'm sure I'm sure.

I bet you for whatever. 220 then in that situation, right, right.

Yeah. Right. At least. Yeah, exactly. So,

Jenny, if you and I were one person, we'd be a super diabetes brain.

Oh, my goodness.

No, in one place.

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

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

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

rather step off the path and be like let it run by run by.

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

Okay, awesome. Have a good day.

I want to thank Ascensia 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 Gvoke glucagon, find out more about Gvoke HypoPen at G Vogue glucagon.com forward slash juicebox you spell that GVOKEG l u c h ag o n.com. Forward slash Juicebox. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years, and she works at integrated diabetes.com If you're interested in hiring Jenny, you can learn more about her at that link. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two in Episode 1018 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025, we talked about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active. Took me already from a decent 6.5 A1C 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.

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 CDE 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 revisitable. 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 Ascensia 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 Juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org. And on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke HypoPen Find out more at Gvoke glucagon.com. Forward slash juicebox. So let's start like this. I just put up like the 340/5 episode of the show, which is mind bending to me honestly,

what was the first first year first, cuz you've been blogging for a long time before

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

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

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

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

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

And I think you really I think you really like realized it when you guys started using the do it yourself, right?

As soon as day one came.

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

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

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

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

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

right. And it becomes such a way of life. Right? I didn't think of it anymore. So now, I want to leave that thought here. And we're going to come back to it later. Because I do think that being fluid around diabetes is incredibly important. And that you can't just keep resetting your Basal rates every day for all the variables that are going to come up in your world. And I noticed a long time ago, that idea that concept is what causes people problems, right? The idea of like, well, I'll go to my doctor, and we'll find a Basal rate and Oh, my doctor was great. They saw between 2am and 4am, we had some highs. So we moved our basal up at 1am or 12:30am. And it worked. But then they started getting low, you know, a couple weeks later, but I just fed the lows for two and a half months and went back to the doctor, the doctor moved the basal again. And that's how people that was considered a successful use of your physician and your insulin right. It probably still is in many people's minds. I saw that and thought this doesn't work. I don't want to be involved in this and I've said it before and I'll say it again this podcast is a it's partly in place because I don't like the math around diabetes. I don't like the waiting. I don't like the we'll wait and see. I don't all that stuff makes me uncomfortable. Like all the things that you're supposed to do. I just was always like, Oh, that seems wrong. Like I don't I don't want to do that. That remastered diabetes Pro Tip series is sponsored by Ascensia 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 Juicebox free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash Juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen. It fits well in your hand and features Second Chance sampling which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one. Contour next one.com forward slash Juicebox free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips you can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips 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

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

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

nine year old child, this is going to be the applicable method that I use.

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

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

That's how you make a tennis pro. One in a million times. The other 990,000 times is how you make a kid who hates tennis eventually, right? So Right, exactly. But so these people were doing great stuff. And they were talking about these these ideas, but they didn't realize how specific they were to the age group they were talking about. And, and I think that that's why this longer conversation while I mentioned how long the podcast has been up has been important, because in my heart as crazy as it sounds, I think if you want to have great success with your type one diabetes, you go back to Episode One, and you'll listen through, because you'll take a journey through somebody who's talking about a kid with a nine or 10 year old body that you know, you actually can hear in this podcast art and get older art and grow art and have problems her start to get out period, changing devices meters, like all the way through. And I know it sounds crazy, but in your 347 hours as of today. I think when it's over, you'll go who Okay, and then your kids just gonna have an A1C and the fives it like if you want it to be or maybe you you'll make an adjustment and it'll be in the sixes. Right. It'll also works for adults. And that was that was really cool. I hadn't had that like greater expectation. I thought it would but it didn't have a lot of a lot of adults weren't reading me as a blogger. You know what he mean? There were some, but there weren't a lot. Anyway, at some point, I recognized that was really long winded, but I guess the people there I guess there are used to that at this point. But it's a very long way of saying that you can't just set your Basal rates up, set up your insulin to carb ratios and go with that's what the pump told me and that's what they've done. After told me to put in the pump, right? Because things are going to change, sometimes day to day, sometimes hour to hour activity to activity, there are going to be too many variables. And you can't stop every time. Like imagine if I had to get up tomorrow and go, today is going to be a sedentary day. I will now go fix all of my Basal rates for sedentary and change my insulin to carb ratio for sedentary by the way, do you realize that that could end up for some people meaning more for some people meaning less, it could end up meaning less for basal and more for insulin to carb or vice depending who you are and what you eat. And so when all that exists, what ends up happening to people is they just go Ah, today was a good day. Today was a bad day. Yeah, right, they leave the settings, and then they have good days and bad days. And what I thought was, if we stay fluid enough, you can almost be ahead of what's happening and make these adjustments. Okay, right. All right. That's a long, long explanation. But to me, that's what led me to bumping and nudging. Now, for context, while Jenny and I are talking about it, I think of bumping as using insulin bumping your blood sugar down. And I think of nudging as nudging your blood sugar up with carbs, Jenny thinks of it the exact opposite way. So don't get confused. If one of us says one thing and one of us says the other. But in the end, the idea is to keep yourself between these smaller parameters, a range, a smaller range, and the range is defined by you, right? Doesn't matter to me what range you choose, right? It's

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

target, right. And so some of the things I learned is, I wish people could

see us by the way, our hands

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

Which by the way, is just like bags. And you know, it's not random strangeness. It's like bags and like colas. That's it.

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

The easiest for them to get to

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

keep going that way. Yeah. Yeah. For

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

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

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

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

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

get the result. Right. So in my mind's eye, touched by type one has the back of people living with type one diabetes. Take for instance, their D box program, touched by type one knows firsthand the intricacies of living with type one diabetes, and so their team has created a D box, which is a starter kit that provides important resources and supportive materials to individuals with diabetes, they want you to thrive. The D box is completely free and available to newly diagnosed people. All you have to do is go to touched by type one.org, go to the program's tab and click on the box. While you're there, check out all the other resources and programs available at touched by type one.org. Speaking of support, touched by type one.org is available in English and Spanish. Don't forget to find them on Facebook and Instagram too. You do not want to miss what touched by type one is doing. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. Gvoke 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 Gvoke glucagon.com forward slash juicebox Gvoke shouldn't be used in patients with pheochromocytoma or insulinoma visit Gvoke glucagon.com/risk. years ago, I used to think of scale. So think of like the scales of justice where each side has this big dish and you can you know, pile weight you know. And so think of insulin on one side and carbs on the other or weight the weight of your blood sugar on the other. And you can kind of imagine yourself throwing it a little on one dish and going oh, that was too heavy and taking a little out. And you know, we're taking some out. Like that's how I think of insulin like put a little in take a little out. You know and then you know I say a lot on the podcast and that I think we talk too much just about how insulin impacts the number. And there are so many other things to think about how food impacts insulin right like, like you'll hear me tell a story about like creating a drop, and then catching it with food. And write to me that's how the food impacts the insulin. And it's just there's it's a weird thing. But there's a lot of different ways to think about what's going on that little game that's going on in your body between the sugar that's in your blood, or that's going to be in your blood or the food that's going to put the sugar there and the insulin that's trying to take it out again. So anyway, you can bump with a Temp Basal, right it just as like to take it away like Jenny and I have explained. Also the same goes for going up. If you see, you know a 90 that turns into a 95 it turns into 100 It's going to be one of those slow drifts up. There's nothing worse than that, in my opinion. I always think of it as the the mountain climber on the prices right? That guy because every time you're like it's gonna stop, there's no way that guy is falling off the end. They're gonna figure this out like and it just totally HE WHO and it just goes on forever, right? And then that little guy just pops off the end and then Drew Carey takes your money back from you and you're screwed and you walk away. Right? So like you see this 90 blood sugar that's drifting up. Two hours later, it's 250. And you think, Oh, why did I do something? Yeah, like I should have done something. You know. Maybe that's a Temp Basal increase. Maybe it's a Bolus. But all All I know is that a 120 or one you know, whatever you wherever You decide to be diagonal lop can be brought back to a stable 90 with far less insulin than it will take to address the 252 hours later. And when you're only using small bumps of insulin, you're very less likely to cause a low. And so when you see that 120, to me, that's you approaching, you know, the, the line on the side of the road. And you just want to come back almost in perceivable amount with the wheel or the tiniest bit of insulin to bring it back in line. Now. I have done this with my daughter for years with an amazing amount of success. And I've seen people, scores of people who listen to this podcast do it too. And it works. It really does. But the idea is that you're not always going to get your Bolus right. You're not always going to have the right amount of basal going for your specific situation that's happening right then in there. Correct? Wow, I'm more comfortable. You're with me? Don't tell your

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

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

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

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

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

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

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

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

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

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

feed here, give more here.

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

doesn't happen not 100% of the time. It's

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

Well into this kind of experience that you had to I think one of the funny texts was relative to Pre-Bolus.

Yeah, I was tested on you're like,

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

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

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

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

following my child until they're 50. And I'll be 89. And you know, what's happening to their

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

that is one field, you

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

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

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

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

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

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

Work. Go back to what you're doing. Go take care of him. And thank you very much.

Yeah, absolutely. Have a great weekend. Thanks.

I want to thank Ascensia 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 Gvoke glucagon find out more about Gvoke HypoPen at Gvoke glucagon.com. Forward slash juicebox. you spell that Gvoke glucagon.com. Forward slash juicebox. Chan Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com If you're interested in hiring Jenny, you can learn more about her at that link. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two in Episode 1018 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025 We talk about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active. Took me already from a decent 6.5 A1C 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.

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 CDE 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 revisitable. 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 Ascensia 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 Juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke HypoPen Find out more at G Vogue glucagon.com forward slash juicebox good and fresh.

Because I'm not gonna sing. I don't say

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

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

That's possible. But

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

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

that is that anyone see in the fours? Is that is that high fours to look

for the E one C listing because what I think, Zack, they were that

I think what we're talking about here is that you have to know how to manage your blood sugar's tightly and see some consistency through weeks and months. So it's not just a fluke, like one month, you're just like, Oh, I did it. And you have to be able to do it without low blood sugars that are going to be dangerous for you or the baby to write, you know. And so yeah, get it right, and then prove it over and over again, over and over again, through your period through different meals, because you also could, I just finished what I really enjoyed, I haven't, I did a four part series with a pregnant person who has type one. And we interviewed together after her first trimester after her second after a third and just yesterday, when her baby is three months old. And so I went through the whole process with her to try to understand it. And her agency was like 4.8, during her pregnancy, and she was describing needing insulin, more than double than what she normally needed. And that like swallowing that pill of like, oh my god, there's way more insulin needed here. I have to do it. And yeah, and I want to get to all that. But But yeah, to me, what you're saying is, you can't be a person who's got an A1C of nine and say I'm going to have a baby. I'll just get pregnant now. And I'll fix it. Because what could those things lead to, like what Ohio one sees in pregnancy lead to?

So that's where the typical national standard is? A1C less than 7%. At conception, right? That's, that's the broad goal. We aim for a little tighter than that. Because as you're kind of getting to, it's easier to have things tighter to begin with. Oh, goodness, I've not really done anything, or I didn't plan it. And I also haven't done anything. And now I really have to tighten everything up. That's a lot of change all at one time, along with a load of hormones impacting things at the same time. Yeah, so it's a lot, right. So the standard center conception is really because what they've seen in research is the risks of things like early miscarriage, or many of the genetic problems that can come up from those early weeks of forming all of the different body. All of the different body organs and everything. That's what's happening in that first trimester. So the goal being under 7%, your risk is is about even with the general population who doesn't have diabetes, for those same types of problems to have, okay? Okay, the higher the agency, the more potential for early loss or or miscarriage, the more potential for the heart to not form the right way or any of the organ systems, you know, a lot of those genetic types of things. Then also a lot of things that are not specifically genetic, like they don't come from down the gene line, but they just happen because glucose levels aren't allowing the cells to divide and form into what they're supposed to do.

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

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

and it happens. I've seen it happen personally.

Yes.

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

Because you're gonna need it. There's gonna be another person,

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

There you go. So you know that it happens, right. And I mean, and I've worked with a number of women through pregnancy, who that has been the case while they were planning events. Really right now, and A1C really was not where we would aim to have it be the highest I've had someone start a pregnancy, which was really not planned. It was a teen pregnancy was 11.3.

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

they, you know, they came in early second trimester it was you know, they had gotten through their first trimester, with OB TM, and some endocrine, I can't even remember how the family found integrated to, you know, get in contact and get. But I worked with her through her whole entire pregnancy. And we pretty quickly got her agency down. Yeah. And then, you know, by the end of pregnancy, her agency was 5.7. That's great. So I mean, and she has, she's a beautiful little kid now that there are no. So can things be okay? Yes, they can. But the risk increases dramatically as the A1C. And the glucose levels are not managed

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

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

just feels like a false start. And that's what happens. Oh, that's sad. No, of course.

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

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

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

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

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

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

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

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

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

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

There you go. Yes, it opens up a whole can of worms Pandora's box, so to speak. We have

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

And I brought it up. Because in my sort of peripheral understanding of this, this whole time that I've been in the diabetes space, I've always thought of it as people would people with, I was gonna say people with pregnancy, people who are getting pregnant, are somehow asked to do some superhuman thing with their health. That's not even necessary. And it took me a while to realize that's not what we're really saying. What we're saying is that every Listen, there's a lot of people that have type one diabetes, and we all have different access to different technology insulins, all these different things. And so there's a, there's a blanket statement out there, like, if you're a one sees, you know, under this number, you're probably have a really great chance of being okay. As it gets lower your chances of problems get differently, you know, maybe they lesson, but then once in a while someone will put out a report, this is all there's no benefit in having A1C under this number for some reason. And I every and we've talked about on here before and I see that and I think I don't, I don't believe that that's true. And I think that that's going to be one of the things that 10 years from now someone's gonna say, oh, there was a report 10 years ago that said this was wrong. Yeah. But oops. You know, and I also think that it's a, it's an emotional idea. Like, if someone has a seven, you don't want to make them feel like a failure, because they're not five and a half. Right? Right. Because they're not, but it doesn't mean that they should stop trying for the other day not make themselves crazy, or you know, like anything, but write better goals. It's, I don't know, right? It just, you know, it's like if I went out and ran a 300 yard dash today, I think I'd finish it. And I don't know, probably an hour and a half. And so right. Now, that might be my personal best, but I saw on the Olympics, it can be done. You know, it about seconds, about 15 seconds. And so I can't just sit here and say, Oh, I did the best ever, because that's my best because it's not and it's your health or your child's health. And you can't just I mean, I think that one of the underlying concepts of this podcast is that you can't just say, oh, that's fine. It's good, or it's good enough. 300 after pizza usually go to 400. That was a huge win for that.

Was that right? And maybe that was a win. Maybe that was a win, you know, but if it's,

yeah, it's totally better. Again, try again, try it.

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

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

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

Interesting. So that makes sense, obviously, but that's Yeah, interesting.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

like drop the delivery of the baby to get the

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

it fine. He can do his homework by himself.

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

our blood sugars to the breastfeeding process does that impact the milk at all?

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

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

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

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

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

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

damage. And of course, she didn't think of it either.

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

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

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

that, especially with another condition to manage like diabetes. Yeah, there's there's more to manage than just connecting with this new little person. Yeah, so

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

they should absolutely. I think the farthest I've heard that somebody's purchased. Our book is Bally Bali or Bali? Yeah. I'm in Bali. Yes. Bali

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

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

I want to thank Ascensia 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 Two episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org. A huge thank you to one of today's sponsors, Gvoke glucagon, find out more about Gvoke HypoPen at G Vogue glucagon.com forward slash juicebox. You spell that g vokeglucagon.com. Forward slash Juicebox. If you're living with diabetes, or the caregiver of someone who is and you're looking for an online community of supportive people who understand, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, there are over 41,000 active members and we add 300 new members every week. There is a conversation happening right now that would interest you, inform you or give you the opportunity to share something that you've learned Juicebox Podcast, type one diabetes on Facebook, and it's not just for type ones, any kind of diabetes, any way you're connected to it. You are invited to join this absolutely free and welcoming community. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two in Episode 1018 teen pregnancy 1019 teen explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025, we talked about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer, he'd really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning that Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active. Took me already from a decent 6.5 A1C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com If you're interested in hiring Jenny, you You can learn more about her at that link

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 CDE 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 revisitable. 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 fold with insulin. This episode of The Juicebox Podcast is sponsored by Ascensia 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 Juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke HypoPen Find out more at Gvoke glucagon.com. Forward slash juicebox. The Pro Tip series that exists inside of the Juicebox Podcast is mainly about management of type one diabetes. There's also some informative stuff like what can you do when you go to the emergency room to make your experience easier. And today, I'm going to be filling a need that's been presented to me by the listeners. So I don't know if this episode is for them to get ideas from or for them to share, or maybe both. But in this episode of The Juicebox Podcast, I along with Jenny Smith, Jenny, of course has had type one diabetes for 32 years, she's a certified diabetes educator and an all around amazing person. And me Scott, who's you know, just the host of the podcast and the parent of a child with type one diabetes. So this episode is for people who need to understand type one diabetes more, or for those of you with type one who struggled to talk to those people about what type one diabetes is. See, if you're like the school nurse or a teacher, maybe my boss, friend, a neighbor, somebody wants to have my kid over for a sleepover. This episode is for you to try to understand better what type one diabetes is and what your role in it can be. And if you're a person living with type one or the parent of someone living with type one, and you're struggling for how to talk to people about it, this will be beneficial for you as well. And a huge welcome to those of you who don't usually listen to a type one diabetes podcast, those of you who care enough to try to learn a little more about type one so that you can be a better support system for the people you know and love living with type one diabetes, it means a lot to them. I'm sure they're really, really excited that you that you took the time. So I hope we can make this informative and fun for you. I think we have let's get started. I want to jump right into this because this has been interesting since I brought this up to you the other day, I I sat down myself and I thought who in my time have I spent? Have I had to describe diabetes to you know, when I started kind of making a list. And then I just a lot of people, a lot of people and then I went online and I said you know into the private Facebook group for the podcast and I said hey guys, Jenny and I are gonna do this thing. Who do you wish? You know, we could talk to and here's how the list came back. Grandparents, teachers, parents, babysitters, somebody who might have My kid for a sleepover, my child's friend's parents, a coach of a team, spouses or significant others, co parents, roommates, extended family, school nurse, co workers, bosses, bus drivers, and, and and family of adults with type one. So people who are diagnosed as adults who then are around other adults who never end up getting it. And then very much at the end of the list, someone said, Oh, I wish you could explain it to chaperones. And I started thinking, everyone should have just answered with the same word, it should have said, people, because this is just, this is like everything else around diabetes like you like, oh, explain it specifically to a coach. So what I'm going to tell you is, I think we're going to have a conversation, that whether you're one of the people I listed, or just a person who knows somebody with type one diabetes, when you're done, I'd like you to understand the basics of type one better, maybe a little bit of terminology. So things are happening, and maybe more so the mind of the person with type one, what's happening to them, and how you can be supportive of them. I think that's the goal here like not to speak to like, like there was there in the beginning, I thought, oh, we'll do a couple of minutes talking to grandparents, and then a few minutes tall, and I'm like, No, it's all the same thing. Really. Right.

Yeah, it is. And it's, it's really funny, you bring this topic up, because it's actually we do a monthly newsletter, and my my article last month was sharing your diabetes. Okay. And it was it was kind of along this same line it was, how do you talk to other people about your diabetes and give them the baseline of what you need them to really know. Without like a textbook, that's like 4000 pages long, overwhelming. It's overwhelming. And I some of the big points were one set a time to discuss specifically diabetes, with these people, or this person, or this culture, whoever it is, I like your term, just people in general, right? Pick the person. You need them to know this, this and this, these are the important facts. Because it's a lot easier if you've set a time for it, than if you go to the coach at the end of practice. And you're like, Hey, can you just take five minutes with me, I really want to talk to you about you know, Billy's like type one diabetes, and the coaches got, like, you know, soccer balls over is trying to get home

to go home and get yelled at. There's a lot going on in my life right now. Right, right. So

setting up a time, again, the timeline of what are the important things you want these people to know? Like you said, the basics.

Let me add this to that. The other things that people came back in their, in their responses, very overwhelmingly was, I want this episode to be something I can text to somebody like a link and say, Please, can you listen to this and understand diabetes? Because many of the people who came in to speak said, Look, I'm not very good at describing it. Like I can take care of myself. But when I start there was an overwhelming feeling of when I start to explain it to somebody else, I either get frazzled or too detailed. You and Jenny do it. And I'm like, alright, well, we'll do it. So Jenny's after you listen to this episode, and you decide you really want to help a person you love with type one diabetes, or someone who's in your class, or because there was one very specific woman who said, I'm a college professor, I wish I could explain it to my students. Better, right. And so whoever you are, in this scenario, here's what I can promise you, Jenny, and I will not make this boring. And we will not make it overly like taxing. It won't be so technical, you won't understand. And it should be a good runway up to you having that conversation that we just spoke about with this person in your life who has type one diabetes. So that's my overarching goal, Jenny, don't mess it up. Okay. I'm talking to myself. I don't want to mess it up. Do we start with? Well, we usually talk about diabetes in such a specific way. But why don't we start with just a really simple description of type one diabetes? You want to go?

Yeah, absolutely. I mean, type one. diabetes is the body's inability to create insulin or to put it out into the body. And so without it, your blood sugar gets too high. So type one diabetes is a deficiency of insulin. It's specifically an autoimmune disorder, which means the person did nothing to cause type one diabetes. It's not because they sat and ate hohos for you know, three years or whatever. So and I think that's a that's an important one to put out there. And just the simple explanation because there is a lot of misunderstanding And around just the term diabetes. Sure.

So yeah, and it is a listen, it's a genetic issue, right? It's an auto immune disease, you know, you can use an example, my daughter was two years old when she was diagnosed, she weighed 19 pounds. And I, you know, fed her the same stuff, all of us feed our kids. And, and her body just was like, you know, got confused one day. I mean, that's even that right? For these people listening. I don't know exactly what triggered my daughter's type one onset, what I can tell you is that testing can prove that you have markers, that that make you more likely to get diabetes. I don't know if my daughter had them, obviously, because no one ever checked her. But she got sick. And you know, it's always been my belief that her immune system got confused. And instead of killing her virus, Winton killed her pancreas for the lack of a better term. And I want people to understand, too, that the advent of insulin is still fairly new 1921 one, right. So, for context, if my daughter's pancreas would have crapped out in 1919, she would have died in a couple of weeks, right? That's correct. Okay. The insulin is the only thing keeping people with type one diabetes alive. Otherwise, the first time your blood sugar starts heading up, it will just keep going up and never stop. That's right, right. And you'll slip into a coma and die. Okay, I told you, this wasn't gonna be too technical. So so people are getting this insulin in, in a ton of different ways. And so I think that would be important, what are the different ways people get insulin,

initially, and some people even long term after diagnosis continue to take injections. So the age old, you get a little like bottle or what we call a vial of insulin, they now come thankfully, and easily dispensing pens. And you dose it through the course of the day based on many factors. There's other ways such as an insulin pump, that you could take your insulin, kind of a fancy little pager size device that sort of drips it into the body through a tube, or if you're using a tubeless, one like Omnipod, then that would be another way to do it. So essentially, an injection or a pump, those are two ways to get in the body. Now there is one other way. I mean, if we wanted to be truthful about it, there's also an inhalable insulin called the Frezza. So that's another way to use it,

most people inject insulin correct. And so inject like Jenny said, with a pen, which really is just a very fancy syringe, you might see someone do it with a syringe, you might see someone wearing a device on their body, or carrying a device that's connected to their body with a tube, there's different ways, but in the end, you need to get that insulin under your skin, right. And this could happen for a number of reasons it could happen because you're eating if you happen, because your blood sugar just went up on its own, and you need to bring it back down. When it needs to happen, it needs to happen. And I want people to understand that asking a person with type one diabetes, to go into the bathroom, and extensively hide while they're injecting is is not the right thing to do. So if please, there's, throughout this, I'm gonna tell you say things like, please don't ever say this, here's one of them, people around here might be uncomfortable with your diabetes, you can't do that to a person. If they're uncomfortable, they can leave, I need to give myself this insulin. So my blood sugar doesn't go up really high. And don't get me wrong, like not getting the insulin is not going to you know, it's not gonna kill you in the moment if your blood sugar is going higher, but here are a lot of things that could happen. They're thinking could become cloudy, right? Right, they could become agitated. So if you're a teacher, you don't want your kids blood sugar high, because they're gonna have trouble concentrating, thinking, they're not going to learn performing in all kinds of different ways. Same thing with sports, your blood sugar gets too high, you slow down your body has a difficult time, you know, I can see at my daughter's foot speed. If my daughter's blood sugar gets over a certain number high where it doesn't belong. I can literally see her slow down while she's running, she just can't go as fast.

Right? It would be the same thing too. I think in like a corporate world type of setting where someone may leave, feel like it wouldn't be acceptable in order to use their insulin or to respond to their pump, telling them to take the insulin or whatnot. And the same thing if they're being asked to present or to discuss something that's very, very important. They may not have the ability to do that. And if their blood sugar is not in the right place. Yeah.

So you need to give people the freedom to do what they need to do. If you want them to be themselves or be able to do that. thing you're asking them to do or hope that they can do. They need to be able to take their insulin and feel comfortable about it, it's difficult to have. This is a lifelong disease, like it's not going to, it's not going to get cured anytime soon, it's not going to, it's not going to go away, it's not going to one person said, make sure people understand it doesn't just transform it to type two diabetes, like it's a progression from one to two, right? Doesn't happen type two diabetes, completely different thing, right. And so this person, it's hard, it's really difficult. Like, I really want people to listen and think that every time you have a body function that puts pushes up your blood sugar. And so for people whose pancreas is work fine, could be adrenaline, stress, pain, so many different things can make your blood sugar try to go up, when that happens to you out there. With a working pancreas, your pancreas just stops it, you don't even see it happen. Like if you were monitoring your blood sugar in real time, and you got some adrenaline like it might blip for a second, but it would come right back. A person who doesn't have that their blood sugar is going to shoot up and keep going or get too high and stay there. And then they need to put that insulin in into their body to bring it back down again. It's just it's 24 hours a day and to have somebody make it more difficult for you is is kind of terrible.

And I think in terms of even bringing up the technology that is available, such as an insulin pump in terms of delivery, I know that there's also the misconception even in our day and age right now. Oh, you've got a pump? That takes care of it all. Yeah, that's a, that's not true. 100% not true at all, there is so much that the person with diabetes has to interact with in order for that technology to do what it needs to do for them. So just because they're connected to these devices, can be helpful. But it's not doing anything without their interaction with

it. Yeah. And it's, it's easy for people to understand to make an assumption, like, Oh, they got the machine, the machine fixes it. Right, right, or something like that. And I want to be really clear for everyone listening, like, I'm not coming down on you. There are plenty of disease states that I don't understand in any meaningful way. But what that does is it stops me from, you know, saying things about it that I don't understand. And like, there's a ton of different things. You might think, Oh, this is helpful. Like, if you find yourself with a parent of a child with type one, and they've just been diagnosed, and you think, Oh, this parents so smart, or look how well they're handling it. It's not right to say to them something to the effect of you know, Well, God gave the child with type one diabetes to the right person, because you can really handle it. Right. Really think about that sentence. But you know, when you're in it, because it happens to a lot of people. No one's lucky that their kids got diabetes. Nope, no adult feels lucky. And no one walks around going, thank God, I'm a head screwed on straight kind of person. And I'm the one who got type one, because Jimmy up the street hot mess. And if he would have gotten it, it would have been way worse for him. It's bad for everybody. Okay, it's just that's a, so be careful how you speak to people. Right? I think I think about a person who's been on this podcast before who had a child who passed away and I asked like, what's the right thing for someone to say to you? And she's like, there is no right thing for someone to say to you. And, you know, anything you do is just going to, it's not going to make anything better. Unless you offer like sincere, simple support. Hey, if there's anything you need, I don't know what to do. But if you tell me I'll do it for you that works with this as well. You know,

I think it's I think it's along the same line as offering up information about your neighbors grandma, who is something Something happened because they had diabetes, I same thing. It's like, don't, don't offer up in terms of like a connecting point. You know, if sure if you've got a cousin who has type one or you know, an uncle who had type one, and you have a little bit of understanding that might even further your discussion in terms of what the person with type one talking to you could put back into the conversation. But unless you've really lived with it, or you have taken care of somebody with type one, please don't? Yes. Tell them about your neighbors, uncles friends.

This was Jenny's politely saying don't look at somebody go diabetes. Oh, where have I heard diabetes from my grandmother? Oh, you know what? Oh, my grandmother had diabetes. They cut her leg off. That's not a good thing to say to somebody. Yeah, right. And just yeah, don't don't do that. Okay. So keep keep those thoughts inside. Because that's not helpful. And it might have nothing to do with the person you're talking about your grandmother's situation. Very well could be a ton different than this person situation and that It's important to understand too is that in this day and age right now, I know this sounds kind of strange, but this is the best time in the in the history of the world to be diagnosed with type one diabetes. So people have a much greater chance of staving off, what could be long term complications, and they have a much better chance of managing day to day in the moment in a way that won't impact their lives too badly. Now, I feel strange saying this because on one hand, what I'm telling you is, these people need some leniency. They need some understanding they need a little space because they're making decisions about how their bodies are, you know, working. And at the same time, I want to tell you that they can do anything, and so don't limit them. You know, and that's hard to do too, because you might not feel like you're limiting them you may feel like you're protecting them. The remastered diabetes Pro Tip series is sponsored by Ascensia diabetes makers of the contour next gen blood glucose meter, and they have a unique offer just for listeners of the Juicebox Podcast. If you're new to contour, you can get a free contour next gen starter kit by visiting this special link contour next.com forward slash Juicebox free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash Juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and 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 an 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 Juicebox free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips, you can use my link and save time and money buying your contour next products from the convenience of your home, it's completely possible that you will pay less out of pocket in cash for your contour strips 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 just click on that to check that out. Both are caused their awareness campaigns and the annual conference that I've spoken at a number of years in a row. It's just amazing, just like touched by type one touched by type one.org or find them on Facebook and Instagram. links in the show notes links at juicebox podcast.com. To touch by type one and the other great sponsors that are supporting the remastering of the diabetes Pro Tip series touched by type one.org. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. Gvoke 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 Gvoke glucagon.com forward slash juicebox Gvoke shouldn't be used in patients with pheochromocytoma or insulinoma visit Gvoke glucagon.com/risk. And correct they don't need that. And if they do need that, they'll know and they'll ask you for it. Yes,

right, exactly. Which is part of this. You know, the purpose of this is understanding if they're having a conversation with you about what you need to know. The reason is because a lot of times they want you to know what to do in case they need help. Right some understanding about this is diabetes, this is what you might see me carrying such as the devices this is I might make some noise my products might be bit tight, or whatever you know, but in case of this, this and this, these are the things that you could do to help me and this is how to help me right

because they may at some point need that help. And it's so you understanding like say you're a teacher, you understanding like signs like visible signs of hypokalemia anemia Okay, so low blood sugar, blood sugar. And I'm gonna read your list which I'm not a big list reader on the podcast but this person could feel shaky, be nervous or anxious. They could be sweating, have chills feel clammy, irritable, impatient, confused, their heartbeat might pick up, they can feel lightheaded or dizzy, voraciously, hungry, nauseous. Their skin sometimes can get pale, they'll look tired or could feel tired, they could end up feeling weak. Their vision could get blurred or impaired. My daughter talks about her mouth gets tingly and numb if her blood sugar gets too low headaches, trouble coordinating themselves clumsiness. This is coming right from the ADA A's website, the American diabetes Association's Association's website, in their sleep, they can have nightmares or cry in their sleep. And if their blood sugar gets too low, they can and if it gets low enough, we'll have a seizure. And so they'd like to know if they're not making sense when they're talking so that they can take in some carbohydrates of some kind to bring their blood sugar back up. And so you being a person around them, like like a coach. And you have to figure out the line, right? Because these things while they can happen, may very well not happen. So think of the other side of it. You know, you've got a little girl on your soccer team, and she's running around and every three seconds you're jogging next to her. Becky, do you feel okay? Becky, Are you dizzy? You don't feel clammy? Do you? Hey, Becky, Becky, Becky, Becky, you're ruining Becky's life when you do that, okay? Don't Don't do that. But at the same time, you could look over once in a while and visually, just, you know,

evaluate the performance, if you're the coach, you know, how your kids usually perform or do things, you know, how they interact with their other teammates and whatnot. So yeah,

it may not be at all, a strange thing to say, like, look, we have a two hour practice. Everyone sits down, you know, halfway through and drinks water. I'd really like it. If Becky tested her blood sugar, then, you know, because I don't maybe you don't feel comfortable as the coach like you don't want to be on the hook for like, seeing if this kid is about to fall over or not. Right, I get that. So talk to the parents and say, Look, can we just coordinate a blood sugar check, you know, at some point, you know, for safety, and then make it normal, don't call attention to it don't like it's happening. And everyone doesn't have to stare and people are going to stare in the beginning. But you got to just give the kid the the space to let it happen because everyone will get used to it. And I guess that's what I want to bring up with. Um, when my daughter was very little the first day of school, I'd go in and it's and I would give a talk like to the kids like five minutes on the literally the first day. Hi, this is Arden. Arden has type one diabetes, her pancreas doesn't make insulin, once in a while you're gonna see art and pull out this thing and give herself insulin within her controller for her pump. Hey, you know what Arden is just like the rest of you. She doesn't need, you know, she doesn't need you to check on her constantly. But if she looks like she's dizzy, or she's not making sense, you know, it'd be nice to tell your teacher, right? But it still didn't stop this one little girl from mothering her. And so she came home one day and she's like, this kid will not leave me alone. Like, like, and she goes, it seems really sweet. But she won't stop, I need this kid to stop back off. Like leave me alone. So that there's, there's a balance in there somewhere where you can be supportive, and understanding without being a burden to them or making them feel different or looked at. And this is very important. Like it really goes across the

board and what you're saying to not just the little kid component, but the teacher or the coach, like you said like bugging, bugging, bugging, are you okay? Do you feel okay, do you need some more juice, you know, that kind of thing, or maybe even goes cross crosses over into spouses, significant others. You know, especially and I would expect that later in marriage or later in partnership. You've had enough visualization to not be like bugging, bugging, bugging, but in newer relationships, I think an upfront important talk when you know that it's going a little bit further than just let's go out and get a drink or whatever, right? I mean, it's important to bring up this is how you could help me Don't bother me though. You know, don't don't tell me not to have the potatoes with my dinner when we go out for dinner because oh my goodness, they have carbohydrate in and

the potato makes your blood sugar go up. Thank you. That's what I want you thinking about right now. Unless the person says look, I have trouble saying no to potatoes. So if you could like if they want it

that's different, right? It's Could you remind me not to do exactly

what I say? See the french fries, if you could just go, Hey, you told me last time, I shouldn't get french fries to bring it up. I don't think anything that we've said the last couple of minutes about kids and coaches and teachers doesn't specifically apply to adults in adult situations, either. It's correct. It's all exactly the same. It's why I didn't want to break these up into like, Okay, now, here's 10 minutes for your boss, if someone's working for you, and they have type one diabetes, they're going to have some needs. And the most important thing is to support them and not make them feel awkward or odd about it. And I'll tell you why. And as a person who I'm hoping cares about other people who have type one, you know, you could create a, an eating disorder by telling someone don't, don't use your insulin here, because what you're saying to them is don't eat right now. And then they start associating the awkwardness of giving themselves the insulin with eating, and then they'll stop eating. And I know that sounds like oh, that won't happen, that happens a lot,

or hide their eating. Right, right, in an effort to not like show others. I mean, there there is, it's I mean, it's a whole another broad topic in terms of diabetes, the eating disorders that are associated with diabetes. It mean, food is a huge part of diabetes management it is. And so it's not odd, that it can become an issue. But it certainly is something that in terms of being supportive for another person who has diabetes, you don't want to push the envelope that way. And I

know that people listening right now don't know us. And they are like, it's 2020. Like, everybody seems super sensitive and social justice II and everything. We're not like that. Like, I'm not saying that at all. Like, I you can hear my terrible accent, I'm from the northeast, I'm good with like, Hey, get up, you'll be fine. I'm good with that I really am. But what I'm saying is, there's a real opportunity to mold a person in a positive way, or a negative way. And that goes for everybody I understand. But around this specifically, it does not take long to make someone feel different in a bad way. You know, and it'll stick with them, especially you teachers, who, you know, hear an alarm and are annoyed because you're trying to teach and it's alarming. Try to keep in mind that when that's happening, the student whose blood sugar is falling, who's now scared that they're going to pass out or die or something like that. They don't want this to be happening either. Correct. And you can't say let me just finish this lesson. Or they need to address because we've talked about high blood sugars, but low blood sugars are more immediate, immediate, yes. Right. You can't just ignore because a blood sugar that's falling, could be falling quickly. And one of those issues could pop up out of nowhere. So if this kid's wearing a monitor that tells them live, Hey, your blood sugar is getting low, or they say I feel dizzy, I need to test or you know, like, you can't just say, Okay, well wait till after recess is over. Or as soon as I get done explaining this math problem, like they need to do it now. Which is another great reason to normalize it, let them take their meter out at their desk and check their blood sugar. It's not going to hurt anybody. And and they'll have an answer immediately about what to do next. But the five minutes you want them to wait could end up being much too long. A time for them? Yeah,

yeah, absolutely. I mean, in terms of you know, even that also acknowledging what they're using to treat a low blood sugar is, is something that you also don't want to form any, like, wrong feelings about someone might use, you know, in terms of carbohydrate, it's just simple sugar that we really want to use to treat. So simple in terms of it could be juice, it could be Skittles, it could be something that we call glucose tablets, it could be honey in there multiple things. And everybody seems to have a preference for what is great for them and even flavor preferences. So just because the kid in your class is using like Skittles, and you're thinking, Oh, my goodness, Skittles, why are they so unhealthy?

Right? Yeah, you don't understand what you're talking about, which is a good is a great example of keeping your mouth shut in that situation. Like, they're not eating Skittles. Because you're here's what's going to happen to you. You don't know what you're talking about. The kid takes Skittles and you think in your head, this is why they have diabetes, look how they eat now, they need sugar to go into their body so quickly that it can literally fight off this extra insulin and stop from making them too low. So know what you don't know I think is important. And if you want to know find out more, but don't say silly things to people that, you know, it's not there. It's not their preference to have diabetes. The kids not looking for Skittles, you know, like, an adult doesn't want to get up in the middle of a business meeting and bang a Gatorade back. They're not like, oh, you know what I want to do to lay in front of 30 people who I'm trying to get to take me seriously. And that's the other thing too, is that you have to understand that adults are often are hiding their diabetes at work because they don't want you to judge them and like and lose out on unprofessional opportunities,

correct? Yeah, promotion and those types of things. And I think that's also, in terms of people with diabetes. As I mentioned, initially, you have to really know, who do you need to share your diabetes with who is really important as an adult, it might be your boss, it might be the co workers at the team members that you work with, as a child, it might be, you know, your teachers, and hopefully your parents will help with that. Even some of your really good friends. I mean, I remember as a kid, when I was diagnosed, it was really helpful to have some of my really good friends know, a lot, you know, in terms of like, their understanding language, teaching them things about why I was, you know, doing a finger stick and all of that, but I think it comes down to defining who do you need to share with and what applies to this situation? You know, you're probably not going to teach your soccer coach about carbohydrate counting. I mean, that's, that's not purposeful. But you're going to teach them things like hypo awareness and you know what to do in case who to call emergency contact to there are defined pieces, I think, to teach everybody

Yeah. And so it's also important to understand that diabetes is mostly an invisible disease, meaning that the people around you unless you're having a struggle, aren't ever going to see it. As a matter of fact, I pulled this up here just so that people can have an idea. Former Chicago Bears quarterback Jay Cutler has type one diabetes. Bret Michaels has it Nick Jonas has it and rice the author has it. Mary Tyler Moore, my close friend of mine coaches for the Philadelphia Phillies Sam fold he has he used to play for the Oakland A's he was in centerfield had type one diabetes. There are plenty of people. The Justice Sonia Sotomayor, right. Right has type one. So you can do

was a baseball player? Atlanta. Oh,

yeah. There's a guy. Well, there's a guy pitching for the Cubs. He's been on the show before Brandon Morrow he has, I think the tight end of the Ravens has it. There's, there's nothing you can't do with type one diabetes. There's a there's a guy that I know really well, who's a four time Olympian who has it, right. So and, and the point is, is that you look at those people, and I don't tell you they have type one diabetes, and you're never going to know these people are. It doesn't mean it's easier for them. They don't have the easy diabetes, because you don't notice it. They work very, very hard. At their health. I know it's hard to imagine. But the best I can say is imagine that you had to think breathe in, breathe out, breathe in, breathe out, or you wouldn't breathe. Like that's what it feels like having type one, I'm going to eat something I need insulin, I'd has to be this much. Not that much. I don't want to get too high. I don't want to get too low. I can't have a bunch of insulin in me when I go for a run later, because I might get low then he just like constant kind of tapping on the back of your head. You know,

I call it diabetes inner monologue. Okay, let's see Jenny and

Jenny has had type one for 31 years now. 3232 graduations. And, and she can tell you that you Jenny's really, really good at managing her diabetes. But that doesn't make it so of course, but that doesn't make it not in her mind. And and so it's there. Right? And it's an everyday conscious effort. Yes, it's so if you're a and I said that, so that you'd hear that. And so that if you are the spouse of a person who has type one, or your child has type one, but your spouse takes care of most of the management, you may not understand what's going into it on an emotional and physical and maybe sometimes lack of sleep level. It's really hard. It's incredibly hard to do well, it's also incredibly hard to do poorly. So if you're really great at managing are terrible at managing that comes with different struggles, people who are great at it understand, you know, the timing and how to take care of things in a way that maybe some people don't get to understand. But the people who are struggling, are aware every moment of the day that they're probably on their way to complications that are serious because they can't figure it out or because no one will help them. It's constantly in their head. Now, if you're co parenting, I can't tell you how many people come to me and say can you please find a way to talk to people who are like a divorced spouse or you know a step parent or somebody who's not for the lack of a better term in the fight constantly. Right, they only see a look, he's fine. Yeah, this isn't that hard or is blood sugar just went up for seven hours, that was no big deal. It is a big deal. And and either, you know, I, I don't normally get preachy, but either figure it out and help or get out of the way. But don't let your ego stand in the way of someone managing their health, which happens a lot, it may not be happening to you person listening right now, but it happens a lot more than you might want to think. Right? You know? Anyway, I didn't mean to get like that. I just I know if you saw the notes from like, my ex, you know, my kids blood sugar is terrific for a week and then they go to my exes for the weekend and his blood sugar's 300, all weekend long. So incredibly unhealthy. And, and I

see the same thing with you know, as good as family caregivers could be like, you do the best that you can as parents, and then you have a weekend away, and you're like, Yay, we've got a weekend away. But even in terms of those parents that weekend away, is not free of diabetes thought, right? You know, their thought has gone into prepping whoever the caregiver is prepping their child for they may not know this. So you know, text me if something comes up, or you know, the grandparents or caregivers or God parents or whoever they are, that's taking care of them thinking, well, can't they just have a little of this, or can't we just give this to them, and we don't have to really worry about it, everything, everything is considered in diabetes. And as you said, you know, that couple of days that they're running now at 300, because you didn't follow the set of directions that you were given. That's making a difference in that person or that child's life,

ya know, and so that people can understand when your blood sugar is high, there's too much sugar in your blood and no way to release it, the insulin is what releases it, we're not going to get into super technical stuff. But when you hear later, you know, when you turn on the news, and some guy died of complications of type one diabetes, now, you know, what they really died from was a heart attack or a stroke or an aneurysm or something that comes from too much for the lack of a better term sugar scrubbing away, you know, in the inside of your body, is it going to happen today, if a kid's blood sugar goes up to 300 Watts, because you messed up the insulin? No. But if it keeps happening, it will happen very likely one day. And so you're making a decision today on Sunday to maybe save someone's life 30 years from now. But that's that's worth understanding, you know, and just because it's going to be later doesn't make it not super important. And don't forget to you're helping them be clear minded, you know, thoughtful, being able to learn or perform like a lot goes wrong inside of the functioning of your body when your blood sugar's high. It just, it's just very important. And the people who love you and are hoping you'll understand are, they don't know how to explain it to you. So they asked us to make this. I will tell you, Jenny brought something up a minute ago that I wanted to kind of like add on to if there was a super simple way to make it, okay. Everyone with diabetes would be doing it already. And you wouldn't have to worry about it. There's no shortcut to it. So if you're having a pool party, I think you really need to try to understand how terrible it is to not invite one kid, because you're scared or you don't understand, or you just don't want the hassle. Like, just find some time talk to the parent come up with a simple plan that everybody can deal with because that kid sitting at home, and they're thinking, I'm not at this pool party right now. I'm not asleep over right now. Because I'm a problem. That's how it feels to them. Right? I'm broken, and nobody wants me around. And you can't you can't be a part of making people feel that way.

No. And if you don't know, like you said, it's ask, you know, a lot of the kids that I work with, that's one of the big things I bring up with the parents, you know, it's if there's going to be a sleepover or something they've been asked to, again, defining a time to sit down with those parents or even the good, the good friends, parents, and make sure that they have a basic baseline kind of understanding. But I think it also takes from the standpoint of not not being the parent with a kid with type one or not being you know, the employer who has type one or any experience with it. It takes asking, really just I mean, don't be afraid to ask any question is a really good question. As long as it's not, I guess derogatory or you know, it doesn't come out as what should you really be doing that? You know, I don't know very much about this. But should you be doing that? I

know a lot of people have type one diabetes, don't ask them if they should be eating something that really doesn't sit well with them. You know, they'll they'll they can eat anything they want if they know how to use the insulin to manage it. And, and so in the end, it's just that idea of, of being supportive. And like Jenny said, If you don't understand, try to find out and understand that when you go to find out, it's very possible that the person you're going to ask the mother of a kid has had diabetes for six weeks. She might not understand yet either. You know, and so her her instructions might seem like a lot, or babbling like, or I've babbled a lot of people when my kid first had diabetes, I'm like, Listen, you don't understand, she can't get high, she can't get low and you start rambling. And before you know it, you're like, Oh, great. I'm the crazy person in the room.

You get the glazed over eyes. And they're just like, I always

imagined that they're somewhere in between, like, I'm so glad this didn't happen to me, and why won't they shut up, but they won't shut up because they're scared, right? Because this stuff as much as it seems like, you can make it seem mathematical. diabetes is not like I take a pill every morning. And I'm okay. It's very fluid, it changes pretty consistently, depending on a ton of factors. And the people who really understand it, or the people who are living with it, are just sort of struggling moment to moment, because they don't know what's going to happen next, it feels like you're running for your life in a disaster movie. And you know, you're like, a bridge collapses underneath of you, and you pull yourself up on the bank. And then as as that's happening, a zombie bite your leg and a building falls on your wife, you know, like, you're just like, Wait, when is this going to slow down? You know, and at the same time, I know, I just said that. And it's true. This is gonna sound crazy. Don't treat people like they're running through a disaster movie, because they're trying to find some normalcy. And you could be a big help in that.

And I think sometimes, within that understanding, let's say you're the teacher, or you're the boss, or you're the coach, and you've, you've been schooled, right, somebody sat down with you, and they've given you information. They're like, this is the plan of action. And then next year, they come to you, and they're like, Okay, do you understand everything? And you're like, Yeah, I got it, you gave me this whole, like, you know, hour long, entire, you know, information session, you're like, okay, but this year, this is a little different, right? This is what we're experiencing now. So know that life with type one diabetes also kind of, it's a little bit more fluid, there's, there's change that ends up happening, you know, last year, to juice boxes at the middle session of a soccer match, might no longer need to be there. This year, the reaction is a little bit different. So, you know, also continue to ask questions along the way to say, well, has anybody anything changed for you? Or you know, is it is it still the same? Do we need to consider anything different? I think that's why in the beginning of the year for kids, especially, there's always a, there's a point at which you need to go in and you need to reestablish that care plan for this year, what's going what needs to be different, what needs to change? Because Because life changes,

and seriously, because your grandmother or your aunt, or your uncle has type two diabetes, you don't understand type one at all. There's nothing about that, that translates over to this in any meaningful caregiving kind of a way. I remember just recently, we were having a conversation before a school year. And one of the teachers, you know, my daughter's information about her blood sugar is on her cell phone, right, which is really cool. And so the teachers like, well, we take the cell phones away at the beginning of the class, and I laughed, and I was like, that's fine. Arden's not going to be giving you her cell phone, she needs it to, you know, make life and death decisions. And she's very good with their cell phone. She's not going to abuse it and everything like that. She was well, what do I tell the other kids? And I said, I swear I said this in a roomful of about 10 teachers is that tell them if they want to get a lifelong incurable disease, then they can keep their cell phone on them too. Otherwise, they should shut up. And like, and you have to have the nerve to do that, like you shouldn't to turn to 20 other kids and go, Listen, her situation is different than yours. I don't even care if you but just stop, you know, like it's a it's a big deal. Imagine wanting to use someone's diabetes as an excuse to keep your cell phone or to be a malcontent for a second, and then you as an adult, don't just shut that down right away. Instead, you're like, Oh, well, you know, Kim does have a good point. It's not fair. Of course, it's not fair. It's also not fair that my daughter's carrying a Juicebox with her and like, something called glucagon in case she passes out to somebody could stick it in her leg. It's not fair either, you know. So just think I'll tell you a common sense is, is a huge help with diabetes. It really is, and especially about being around them. But let's look, I think everybody understands now hopefully, why don't we drill down a little bit more about how in a situation whether you're a teacher or grandparent who's babysitting or something like that, or a you know, a boss who's trying to, you know, keep somebody healthy, like Let's give him more nuts and bolts of what goes on in the day of a person with type one diabetes and how they may be able to be helpful in those situations. So, I mean, but before we do that, Jenny, I'm sorry. Can you explain to people what it feels like to be high and what it feels like to be low? For you personally, it's gonna be different for some people. But

yeah, so lows. As I said just a bit ago, low symptoms for the person can change through the course of life with type one, two. So my lows now, I feel as though I have like these racing thoughts. I feel like things are going really like exponentially fast. But I feel like I'm moving through mud. Like, I feel like I just can't get there. Even though everything in my brain feels fast. I feel like I'm just moving at like a snail's pace. It feels horrible. I also, for a long time, it started in college, and I didn't have this symptom before, but kind of like you mentioned that like Nam. With Arden, I have like this numb, tingly tongue kind of feeling for low blood sugars. And I've never thankfully knock on wood, I've never gotten to the point of needing glucagon, I've never had to use it in my 32 years of life. Nobody's had to give it to me, I have had to have assistance for treating low. But um, you know, sometimes I've, I've, like started talking kind of weird, like, not really what the whole conversation was about, or like mumbling and sort of rambling. And my husband said, like, Thank you blood sugars kinda low. And this was before CGM, like we're married early on. You know, he knew some of the things to watch for. So I mean, those are my lows. Now, when I was younger, I definitely was shaky. I mean, it was very visibly, my blood sugar was low. And again, that was a time when there were no continuous monitors and pumps were not really beneficial. So but highs, highs, I get really, like tired, and really kind of, like more annoyed, I don't get annoyed, I don't get that like irritated angriness with lows like many people can get, I get that more when I'm high. And I feel like I just can't put a lot of really good, like thoughts together consistently, I feel slow,

so hard to put the effort in for anything. And it's not something that you can just fight through. It's not like that. It's not, it's not like I didn't get enough sleep last night, but I need to be at work. It's an absolutely physiological issue that is limiting you. So for people listening, it's sugar, glucose is the is the energy your brain runs off of. And having the right amount of it is perfect. Having too little of it, you know, is goes the way we've discussed and having too much of it does something to your body with a working pancreas just keeps you in a great range all the time. So you don't experience all of these things. But a person who may be could do something so simple as let's see, let's say you have a kid in your class who says I have to give myself my insulin right now, because I'm eating in 10 minutes. And you say, no, no, no, we're gonna finish this first, don't do that. I don't want you giving yourself insulin in front of all these people. Well, you've now missed time, their insulin with the impact that the foods going to have on their body, which will very likely drive their blood sugar higher and cause what Jenny just described. Similarly, if they say I put my insulin in 10 minutes ago, and I know you want to talk for five more minutes, but I have to start eating now. You can't say no, because then their blood sugar could go the wrong way the the insulin will continue to pull the sugar out of their blood, it doesn't know how to stop like, like a healthy body does,

it's expecting there to be food there to work with.

Yes, and when that foods not there, they can get awfully low and all the way up to like I don't want to, like, you know, I don't want to make you feel like I'm trying to be dramatic, but you could kill them. And you know, anywhere from shaky to not making sense to angry to seizures to passing out to dying, like if you take too much of that sugar out of their blood. That's like taking electricity away from a light bulb and you can't turn it back on again by putting the sugar back in after it's off. So it's really important. And at the same time super important not to make people feel like pariah and and not to give them long term, serious psychological issues around this thing that they you know, I am going to say this, but I don't think it matters. They have nothing to do with getting it. But even if they did, why would you? Why would you want to make them feel that way? You know, and I think that's important and I don't think any of the people listening to this want that. I think it's just it don't know what they're talking about. And then you make assumptions you No, I don't know, a lot of the things that we think are is anecdotal. You know, we kind of went over like, oh, diabetes, that keys off. My grandmother had diabetes. I understand diabetes, I live with my grandmother for three years. No, that's different. That's probably type two diabetes. And your grandmother probably took a couple of medications and, you know, different thing. But the person who says that, I don't think they say that out of malice, I also don't think the person who tells you, you're so strong, thank God, this happened to you. And not me. I don't even think I don't think that person means that with malice. No, you know, they're in any

conversation, we're always trying to find a connecting piece, you know, I mean, communication is that it's a give and take between two people or six people or whatever. But if you're in the, if you're the person that doesn't know, then ask more than talking. Yes. Right. It's, it's always, well, oh, goodness, I, you know, I didn't know that you had type one diabetes, tell me what that's like. I mean, that's a very easy, simple, you know, and if the person really doesn't want or need to share with you, maybe they would just say, Well, you know, I manage it, and it's okay. But if they're, if you're sharing with them for a reason, then continue to really be more of the ask the questions. But don't share too much. Unless you truly have some experience to share. I feel

like before we go over nuts and bolts like management ideas that people will have to intersect with, I think what we should really be saying here is, in case you haven't been paying attention for the last 49 minutes, this is about communication. And most people are terrible communicators. And it's because they don't listen enough, and they interject their thoughts. And it's a very human thing to feel like, you know, but you don't like I could sit here for the rest of my life and make a list of things I don't understand. You know, but I'll tell you what, put me in a situation where one of those things, I probably puff up a little bit, start reaching into my common sense, or, you know, a little bit of my anecdotal information I have, and I start saying now, now I know what's up here. You know, it's, it's like talking about, I know, we're recording this during Corona, but like, it's that thing when people step up, they go, Oh, no, no, you know what you have to do you have to do this. How do you know that? Is it because you're a Harvard researcher? Or is it because you heard a guy say a thing, and now two people said it, you're like, oh, that must be true. And that's just how our brains operate. And it's very valuable day to day, it's not very valuable when you're trying to talk to somebody about something important like this, that you don't understand. And they very well may be struggling with as well. You know, so anyway, all right, I'll start you jump in. Okay, I'll do breakfast, you do lunch, and we'll, we'll go from there. My daughter gets up in the morning. And if we're lucky, her blood sugar has been stable overnight. But if she's been low, overnight, we may have had to take away some insulin, or give her food, she could wake up a little higher. Because of that, it could throw off the timing of her eating, she might end up being late for school. Because of that. She may end up being a little rundown, you can wake up if you have a bunch of low blood sugars overnight, you wake up with what people some people call a low blood sugar hangover. Yeah, right. And so that could be that. So you got to give these people a chance to get their lives moving. And then they've got to get to work. And what if I get myself insolent or on time and I have to get my car then and drive to work. And now I'm scared, I could get low while I'm driving like these poor people, or you're just eating, you got a pancreas, it works. You get up, you make some eggs, you throw them in your face and run out the door. And it's all good. People with diabetes are already 45 decisions into life. And it's 730. And they haven't been in the shower yet. So they so they get that together. My daughter, you know, heads off to school and, you know, half an hour, 45 minutes later, she needs to know what her blood sugar's doing. So she's gonna have to look. So you see, my daughter looked down at her phone in the first in first class, she's not ignoring you. She's making sure that her blood sugar doesn't get out of whack. And then she's got to start thinking about like, Oh, I'm getting low. And I have Jim two hours from now. And, and lunch is going to be in three hours. And, you know, I have to give myself insulin during social studies so that it's working for, you know, all that stuff, right. And they have to count their carbohydrates in their food. So I'm going to ask Jenny to explain like, what what they're doing, they're around their meals.

Yeah. So I mean, carbohydrates are it's just a big word for sugar, right? I mean, all all carbohydrate foods, like starchy foods, fruit, even vegetables have some kind of carbohydrate or sugar in and when we take insulin, insulin is meant primarily to cover the impact of carbohydrates. So timing is really important around that in terms of like you said, she might need to take her insulin and social studies so that by the time she gets to lunch, the insulin is already there. The way that our insulin today works, it's meant to meet with her Food in the system. But our insulin has to actually do what we call peaking, kind of get in get working get circulating in order for food, carbohydrates was which digest really fast. Once they start, you know, getting into the stomach, that insulin has to meet it at the right time. And so when we count our carbohydrates, it's a certain amount that goes along with a certain amount of insulin, so that our blood sugar doesn't get too high after that might involve looking at a food label that might involve looking up information on your phone. So that maybe you're you know, visiting an app that's got a calorie or a carb counter in it, you might see somebody again on their phone or their device looking something up. And I guarantee that diabetes is fits around a mealtime. It's not that they're ignoring you or trying to be rude, it's likely that they're looking for information, or maybe that they're telling their pump to do something important. Coming into that mealtime.

And if you stand in their way of doing that, than most people to feel like they fit in next time won't do it, then you'll make their insulin late and they're gone. And their blood sugar is going to be higher. Not everybody's me, like I don't care what people think I would just do whatever, you know, and I've raised my daughter that way. I'm like, Oh, don't worry about them just do what you need to do. But but you have to understand that many, many people can't overcome social pressure. And so you pressure him even on the way you don't understand, you may send them in another direction. So they count all these carbs that give themselves their insulin. Now they're not sure if it's going to work, their blood sugar might go up and might go down. Now they might have to have their meter out to check their you know, they might have to poke a hole in their finger, make some blood come out, check it with a test strip, some people might be wearing a glucose monitor that's feeding their their blood sugar live to them on their cell phone, there's a lot of gear they have. It's not, you can't restrict their access to their gear is is a big thing. Because I've seen people say like, oh, just leave your bag here. Like I need that bag. I can't just leave it here. And that might mean if you're a teacher, that at recess for this year, you're going to be wearing some kids bag over your shoulder at recess. And just I know it sucks, but just do it. And that's it. For for, for I was good, please.

Oh, I was gonna say along with that, like in terms of like, what do you have to leave your bag here, whatnot, I've worked with quite a number of adults, especially who are government employees who aren't allowed to run their phones aren't allowed to have certain devices like a phone or whatnot within their government building. And I think the important thing, I mean, if you are certainly, you know, within the realm of being an employer, for people with type one i policies need to change, then that's the biggest thing that I can say, because while the device itself might have pieces that you don't want within the building, you're really restricting their ability to have a healthy life in terms of also what you're asking them to do performance wise on the job, things

change. And that goes right to what I was gonna say with like school nurses, like, I know, You've been a school nurse for 25 years, and no kid here has ever died from type one diabetes, except the way that you took care of it 15 years ago, it's not the way people take care of it anymore. It's much more fluid, it's, it's better. It just it really is and saying to somebody, Oh, it's okay. Or I'd rather their blood sugar be high than low? No, you wouldn't rather their blood sugar be high than low, you'd rather the blood sugar be normal normal than either of those things. Stop finding either ores in your head, I don't want to go down the wrong road away from away from diabetes, but everything's not black or white. It's not this or that. There's all kinds of other options and gray areas. And just because your brain picks, I'd rather be high than why rather than behind the load that doesn't make you right, and that doesn't mean that's the only option. There are a ton of options. Kids having to leave class to go to the nurse to do diabetes related things. That's bad. Okay, I know you think it's Oh, they need to be around me. So they do it right. You need to everybody needs to teach them how to handle it on their own because losing five or 10 minutes of math when you're too you know in second grade is one thing, but losing 10 minutes of advanced trigonometry is another thing you know like or may miss a whole concept. Yes, and it's gone and and if you learned how to manage on your own in the moment, you can just kind of find a need meet the need keep going instead of wait till the needs a problem. Go to the nurse spend a half an hour getting out of the problem going back much better to be proactive than reactive. And the going to the nurse thing all the time is reactive. It's waiting for a problem. These things can can be done in classrooms. Technology is amazing. My daughter has been managing her blood sugar through text messages with me for a decade. Right and she does no lie. Since the last day of second grade. My daughter who is a junior in high school has not been into the nurse's office for anything diabetes related in all that time?

Well, even in terms of like safety to, you know, I know that there are a number of schools and families that have worked with well, they have to send my child to treat the low blood sugar to the nurse's station, it's down three levels and across the building and whatnot, like, blood sugar is low, they need to treat it in class, there's no reason that you're you're sending a kid whose blood sugar is dropping, you know, for a five minute walk through the halls in order to go suck some juice down and a nurse so they can watch and make sure they drink the whole box. That's ridiculous. Like,

they're like, well, we'll send a kid with him like, Oh, great. So there'll be another eight year old there, because I am always putting eight year olds in charge of important things, you know, hey, listen, you just go with Jenny. And if she passes out, you know what to do your age. Right? Exact my 20 year old wouldn't know what to do, we'd be like, Oh, what happened? Jenny fell over, we left her there. And she died. Like, you know, like, you just don't put kids in charge of stuff. It's weird. Like I get if it's a little like, Oh, she just wants to have somebody to go down with and it's all nice. But the nurse's office is for emergencies. And here's the crazy thing. Having type one diabetes is not an emergency. It's just, it's just an extra thing you do during the day. So stop treating them like they're sick, Trump's stop treating them like they're broken. They're, they're just they're not, you know, and so and so listen, that they're gonna have to get on the bus, or you have to drive home from work. And you're still thinking about your blood sugar. And so if someone comes to you and says, Look, I need you to watch my kid tonight for a couple of hours, or you're the babysitter, or a grandparent, it's very doable, someone's gonna say to you look, eight o'clock, test their blood sugar, you know, text me the number, I'll help you do what you do. If you know if the numbers in this range, that's cool, give him this much insulin, let him eat this snack, you know, and here's what the snack is. Just follow the instructions, the person giving you the instructions is fairly confident that they're that they're right. And questioning them all the time is bizarre, you have any idea how many school nurses fight with parents, like I've been taking care of this kid for 10 years. And you want to tell me how to do it now. Because that's how we've always done it here. Very strange way to come at something. I get that you don't want to get into a long conversation with a family who maybe doesn't understand and maybe, least common denominator, it might make it easy for people who don't know, but instead of doing that to them, like what if you said to them, Hey, I think there's a way we could do this that your kid could be healthier, or you know, that kind of thing. And, and I want to say too, I'd like to give Jenny a chance here to talk about what it would feel like if her spouse had those kind of like anecdotal thoughts and was leaning on her all the time. First of all, I'd be dead. She'd bury him somewhere. It's over. She wouldn't take it. But But like, what would it be like for another adult who you respect in all other things, to suddenly have thoughts about your health that that aren't warranted or founded?

It would be it would, it would feel horrible. I mean, this fact that somebody that, like you said, you care so much about and that you have a lot of good rapport, and almost every other thing that you talk about and live with and decide about together? I mean, it would make you feel kind of countered, honestly, in terms of what you've been doing. And also like visually how you feel like they're now seeing you. Like, is it all about this? Is this all they see now? is are they really gosh, they're they're really worried about this, or they feel like they don't have any, there's no confidence there, in what I in what I'm able to do for myself, you know, I've been managing this for 30 some years. They feel like I can't do it anymore, that they're constantly asking, like, are you okay? Or did you just check your blood sugar before bed tonight? Because, you know, I heard your Dexcom last night or whatever, psychologically to

feeling like feeling like someone looks at you and sees diabetes, not you. Is is is kind of crushing. You know, and that's another great little tip you're looking for a tip don't lead with how's your blood sugar every time you see somebody, something else first, how's the day? Isn't it sunny out, blah, blah, blah. Like, even if you're the school nurse, like just walking in there. It's a drudgery for kids right to do that.

Like it's very rare for my husband to actually like, ask, even if he hears like my Dexcom making a noise or something. It's very rare for him to ask I he does have the follow app on his phone. And even with that, he never I think it was maybe a month ago that he texted me to ask, you know, I've gotten these like urgent, low alerts. He's like, you know, and I've gotten a couple of them like, are you okay? It's kind of all he asked or, you know, and I was like, Yep, it's a sensor. That's totally off. I was like, I just restarted it this morning. A little difficulty. Yeah, I actually texted him a picture of like my actual life. finger stick, I'm like, I'm like, 92 totally fine. It's like, okay, I just wanted to make sure that he's like, because I keep getting them. And I just wanted to make sure that everything was okay. But other than that, usually it's not, you know, it's not even something I

brought up, but it wouldn't be pleasant if if he was constantly.

No, in fact, usually my my late native work in which he doesn't work, he usually makes dinner. And he'll actually usually text me and ask, you know, hey, I was gonna make this this evening, you know? This is how much carbs in it, because you know, is that I need to Pre-Bolus Or he'll have measured something for me. And this is how much was in it? Or, you know, when do you think you're going to be done, because he knows that the Pre-Bolus component is really important. So those kinds of pieces are really helpful. They're not like, annoying

to good example. It's a good example of him. Like, look, what are we saying, listen, talk, ask questions, be empathetic, do things that are actually helpful, not that you think are helpful. I learned that from being married, by the way, that the things that I think my wife wants aren't necessarily the things that she wants. And that you know, and then I wouldn't be much more helpful if I did the things that would actually be beneficial to her and not the things that I feel would be beneficial, right. So listen, talk, ask questions, let them talk, realize it's hard for them as well. And like Jenny said, at the beginning, set a time to sit down and talk about this. And if you don't understand, keep asking and understand that things could continue to kind of morph and grow and change and that what you know, today to be true, very well may not be true a year from now. Right? You know, you have no idea how things evolve and change hormones and kids are huge stress is, is can sometimes be hard on your on your diabetes, but I really do want to make sure that no one leaves this feeling like oh, well, people with type one diabetes, I shouldn't hire them. I shouldn't put them on my kids baseball team. It's not the case, with with good support and understanding. I mean, this, okay, you guys are listening. Because somebody sent you this episode, you don't know this podcast, you don't know me. I've met 1000s of people with type one diabetes in my life. And overall, some of the kindest, smartest tuned in people that I've ever met in my life. Like, imagine how tuned during you are when you have to understand the inner workings of your body constantly. You want these people on your side, like they're, they're great teammates, they're there, they're great coworkers, there's just a little bit that they need you to understand. And then you'll find a rhythm. That's the other thing is like, this isn't forever, you'll find a rhythm together, whether you're you know, a, you know, the parent of a friend of a kid or something like that, or whoever you are in the scenario, you deal with times, it won't be a thing anymore, you'll just you'll have it, you know, and it's worth doing because you're gonna get to know some great people who otherwise may be marginalized. And I don't know, just think about it, like you have an opportunity to put in a little bit of effort to figure something out. And keep a kid from being a kid who's not invited to a birthday party, or a person who loses a job that they're completely qualified for, because they got low at work, and nobody knew how to help them that made all of you nervous, you know, that that sort of thing. I want to say to that, if you really want to dig in more, there are episodes of the podcast called defining diabetes. And they're very short. And they, they define very specific things. So like, if we set a word here, like Bolus or Pre-Bolus, that you didn't understand, it will explain that to you very simply. And if you really want to dig down deep and understand what people are thinking about when they're managing their blood sugar's, there's an entire series of episodes called diabetes pro tip, right? So it's diabetes pro tip Pre-Bolus diabetes, pro tip, something, there's maybe 20 of them by now, if you really want to understand what people with type one diabetes are thinking about. Those episodes will take you well inside. And same thing for people listening who were like, I can't make anybody understand Pre-Bolus saying like, just you could send them one of those. So yeah,

I was actually going to mention that too. So yay.

Thank you very much. And this is the first episode that Jenny and I recorded with her new microphone. And I have held in my excitement about how good she sounds the entire time we were doing this. So for regular listeners to the podcast, you're there. All right now going like 20 sounds so much better. And for everybody else, they're like, Hmm, I didn't know that was a big deal.

I asked Scott if it was actually going to get rid of my Wisconsin accent. And he's like, yeah, probably not. But no, it'd be so much clearer.

You talked earlier about the night your husband, would you work late and your husband cooks and there were four words that if I hadn't spoken to you so much, I don't know that I would have known what you were saying. Oh, really? That's right. I've said water a couple of times in here. So everybody who's not from Philly is like what is wrong with this guy? They think and I'm having a stroke probably Anyway, I really hope this was valuable. I know it's not possible for us to cover everything. But the goal was for you to be the person who's in some way supporting someone with type one diabetes or wants to understand better. And I hope that by listening to this, you, you have a better understanding, I think you will.

And also know that you are really important in terms of the person's like feelings about things and that background support piece, you're a really important part of that as long as you understand things in the way that you need in order to provide that support. So

I think in the last thing, I think I want to say is that, as my dog barks, that you don't want to separate yourself from a person's life because you're scared of their thing. Like that hurts like it might, because I talked about co parenting earlier and spouses who aren't as involved, I believe, sometimes they just don't want to mess up. So they step back, but you end up alienating the person with diabetes and stranding the person who's trying to help them. And and I know, it's a lot to figure out, but you could like trust me, I know, as you're listening, you don't know me, but I am. There's nothing special about me and I understand diabetes really well. And everything I know about it. And Jenny knows about it, we put into those pro tip episodes. So if you're just a dad or a mom, or you know who's like, I don't want to get involved, because I'll mess it up. You know, you're doing other things that I think you don't mean to be doing in your relationships. And if you understood it better, I think you could do better it would help. Yeah, it really would. Anyway, I could keep talking about this forever. So let's just stop. Jenny, thank you very much for doing this with me. Of course. I want to thank Ascensia 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 Gvoke glucagon, find out more about Gvoke HypoPen at G Vogue glucagon.com Ford slash juicebox you spell that Gvoke glucagon.com. Forward slash juicebox. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed you're starting over episode 1001 all about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two in Episode 1018 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and an episode 1025 We talk about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with this and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics. Scott brings useful info Emeishan presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so it is active as the carbs become active, took me already from a decent 6.5 A1C 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. If you're living with diabetes 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 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. 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.

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 CDE 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 revisitable. 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 health care plan or becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by Ascensia 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 Juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke hypo pen. Find out more at Gvoke glucagon.com. Forward slash juicebox. Okay, Jenny, so I know how people's minds work. And the problem with this episode is it's going to be incredibly important. And they're going to see the title and not listen to it. Right? Nobody. I'm just going to curse and I'll bleep it out later. For some reason. Your mother during glycemic load and glycemic index foods you're making me crazy. Okay. So here's the here's the problem. The core of this cod podcast, the concept behind it is I don't think you should have to limit your diet. The unspoken part of that sentence is I also don't think you should have a bag of sugar every day. Right? So I want you to Yeah, listen, if you get crazy one day and you're like having a pop tart, or I want to eat a bowl of cereal, I want you to understand how to Bolus for that that's really the the reasoning for the podcast that it's at its beginning, like I said, but the amount of people who say hey, listen, I counted these carbs. And it didn't work. So I don't know what you want me to do about it? Well, what I want you to do about it is understand that there's a difference between 10 grams of potatoes and 10 grams of sugar and 10 grams of Pop Tarts. And Cheerios are the I'm fascinated by how many unhealthy foods people think are healthy. Which one jumps into your mind when you say that? Because I think of wheat bread right away. Like somehow it being wheat bread doesn't make it bread.

Right, I think of especially in the past five years, I would say maybe even more than that. I know what you're gonna say go ahead. I think of meal bars. I don't know what else to call them.

I was gonna say go ahead.

It's kind of like the bread idea. Just because Wonder Bread now says that it's wheat bread versus white bread. That's like if you want real bread, like go back to granny. She made her bread right? And even you know breads today being there's a plethora of them on the market. Right? But just because it says wheat bread doesn't mean that it's healthy bread. I mean if you're talking about like healthy bread, if you're going to eat it, you're talking About the sprouted like low glycemic, we'll talk about the glycemic sunsets yes of this whole episode. But right I mean, those types of breads the unprocessed, you can actually physically see the grains in it or the seeds or whatnot. There's a big difference between wonder wheat bread and sprouted grain Ezekiel bread. major difference.

Even when I make bread at the house, I'm only just making white bread, but it's at least sugar, flour, yeast, water, butter. That's it. That's what's in it. Like salt. Excuse me, that's, that's what's in it. It's of course, the the flour is processed and the sugars processed. But you can buy a loaf of wheat bread. And the first ingredient is high fructose corn syrup. Right. And people are like, I don't know what happened. Right? I do.

I do too. Yeah. It's kind of like I said to though, with the bars, people, lives are busy today. Very busy. And I actually did a whole like, I think I did a blog post about this actually, or it was in part of our newsletter or something all about, like, sort of the false advertising of nutrition bars, right? You're eating your nutrition bar, because it's like, it's low carb, or it's low glycemic, or it's follows your keto plan, you know what they're, you're gonna follow a plan, follow a plan and eat real food. Most I say most of the time like these, like 9010 8020, kind of, most of the time you're doing real food, you know where it came from, your grandmother could identify it, I can guarantee that if I showed my grandmother who was no longer living something like, I'm not gonna name a brand, but a general like, a store bought processed meal bars to be like, What is this? What is this? What is this gonna make yourself a peanut butter sandwich or something, you know,

those things are so dense, with calories and carbohydrates and all that stuff. My son uses them. So my son does not like to have a full stomach when he's playing baseball. But you can't go play college baseball in the heat without fuel, right? But he can take like a half of one of those bars and power him through a baseball game. There's so much jammed into it. So he likes them because they don't fill his stomach. But it goes to show how much fuel is in it and you know, things that impact your blood sugar. I thought, you know, when you said, you know, a bar, I thought you might say vegan food. And I thought your vegan diet and I thought you might say no gluten stuff. Because I had to remember one time, they were trying to figure out my iron issue. And a doctor said, Hey, don't eat gluten for a month. And in a month of eating not gluten. I gained like eight pounds. And I thought, but I'm eating healthier. And then I looked back and I went No I'm not. I'm just eating things that don't have gluten in them. Right? Right. I confused no gluten with health. And my daughter's friend is a vegan. But she's basically a human garbage can. You know, it's fascinating.

It is in terms of I mean, just those two, vegan or even being vegetarian is kind of the first right. Okay, you don't want to eat meat. Great. I mean, for the most part, the only animal that I eat is fish, okay, than any of the other animals on the planet. I eat fish. It's occasional, not very often. So for the most part, we are mostly vegetarian. And but you could be a very unhealthy vegetarian, you could also be a very unhealthy vegan. I mean, if you're doing a heck of a lot of the processed, oh, but it doesn't have any animal based product in it. Great, but like, how long has it been sitting in the bag or the box on the shelf just because it doesn't have animal product in it? Or? Right I mean, there are healthy ways to be vegetarian or vegan. They're also healthy ways to be on a ketogenic diet. You know, a lot of the products that are on the market for that type of an eating fueling plan are very processed, you can be healthy and actually eat good real food on a ketogenic diet or on a vegetarian diet or on a paleo or a caveman diet. But much of the process stuff that's out there like you found with the the gluten free stuff. Yeah. Unfortunately a lot of the gluten free packaged processed stuff. It's made out of very this is brings in glycemic index. It's made out of very high glycemic quick impacting refined carbohydrate, rice flour, tapioca starch, potato flour, I mean, the lower glycemic ones would be things like if it's made out of like an almond flour, or like the nut flowers or like a coconut flour or something like that. Those tend to be lower impact, lower glycemic, still processed. But

the reason I bring it up, and I'm sure this happens to you constantly, then to me far last, because I don't speak to nearly as many people one on one as you do. But I am just endlessly inundated with people who want to know like, I don't understand why this isn't working. I eat healthy. It's almost like when people say it's almost like when people say to me, Oh, my blood sugar got really low. I've learned not to infer what I think of his low into what they say in the beginning, when someone say to me, Oh, I got really low, I'd go right over it. Now I stop. And I go, what does that mean? What number is really low? Because sometimes the personal say, 85. And I'll go oh, well, that's not really well. And so it frames my conversation. So when people say I eat healthy, I do. I'm like, what does that mean? Right? Because I need to understand what you're eating to talk to you about the insulin you're using, because we did everything right here. Your blood sugar should not be 200 right now, why don't understand I had a really healthy meal. And then when you talk to them, you know, it's like, oh, I had avocado toast and you think oh, that does sound healthy. Except a they don't know there's carbs and avocados for some reason. They're completely disconcerted with the facts in the avocado and there's high fructose corn syrup and the toast they made and I'm like, yeah. Okay. So, so So I don't care how anyone eats I would think of myself as the only real diet I stick to is an intermittent schedule. I only eat in a certain hours. But other than that, in the past week, I've had Ben and Jerry's ice cream. I'm making ribs tonight for dinner, Texas style, in case anyone's wondering gonna smoke them. And you know, I think last night we had I had chicken parm that I made last night. But keeping with Jenny's point, I made the chicken parm I took a chicken breast, I hammered it flat. I put bread crumbs on it, and a little tomatoes and some mozzarella cheese you at least you could see what was on and

you knew what you put in it.

Yeah, and I didn't. And I didn't fry it in any of the I don't use processed oil either. And the and the the the olive oil I use is only cold pressed I don't I don't use the heat pressed. So those are pretty much the only things that I follow and besides taking, you know a reasonable amount of like, you know, vitamins. I don't really do anything differently. But I'm also not really interested. I'm not trying to impact my weight. I just want to be healthy and I want to eat something

and you're not concerned with your own blood sugar overall. I mean, you're concerned with your daughters, but

other than a glucose monitor a couple of times my body handles my diet. So that's and I'm not over taxing it. I didn't eat like three pints of Ben and Jerry's ice cream. The remastered diabetes Pro Tip series is sponsored by Ascensia 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 Juicebox free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash Juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen. It fits well in your hand and features Second Chance sampling which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash juicebox free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips you can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now through your insurance. Contour next one.com forward slash Juicebox for a meter go get yourself a free starter kit. while supplies last US residents only touched by type one has the back of people living with type one diabetes. Take for instance their D box program touched by type one knows firsthand the intricacies of living with type one diabetes. And so their team has created a D box, which is a starter kit that provides important resources and supportive materials to individuals with diabetes. They want you to thrive. The D box is completely free and available to newly diagnosed people. All you have to do is go to touched by type one.org. Go to the Programs tab and click on the box. While you're there, check out all the other resources and programs available at touched by type one.org. Speaking of support, touched by type one.org is available in English and Spanish. Don't forget to find them on Facebook and Instagram too. You do not want to miss what touched by type one is doing. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. Gvoke 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 Gvoke glucagon.com forward slash juicebox Gvoke shouldn't be used in patients with pheochromocytoma or insulinoma. Visit je voc glucagon.com/risk. You know, I

think it's also I think that actually brings up kind of a good a good visual of the difference between glycemic index and glycemic load when you were wearing that continuous monitor. I remember you either I think you texted and you texted like how much you physically had to eat. In order to get the CGM to register like a bump up in your blood sugar is showing that your body was actually being taxed. He was fascinating by the amount that you ate. And that actually speaks to the load impact. Right. So when we talk about glycemic index and glycemic load, glycemic index is really just it considers the amount of food that you've eaten carbohydrate that will turn into impacting sugar in the next two hours after you consume the food. But that's just the tip of the iceberg and understanding. And that's when when I talk to people, you know, who are trying to consider glycemic index and like, you have to take it a step farther, there are depths or there is depth to glycemic index and a step farther as glycemic load in terms of glycemic load talks about the amount of the food that you're eating at a particular time. And my favorite example to give is watermelon. Watermelon has a very high glycemic index. If you're not familiar with glycemic index, or not quite sure it's a scale of zero to 100, with 100 being pure glucose. So as foods are rated on that scale with a number, that higher the number or the closer to 100, the faster the impact should be on your glucose level. Okay, but again, this is in a simple lab generated testing, right? Where you're only eating my example watermelon, you're not eating watermelon on top of chicken parm on top of like a whole stick of butter. Right?

I also wonder, are these things tested on people with diabetes when they come up with the index or people with a working pancreas when they come up with the index?

I believe it was, I believe it's people with a working pancreas. Yeah, to give a true definition of what the impact could be when sort of outside insulin dosing isn't in the picture. But that is a really good thing it makes me think of maybe looking that up.

Here's what it made me wonder about, you know, when somebody tries to catch a low by turning their basal off for an hour, and then they create, like, avoid in front of them a black hole where there's no and then they have the tiniest bit of carbs, like my blood sugar shot way up, I don't understand it, well, your pancreas doesn't work, and you took away all the insulin in your body and then added even the tiniest bit of carbs. So the glycemic index of anything away from insulin is probably 100, right? Like everything probably hits like 100 away from insulin. And so when you've got the right amount of basal in these foods are going to still hit on this chart. And before we go on, like I just I'm gonna run through it real quick and just pull a couple out to give people an idea. whitebread is a 75 Right? White rice is a 73 cornflakes are 81 but an apples 36. Right strawberry jam is 49 A potato boil to 78 but a potato mashed is at seven. So everything hits differently and when I stand on stage, I try to simplify it down by saying Foods punch at a different weight, some of them just hit harder than others. And that's and it's interesting to they have sugars listed out here. Sucrose is 65. Glucose is 103. Honey is 61. And fructose, if I'm saying that right is 15.

Yeah, because toast is fruit sugar. And that kind of brings into the treatment for lows, then the reason that glucose tablets technically work the best or anything in which dextrose is one of the first three ingredients in like a candy kind of thing. That's the reason it's going to work the best because glucose is the simplest form of sugar that there is, there's no breakdown to it, it gets in and it gets distributed and use. Whereas something like fructose, or galactose, which is milk, sugar, sucrose, they are more calm, there are more combined chemical sugar structures, so your body has to break it apart, to get the glucose out to actually impact the blood sugar.

So in a scenario where a person takes a glucose tab, and it takes forever for their blood sugar to go back up, but eventually it rockets up, that means they have a lot of active insulin that the tabs fighting with Is that Is that what you would infer from that,

that would be the estimate, you know, if there's iob, and there's a load of it, and there's a low and you only take one glucose tablet, that's like a drop in like the ocean of impact the other. The other reason could possibly be whatever is in the stomach already might be hampering the true absorption of that if the glucose tablets kind of sitting on top of that digestion. And if that other food is really highly fibrous or very high in fat or a lot of protein, it may take longer for that little bit of glucose to definitely impact and get absorbed. Yeah.

Okay. All right. So I'm sorry, we kind of got away from it for a second. But it all feels really important, you know, that, that you can't just I mean, all carbs aren't created equal. I guess that's how I've boiled it down for the podcast. But again, the the amount of you out there who I tried to say to people, like when they're really learning about the podcast, and they're going through the pro tip episodes, and they're getting the ideas down, but they're still spiking, and they're getting low later. I always say like, why don't you just simplify your food choices for a little while while you're practicing? You know what I mean? Like, I think I think I said to somebody recently, if you got it in your head that you wanted to learn how to box and you went to the gym a couple of times, you took some sparring, and you were starting to get confident. Once you had a little bit of confidence under your feet. Your next thought wouldn't be, you know, I had to go find iron Mike Tyson and see if he wants to go a couple rounds. And because you're not ready for that yet, right? But people make a couple of good boluses in a row and they're like, I'm gonna try Cheerios like, no, don't try Cheerios, it's day three. You're not good at this yet, you're getting better at it. And so if you're having trouble putting tools into practice, I always say, go for things that are you know, that don't punches hard. While you're practicing it, cut yourself a break, you know,

and also learn and I think I've said this before to some other episodes, but learn the foods are the that are most common for you. Take a look at what you love to eat, write them down. Most people have about 20 foods that are over and over what they eat almost every single day, write, mark them down, look up their glycemic index and see how does it work when you try to cover these foods, even if it's like a meal, let's say you eat chicken and broccoli and rice three nights a week because it's like one of your favorite things in the whole, great, write it down, figure out what you did. What happened if it especially if it didn't work the way that you wanted it to work out, and then eat it again, you know, two nights from now and try it again. Maybe it was more insulin that you needed. Maybe the timing was a little bit different. Maybe it takes into consideration though. Well, gosh, tonight I ate a whole cup of rice with the chicken and the broccoli. And maybe Wednesday night I decided to eat only a half a cup of the rice with the same amount of chicken and broccoli. So there's the load impact, right? It's the portion of the rice, the rice itself in one cup versus half a cup versus four cups, still has the same glycemic index. That's not going to change. But the load takes into I guess what you have to pay attention to is you're eating now like a whole cup versus a half a cup. And that load impact is going to then be the big driver of blood sugar after In fact, you might need to play with timing of the insulin a little bit differently based on portion

right now Jenny brought up earlier that I tried to drive my blood sugar up when I was wearing a glucose monitor and I obviously don't have diabetes. And I took a I think it was a big piece of cake with a lot of icing on it. And I ate it and waited and my blood sugar did not go up very much All right, so I forced myself for you people, I hope you're happy. I forced myself by the way I did not enjoy. I did not enjoy the last third of the first piece. And I really didn't enjoy the second piece. And I was just like, oh, we get this and, and what do I get to like 132? Something like that my blood sugar like something like that

right state under the defined like 140 Mark. Yeah,

I couldn't eat myself over 140 If I tried and, and, but still I got to 130 in a life where I wasn't getting to 130 a lot I was having to like, do what Jenny said to get the 1/3 he was having to stack multiple different tough foods on top of each other, like layer them on top of each other's having to have bread with potatoes, and then something else and more and more. I was I spent one night I don't know if you know those little spearmint leaf candies that are just like they're just sugar with like, they literally they take sugar and then they dip it in sugar. I sat with a glucose monitor in front of me just going like just popping one of those in like every three minutes. And my blood sugar would not move off of 89 like it just wouldn't move. And I was just like I'm not trying to make people jealous curious

did you I was Thank you pancreas thank you so much. No,

I I told you I had a deep feeling of guilt. Eating food and watching my blood sugar not go up like a significant it makes me sad thinking about it. I had a real deep feeling of guilt the first number of days I award. And I was just you know, I'm trying to do these things. So I can talk about them on the podcast. And at the same time I'm looking over at my daughter while we're like correcting a 130. So it doesn't turn into a 170 You know, and and I'm just but anyway, like, let's get back to the fun part. I am throwing these candies into the point where I was like, I hate these things now. I couldn't get my blood sugar to go up. That was it. It was it was pretty fascinating. Having said all that, again, I think that the podcast exists because I think people are going to have a candy once in a while. I think that when people look at the you know at Harvard's good you know what you can swap out for lower glycemic index things. And I think oh, I could have corn on the cob or a leafy green or peas. You know, I think most people are like I would like corn would you like corn flakes or bran flakes? I want corn flakes. You know, even white rice to brown rice is you know now there are ways like you'll learn how to like for us. We I've switched the house over just a basmati rice. It just hits Arden differently. It just does. And who cares why? Like I tried four different Rice's and I finally got to one and I was like this is the one that doesn't hit her as hard. This is the one we eat now.

Does it differ based on how you cook it or prepare it?

I only prepare one way Jenny. I have this aroma is it's a Roshi, people are making fun of rice steamer. I have the greatest rice steamer on the face of the planet. And let me tell you why I am able to afford this rice steamer. I was walking through a Macy's one day and they had this little rack of things that had clearly been returned to the store but bought online that they don't stock in the store. And so they just want to get rid of it because they have no place to put it. And my eye luckily for me, is it zeros? It's ZOJIRU Shi they make bom bom rice cookers right? Wow. And my eye catches this rice cooker that I know in my heart costs like $500 and right and obviously I'm not going to own a $500 rice cooker in my lifetime. And I looked over and that things had 75 bucks. And I moved across that store. like Usain Bolt in his prime. I was like out of the way people. I snatched this box up and I was holding it. I was like hugging it. Everybody just moved like I felt like everyone else knew as I looked around, I realized I was the only one aware that I was holding a very expensive rice cooker with a $75 price tag on it. And I actually it was so crazy. I went over to an employee I was like, This is $75. And she goes yeah, and I would I will buy this. Thank you. So I took it. It makes perfect rice. It is fascinating. You put the rice in, you fill the water up to the line that corresponds with the cups, the number of cups of rice you use. You push a button, it plays Twinkle, twinkle, little star and 55 minutes later, you're eating the best ratio ever had in your entire life. I don't know why it plays tickle. Take a little star when you start up but it does.

My kids love that.

Oh my god. Other than that I am The word I can't make rice. I screw rice up six ways from Sunday every time I try to make it so I

barely have rice. I only have rice when we do sushi.

When my son is trying to gain weight, he wants it in the house too. So I make it and I and it goes in the um, it goes in the refrigerator. He just adds it to everything he's eating.

Yeah, my choices always. My kids love quinoa, thankfully. And then wild rice, which isn't technically even rice, it's it's the seed of a long grass. So education for you. Oh,

I love I love a nice long rice because I like the the the sort of like, you know, spices that go on with it, too.

Yeah. They work glycemic ly better. And I've just found long term that it been my family likes it. So it's not like I even have to cook it separate for me and something like brown rice. So yeah,

I can't believe I spent so much time talking about my excitement about getting a cheap rice cooker and this podcast episode. I'm sorry for all that. For everyone who's listening. It was like, Yeah, buddy, this is not helping me. I'm not buying a $500 rice cooker. Well,

well, you shared it because the way I asked you how you cooked it, right, that does bring in as you were talking about the glycemic index before about like a big potato versus a boiled potato versus you know, the glycemic index can change based on how something is prepared and or how ripe something is. So for example, like your apple that you mentioned before, I think it's in like the 30s or 40s or something right? Most apples are considered low glycemic, anything under 50. On the glycemic index scale of considered low glycemic slow impact. Apples are there a kiwi fruit is there most of the berries are there. But then you get into the fruit that you really eat at its peak sweetness. You're talking about the summer melon, you're talking about pineapple, papaya, mango, bananas, grapes being cherries, they're all high glycemic, because their sugars are so developed to get that flavor that you want. I mean, I guarantee you're not going to eat it. Well, some people do. My husband doesn't care. He's one of the people can eat like a green banana, put it in a smoothie, he doesn't care. He's like the bananas there. Because I liked the nutrition in it. I don't care how it tastes, right. I cannot eat a green but

on the outside when you're biting Do you notice that like the FMD? Like, why is that doing that to my mouth, my mouth.

I wish people could see us sometimes that we make when we're talking. But I mean, I bring that in because glycemic index is higher for a ripe or fruit and the impact is going to be faster. And I can tell you if I make a smoothie with a less than ripe banana because it's what we've got, and I want a smoothie. The impact is definitely different for me. And I strategize my Bolus timing, different based on that. Based on that,

well, you hit one with Arden loves cherries, and they like I have to like swing it those with both hands get you know, when your Bolus saying they're really tough. That is see i i find all this fascinating. And I find it sad, because I don't think that many people think about it at all. They just count the carbs. And then they're like, well, this I counted the number and the number says 10. And so it's 10 I, I'm right, you know what I mean? Nobody thinks about the insulin, because I don't think about the carbs that much like I look at the food and I pick the insulin. I saw somebody the other day. They were, you know, they had this meal. And they're like, We use two units or three units. And I said, Well, what is this? Like a, like, I don't understand is this like a four year old kid and it wasn't it was a teen and I'm like, that's not gonna work. And you know, and then I asked them their ratio, and they're like, oh, it's one to 10. And I was like, You think this is 25 carbs, I was like, this is 60 carbs. You know, if it's one, it's 60. And I'd be scared to say 60. As I was looking at it, I was like, I don't know, I'd like to go 70 To be perfectly honest with you. And, and there are 2030 they're not sure. And then the kids blood sugar jumps up to 240 and they don't know what happened. And then they're correcting, correcting, correcting, then the food gets digested out the kids crashing down and then they're correcting and then they want and it goes by and it's just it's never ends.

I think you know the topics of glycemic index and glycemic load are they really are such they're kind of the like further down the road when you're talking about like just correct carb counting. Get that squared away. That is step number one get get some carb counting, get some labels read even if you have to do portion estimation, that's your tool that you get good at portion estimation. Then for again, those foods that are on your these are the typical things that I eat. Great. Then we can move on further to things like glycemic index glycemic load a little bit better Bolus timing, and then you kind of that maybe another step is, how was it cooked? Right? Am I boiling? My potatoes? Are my baking my potatoes? Am I you know eating a green banana? Am I eating a completely black bun? So?

Well, you're you're kidding on something that I know I want to talk about on the podcast more with you in the future, which is after speaking to so many people, like I realized that there's a, an order in which you should pay attention to things when you're starting, right? And like in an overly simplistic way, like I always say, if I was if I was on the Titanic, and I was thinking you, you, you somehow recognize me as a person who could help people with diabetes. And like, Scott, I have a tape recorder, you're 30 seconds, what do you want to tell people about type one diabetes, I'd say get your Basal insulin right? Learn how long your Pre-Bolus is, and then understand the glycemic load and index of food. And then I would go under and freeze to death and drown. But but those like if the if I could only say those things to you like three things to you, I'd say that. And then from there, I'd start talking about well, it's timing and amount. And you know, and you can't forget about overnight, this happens. And you know, protein and fat cause rises, like there's the variables, I just think of it is the seed of the idea. Like I always think of like management of diabetes is a tree, it's 100 year old tree with 1000 branches. And every point of that tree is important, but at its core at its seed, it's basal. And then it's you have to Pre-Bolus and then it's you have to understand the impact of the food. Like that's the start of it, you never, but I see so many people who are out on the tip of the 700th branch going, I really want to understand this part. And I was like, there's a lot more to understand before you dig into that, you know, back at the trunk. And here's the problem, right? No one tells you to Pre-Bolus No one ever tells you Basal insulin is important. And the words glycemic index and glycemic load are not sexy, and I don't like to pay attention to them. When I hear them. My brain goes. Boring. That's for people who eat good. Like that's how it made me feel when somebody said it to me in a doctor's office one day, I'm not trying to run a marathon. I don't care about glycemic load. They instead of saying, Hey, you over here, these are the three most important things you need to understand. They told me the most important things and then moved on to stuff that doesn't matter as much. So not that it none of it matters. It all matters, but there's a core of it. And if you do the core, you're okay. I'm telling you, Basal Pre-Bolus glycemic load glycemic index isn't a one seeing the sixes. That's my guess. You want it in the fives, start crawling out in the edges of the tree and figure out the rest of it. But this is an exercise. Yeah, get a pump and go for a walk. Like there's I could say stuff all day. But you know, stop eating pop tarts and telling me like it's not fair. I can't have it. Of course, it's not fair. But first your poison.

I remember the last time I had a pop. They're not really college because there was like nothing left in the cafeteria or something. And I was like, oh my god, I have to eat something. But

my insulin Chinni assign to that if you want to goddamn Pop Tart, eat it. I don't care. Just don't act like you don't understand what happened afterwards. Because that makes me sad. Like, I just, you're killing me online, okay, you're putting things up online, and you're making me sad because I want to come sell this stuff. The I don't have time. And you're breaking my heart. So and and when I when I help people privately. Some people get it more quickly. And some people get it slowly. And then some people give it away, like after they know it. And I've seen them do it. And then they stopped doing it. I'm just gonna tell you, like, I don't follow many people's tax comps. And when I do, I don't for long. But when I do, and I've seen you do it, and I've seen you understand it, and then you have a 300 blood sugar, I gotta stop following you. It just It breaks my heart like I just can't, like it eats me up inside. You know, I look at the graph. And I'm like, oh my god, like it didn't Pre-Bolus Or why

are they bad pump site or Cutlass?

It could have been anything. The problem is, it's just it's ripping my guts out. I can't look at it anymore. Like with my daughter, I can do something about it.

It's hard to follow people I agree. I mean, with the with the many, many, many people. I see their data. Yeah, it is. It's hard because and I think, you know, there's, there's no, there's no stop to, like my job isn't like, I go to the office and do my job. I put everything away. I close the door and then I go home, right? Like the people that I work with become like, they're almost like family to me, right? They're people that I I care about the people that I get the privilege to work with and help and I want the best and I Tonight, I feel like I could just like go home with everybody

just texted a person this morning. And I said, if you could just come here for, I think 18 hours, I could just do this for you and you could see, but they and they know what to do and they won't do it. And I'm just like, oh my god, it just really listen, I'm not trying to turn this. It's hard on me. Like I really does. Like it just rips me up. Like, I'm like, you keep making the same mistake over and over again. But it's not out of ignorance. You you quite honestly know not to do it. And you just I don't know if it's fear bits are hard to break. Yeah, or habits are hard to break. But you're just you're doing the wrong thing. Like it's and I've told you it's the wrong thing. 10 different ways. And each time I say it, you say I understand I now you don't have this. I now know what my wife feels like when she's talking to me. It must be Kelly. I'm so sorry. It must be incredibly frustrating to say the same thing to me a million times, amigo. No, no, I understand. I 100% understand it three days later. I'm just doing it again. But But and so it's like, I don't mean to come down on me. I'm not trying to come down with evil. I'm just saying that. Jenny's not wrong, like following someone's blood sugar is it's a lot. And it's tough to win. Like, I don't think I know everything. And I but it's tough. When you look at a graph and you go, hey, you know what, you need more basal? And they go, No, you know what I think? And I always think to myself, I actually started saying it out loud. I just started going like, why don't we stop worrying about what you think? Because what you think led to this graph I'm looking at? Try what I think for a second and see what happens.

That's my way for a little bit, please. Yeah, here. And

listen, I'm gonna cost Jenny some money and save all of you an hour paying her Friday. Stop explaining to Jenny what you think, let her tell you what's going on. Because you're just in therapy at that point. And that's like getting you to a better blood sugar thing. You know what I mean? Right? How many stories do people tell you where you're just like, stop talking, this doesn't matter.

And sometimes, you know, sometimes it's a marriage of what I see. And sometimes it's adding in then what they've seen, but they're addressing a certain way, because they think something's happening, that isn't really the reason for it. So it's kind of a marriage of what I see and how to tell them about what to do differently. It's not that what you're seeing is wrong, it's that the adjustments are not quite the right adjustment. You're

100% right. And I was being too flippant, like you do need to hear it from them. But it's fascinating how infrequently their interpretation of what they're seeing is right, right. You know, you need to you need to hear what's happening. You don't need their interpretation of what's happening is much it's interesting. Anyway, it's like it's like trying to do I don't know, it's the weirdest customer service in the world like it people. This is like that except times like a million. So anyway, Jenny has to go. She's show I do drop bombs of knowledge and truth all over this episode. So I really appreciate that. I will talk to you soon. Cool. Awesome. I want to thank Ascensia 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 Gvoke glucagon find out more about Gvoke HypoPen at G Vogue glucagon.com Ford slash juicebox you spell that Gvoke glucagon.com Ford slash juicebox. 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. If you're living with diabetes, or 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 1000 active members, and we add 300 new members every week. There is a conversation happening right now that would interest you, inform you, or give you the opportunity to share something that you've learned Juicebox Podcast, type one diabetes on Facebook. And it's not just for type ones, any kind of diabetes. Any way you're connected to it, you are invited to join this absolutely free and welcoming community. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two in Episode 1018 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025, we talked about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics. Scott brings useful information and present 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 A1C 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.

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 CDE 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 revisitable. 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 Ascensia 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 Juicebox 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 Gvoke HypoPen Find out more at Gvoke 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 A1Cs 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.

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.

And by the way, that job will die. If you drop it or leave it,

you're gonna kill a million people, if you don't do it exactly the right way.

That's how it feels, isn't it?

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.

Okay, so not only. So there are some people who enter a pregnancy and already have that A1C 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.

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.

And I would imagine to and this is just me imagining but if you live for nine months with an A1C, 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.

Your CGM is going off because your blood sugar is skyrocketing. Because you're stressed out about said incident.

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?

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.

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

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.

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

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,

at least also make another pancreas man if

I mean, why not? I'm not a doctor, but somebody should get on that.

I entirely agree.

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 Ascensia 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 Juicebox free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash Juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and 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 Juicebox free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips, you can use my link and save time and money buying your contour next products from the convenience of your home, it's completely possible that you will pay less out of pocket in cash for your contour strips 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 Gvoke glucagon.com forward slash juicebox Gvoke shouldn't be used in patients with pheochromocytoma or insulinoma visit Gvoke glucagon.com/risk.

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,

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, basal, 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

have type one diabetes, you're a lady with long curly hair. I'm

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

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.

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.

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 basal 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

ish weeks the steady climb.

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 basal 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

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.

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

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

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 Juicebox 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%.

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,

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,

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

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 basal. And I experienced this myself for both my kids, basal overnight, if I even if I had it at all. And my basal is, while I was nursing kids overnight in those early months, it was like near nothing. My basal 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

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,

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,

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.

A lot of

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

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.

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.

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,

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,

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?

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?

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.

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

does it change the milk itself?

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

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.

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

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,

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

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?

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.

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

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.

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.

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.

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.

I know you're like I don't know what else.

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

this was one child. Oh, really? That was just just the four year old the other ones at school?

Oh,

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

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.

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.

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 Ascensia 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 Gvoke HypoPen at G Vogue glucagon.com forward slash juicebox you spell that GVOKEGLUC AG g o n.com. Forward slash Juicebox. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two in Episode 1018 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 A1C 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.

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 CDE 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 revisitable. 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 Ascensia 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 Juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org. And on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke HypoPen Find out more at Gvoke glucagon.com. Forward slash juicebox. Every time I think there's nothing more to do for the protests, then somebody asks something and I think no. Oh, that that would work there too.

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,

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.

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.

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?

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.

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,

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

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,

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.

What is the functionality of the proper insulin dosing that makes you gain too much or not enough

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.

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.

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.

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.

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.

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 basal is too low and it works out or their basal 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.

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 basal, but they're offsetting it with boluses. And maybe the little amount of basal 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

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?

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

work. And they think, oh insulin, put the weight on them. Correct. Okay, gotcha.

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.

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.

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.

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,

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?

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,

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,

you might not need as much as right now

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.

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.

True. In fact, I've also kind of heard people and there's truth to it.

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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,

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

are my favorite. Yeah, I

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.

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.

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

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

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,

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

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,

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,

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

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.

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

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?

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

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.

It's the fun stuff where it causes your problem. Right? It's

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.

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.

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,

I see what she's saying, okay.

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,

then is that a vote for intermittent fasting for type ones?

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,

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.

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

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

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,

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

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

for 50,000, I use and you take one once a week, or something like once a

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

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

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.

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,

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.

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

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.

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

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

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,

so like, I should have just gone and gotten an extra cup of tea. Kind of nice.

I should have just said, Jenny, tell me about weight loss. I'll be back.

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,

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?

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,

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 Ascensia 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 Gvoke glucagon, find out more about Gvoke HypoPen at Gvoke glucagon.com. Ford slash Juicebox, you spell that Gvoke glucagon.com. Forward slash juicebox. If you're living with diabetes, or the caregiver of someone who is and you're looking for an online community of supportive people who understand, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, there are over 41,000 active members and we add 300 new members every week. There is a conversation happening right now that would interest you, inform you or give you the opportunity to share something that you've learned Juicebox Podcast, type one diabetes on Facebook, and it's not just for type ones, any kind of diabetes, any way you're connected to it. You are invited to join this absolutely free and welcoming community. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs in Episode 1015 Jenny and I talk about emergency room protocols. In 1016, long term health 1017 Bump and nudge part two, in Episode 1018 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 A1C 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.

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 CDE 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 revisitable. 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 Ascensia 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 juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke HypoPen Find out more at Gvoke glucagon.com. Forward slash juicebox. Okay, so we're recording I want to tell you that this lovely woman named Isabel has been helping me with the Facebook page. And she came to me recently and said, You need a pro tip for female hormones and you need a pro tip for the end of a honeymoon. She said these are things that people ask about constantly. And they must not feel like they're getting what they need out of the podcast on this. Now Jenny, you know, in my heart, the end of the honeymoon just means use more insulin. And when you get your period it means use more insulin but darn it. Let's dig in. Let's just dig into it and find out the details. Okay.

Sure. Yes, they're both good. Good topics. Yeah,

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

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

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 basal, 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 basal 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

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.

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

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,

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 basal 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?

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,

say 2.7

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.

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.

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.

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

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

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 basal going. So it's, you know, by using too much basal, 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 basal 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 basal 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 basal a little bit? And then on days when that basal 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 Ascensia 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 Juicebox free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash Juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen. It fits well in your hand and features Second Chance sampling which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash Juicebox free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips you can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips 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. Gvoke 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 Gvoke glucagon.com forward slash juicebox Gvoke shouldn't be used in patients with pheochromocytoma or insulinoma. Visit Gvoke glucagon.com/risk.

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

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

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

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?

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 basal 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,

part done, and you get that part time to a bunch of A1C 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

want to know where right. Okay, they want not just more or they're like, but where should I put that more insulin?

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 basal 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,

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 basal. Yeah, add just a little bit more basal, 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 basal, 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.

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 basal 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 basal 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,

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.

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

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 basal. 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,

why didn't I think I was like, Oh, I don't know, either. But I hope that

it helps. And it it seemed to be much better. Right. So

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.

And let and let the Basal

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

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

is not the time to take the basal 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,

we could could pan over here and listen to this music from this producer, you know, whatever.

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

no, that's fine.

You're a busy person well, and I can do it during

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.

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?

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,

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?

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

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

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.

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 Ascensia 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 Gvoke glucagon, find out more about Gvoke HypoPen at GE Vogue glucagon.com forward slash juicebox you spell that Gvoke glucagon.com. Forward slash Juicebox. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed 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 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bump and nudge part two in Episode 1018 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 A1C 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

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 CDE 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 revisitable. 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 Ascensia 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 Juicebox free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries Gvoke HypoPen. Find out more at Gvoke glucagon.com. Forward slash juicebox. Okay, give me a testing. Hello. All right. You're there? I'm there. Okay. Yeah. All right. So I've spent, not my whole life, you know, but the last number of days and weeks looking into all of this, trying to get ready to make a pro tip episode about female hormones. And it's a very scary proposition. There's a lot going on. I'm not scared, scared, but I'm overwhelmed. And then the last kind of piece of it was that I went on to the Facebook page and said to people look, you know, throw out your questions for this episode. I want to be clear, I almost didn't think I needed their questions so that we could talk. I wanted to see if there was repetitive need, like you don't even like what are people like same questions over and over. And my goodness, I mean, it's kind of obvious, right? Like so. The questions ranged from like, just God, is there any rhyme or reason to this to? What about menopause? What about perimenopause, what about the time where my kid isn't getting their period yet, but it's starting to exhibit, you know, symptoms and having hormone fluctuations, talking about puberty and then pregnancy and then and then. Oh, is your head spinning post pregnancy? It's it's listen nature. God, I don't care what you think this is, there's gotta be a better way to do this. Someone, someone, this was an afterthought. Like, like someone at the end was like, oh, you know, here's what we'll do. We'll throw some eggs in here. And then you'll have to throw in some estrogen to get the eggs really roll and then one egg will come out. And if they don't get pregnant, the whole thing will just bleed out of their vagina. Perfect. Like, I don't know who what. Oh, my goodness. PCOS keeps coming up. Is that polycystic ovarian syndrome? PCOS? Yes. Now I know those words. So already, Jenny, I want you to tell me what you just said before we started recording about the inequities of diabetes management from men to men to women,

or from an education standpoint to begin with. I mean, it was not something that was ever discussed in my presence, at least and I don't think my mom had outside of this Did conversations with my peds? No at all about hormones? Right. So I learned all of this as I was having this like, typical cycle, you know, that should happen after a certain point in the sort of teen years. And education today. It's focused as on diabetes, in general, right? Not on, if you're a woman with diabetes, versus if you're a man with diabetes, these are the differences that you will definitely see. So you're a woman with diabetes, you've got all the female hormones pumping in your body. Let's discuss diabetes from the angle of being a woman. Right? I mean, especially for my like, I wouldn't even say, when I start working with somebody, if they're from about the age 1011, all the way into, well, even the women they work with, into the perimenopause and menopause age, that's something in an initial visit, I always ask about, because it, even if it isn't yet visible, it will be at some point. And people need an idea that they need to like, see out into, if I see this, and this and this, I'm clearly not a crazy person. This is body function.

Well, I guess, especially given that, you know, because we talk about things in general terms, like the cycles, 28 days, that's in general, it's not, it's not for everybody, and it might not be for you from month to month as well. So if you can imagine when you hear people talk about like diabetes, like just when I thought I had it, it changed or you know, those memes, there's meat is it memes? Oh, my God, I'm old, you know, where it's like Monday, two plus two is for Tuesday, two plus two is seven, you know, Wednesday, two plus two is zebra, like that kind of stuff. If that's already how diabetes feels to people in general, and then you put this on top. I mean, you really are kind of creating two different spinning layers of confusion that can impact each other, or show up on their own. And I don't know how you're supposed to make sense that I actually after going through all this, I have an idea I'll share at the end about how to get a handle on this. But I just don't know. Well, I guess to give people some context aren't in 17. So this is the depth of my understanding of this. My understanding of this is I'm married, and I've lived with a lady for a couple of decades. And, and my daughter has diabetes, and she's been getting her period for a while.

And I bet you never paid as much attention as when it really was in reference to diabetes management.

Only thing I used to pay attention to was, there's this what I call the nice day, there's like this. There's this literally one day a month, where my wife is a 1950s. Like, I'm making quotes perfect mom, wife, lover, like it's that day on that day, I feel taller and more handsome. Like, you know, like she is so incredibly

kind of like Leave It to Beaver mom, sort of, at that age have an idea of what a Mom was

right? Yeah. 100%. And I, I bask in that day, because the day that comes after it. I can't even look her in the eye. Because if I do something wrong, she's the different like, and then I know that the the event is coming in about five to seven days. Like that's how it works for

us paid enough attention to actually like, I can tell you many, many spouses or partners are,

I thought I was gonna die. I was defending my own life, you know. And so for years, that's the only way I ever thought about it. And then Arden starts to get her, you know, and then we're kind of rocking along and taking care of Arden's blood sugar. Like it ain't nothing some days, you know, it's just like, I do really have this all figured out. And then one day, she started getting her period. And it was all fine at first. It actually almost got more difficult at some junctures. But it was it was very structured. So I didn't have any trouble with it really. Right. And then all of a sudden, her periods got heavy. And you know, people listening will know that, you know, Arden went through a year or two of like us not understanding what was going on. She got anemic a number of times she had to have iron infusions. This was all ended up being because of her period. Right? Yeah. So Arden would get her period for like 11 days, like she'd have like 11 day long cycle, and then only a couple of day break before she started to bleed again. It was just really Nicholas, which led us to put her on birth control, hoping, like, you know that she wouldn't bleed to death, because she was, I mean, the impact on our life was insane. Sure, you know. And so first go round with the birth control they gave her it wasn't strong enough didn't really do anything. But they still asked you to be on it for 90 days before they consider changing it. So you, you struggled all this time you think you have an answer, and then 90 more days is struggling. And then they moved her up to another, I guess strength and that has, you know, straightened out her. Excuse me. Also, the first indication of that problem was nosebleeds. Oh, really bad out of nowhere nosebleeds. That only happened once a month. And it took us a while to figure it out. It was literally happening on a cycle. I never was able to connect it to her periods. But the minute she went on the birth control and the second round of birth control, and it straightened out her periods, the nosebleeds never happened again.

That's really interesting. Well, and I mean, again, a symptom that if you're paying enough attention to your body, there are lots of things that your body is trying to tell you. Right, if we just pay attention to.

And that's why I bring it up, honestly, because part of what I figured out, Jenny, part of what I figured out being a man who doesn't get a period, and a person who doesn't have diabetes, as I consider talking about this with you today was was that you kind of have to, you gotta kind of have to Jane Goodall it a little bit, right, like, you got to take notes and step back and see things and keep wondering what's happening until you can build some, some idea of like, I keep seeing this thing over and over again. And where does that fit on the calendar? And how does it work in relationship to, you know, bleeding or pain or insulin resistance, and then you sort of start making sense of it, you have to track your period. Yes, maybe for six months before you'll be able to wrap your head around it a little bit,

especially if your cycle is not regular. I would say for women who, especially women who are considering maybe you're starting to track things and pay attention because you are planning a pregnancy, or maybe you're really trying to prevent a pregnancy. So then tracking things becomes just as important, right. But then along with the lines of even planning a pregnancy, the goal in diabetes is to have pretty optimized management prior to conception. So yes, I mean, you really should be tracking things for a fair amount of time, if you don't have them already nailed down because you've paid attention, right. And there are a number of really good period apps out there. I mean, there are some that are free that do just as well as some of the ones that have all the 1000s of bells and whistles for tracking everything else. But I think the ones that are the best actually have a place where you can keep notes. Because the tracking app that I like to use, I actually track month to month, how my insulin changes have looked this month. So I can go back last month, the month before and actually see, has it been consistent enough? Is it going along with what is normal for me. And that helps.

Well, even very recently, in the last couple of months, Apple added a period tracker to their health app, which sounds interesting, robust, and it's free, and a lot of people use Apple phones. So I wanted to throw that out there.

I didn't even know that was an option. So thanks.

Yeah, so because Arden uses one that's third party, I don't even know what it's called now. But as I looked at people's questions, and I thought about Hold on a second. The gods are coming after me for talking about periods when I'm not a leader. That's right. As I thought about how I been figured, like, like step back and looked at what we had to go through to try to figure this out for Arden. And then I looked at people's questions. The real fear when you see fear is around the unknown portion of it. And all I could think over and over again, when I saw their questions like how do I know if it's going to fluctuate? When do I turn up my Basal insulin if I can't be sure when it's going to start? I kept thinking you're gonna have to track it, you're gonna have to pay attention you're gonna have to put like work in and I know that sucks because it feels like diabetes has already worked. But it really made me think about like, kind of what we talked about another pro tips, which is, you know, some upfront effort can save a lot of heartache, right over and over again,

are a lot more micromanagement than you really should need to be doing.

Yeah, yeah, you get stuck in that situation where you're constantly constantly constantly adjusting your blood sugar in the moment, which I'm a listen, I'm a fan of if your last to stay flexible, but in this situation where what was the number I saw the average woman's gonna have how many periods like 400. And something or it was like, oh, like

hold on in a lifetime? Well, I guess if you expect an average age of a period starting at the age of 12, and there are 12 months in a year, right? So you would have, let's say, one cycle a year. And then the average time period of a cycle, completing would be about, let's say, age 12, all the way to maybe 55, let's say maybe even 60. And that's a good amount of time that you would be having cycle.

I'm using your math 55 minus 12, is 43 times 12 months, is 516. So you go. So I'm saying, that's a lot of tracking. I'm saying put in put some, like real, like, it's gonna be honest effort, because you're gonna have to track you know, your insulin use every day. And, you know, just giving yourself I think, what helped me was just simple words. Difficult, easy. You know what I mean? Like, referring to my management, you know, meals were, what I expected, easier than I expected, harder than I expected. Yes, you know, my Basal seemed to work well, not Well, today, like just kind of keep it keep it like that, you make a little note for yourself. And I'll tell you to tracking your period is going to help you get better at taking care of your blood sugar, too, because you're gonna see all all around. Yeah, yes, you're gonna see all kinds of things that you didn't, didn't see before. To begin with,

you're gonna learn a lot of things too, in that time of tracking for all of those other variables that we have to adjust around, right? Because I for one, know that my sensitivity, once I've gotten to about day three of my period, after that point, and until about ovulation is a really sensitive time. But it's more sensitive from day three to about like day seven ish. And in exercise, I have to be more aggressive and adjusting my insulin for exercise. Or I will go low. Despite my other tools and tweaks working outside of that, I will go low, if I don't adjust more than I normally would, is

that a progesterone period in there.

So you're essentially when you're looking at progesterone, that is typically like, peaking at certain points, right. And then there's also the luteinizing hormone, there's follicle stimulating hormone and there's estrogen, and you got a lot of hormones that are coming into play. So progesterone kind of starts to really kind of like, fall off. Essentially, once your period is started, it has really climbed in the time of you coming into potentially having a period. And part of the reason for that is in the anticipation that you in sort of that Avi LaTorre time period, have actually conceived, right? progesterone levels will stay high and continue to climb in pregnancy. One, you don't have conception happen, and you start to have your period, that level falls because there's no reason to have that elevated. I mean, again, other hormones at play here as well progesterone being one of them, but it doesn't need to remain where it was because you're not pregnant. Okay. So then it flexes right.

And do do we let's try to think about this. Do we count the the beginning of the cycle is considered when the period starts right?

Day one of your period is day one of your sites.

In that moment, estrogen at that point is lower. Is that right? And then it starts to

and then estrogen starts decline. Coming in to ovulation. And then in that next day is around ovulation and potential like conception. Again, progesterone is sort of like climbing into that time period, right? So, you know, again, all these fun hormones doing different things. I mean, if you even looked up a simple like just Google have a graph of like, what your hormones should look like. You can tell why. One Basal for 30 days in a row if you're a woman who has As a monthly cycle

couldn't doesn't work yeah, it does. The remastered diabetes Pro Tip series is sponsored by Ascensia 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 Juicebox free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips 10 lancets, a lancing device control solution and to carry case but most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen. It fits well on your hand and features Second Chance sampling which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash Juicebox free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips, you can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now, through your insurance. Contour next one.com forward slash Juicebox free meter go get yourself a free starter kit. Touched by type one has the back of people living with type one diabetes. Take for instance, their D box program touched by type one knows firsthand the intricacies of living with type one diabetes, and so their team has created a D box which is a starter kit that provides important resources and supportive materials to individuals with diabetes. They want you to thrive. The D box is completely free and available to newly diagnosed people. All you have to do is go to touched by type one.org. Go to the program's tab and click on the box. While you're there check out all the other resources and programs available at touched by type one.org. Speaking of support, touched by type one.org is available in English and Spanish. Don't forget to find them on Facebook and Instagram too. You do not want to miss what touched by type one is doing. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. Gvoke 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 Gvoke glucagon.com forward slash juicebox Gvoke shouldn't be used in patients with pheochromocytoma or insulinoma visit Gvoke glucagon.com/risk. You know what else I learned by digging into all this? Is that not that I wouldn't expect this because it's a physiological thing. But it's incredibly complicated what's happening. It's not just like, you know your your eighth grade health understanding of it, which you know, in my mind was an egg gets released you use it or you don't use it if you don't use it, you know the uterine lining and the egg come out in a period which I know is high level what it is. But the idea of like the ramp up right like the gosh, like you start talking about like follicles and like there's this process that's happening in there where your body's trying to locate the strongest egg to be released. It's not just like the next one on the assembly line. It's like it literally anyway, it's mind boggling. Even the TED talks on it are confusing. Even when even when nice girl sit in front of cameras in front of YouTube and trying to talk to you right in your eyes. You're like, I don't understand there's so much happening. But I think for the case of but for type one for using insulin is it is it as easy as saying that there's a time when you're bleeding. There's a time when you're ovulating. And there's a time when your body is trying to make your body a hospitable place for sperm to live. So that the process of fertilization can happen well, is that basically like there's I mean, that's

basically the simplified and I think sort of along the same line of what you're getting at is if you if you're having a cycle whether you're on birth control with a cycle or you're not on birth control with a cycle you can expect the times of your period to show similarities for you in insulin need, right? One person may experience during this phase of, you know, hormone release, or this phase of their cycle, that they always have higher blood sugars now that they've been tracking things, they can say, Yes, I'm always getting higher here, one of the first places that that commonly starts is the fasting blood sugar, or the overnight blood sugar. For whatever reason, in the hormone dance of the human body, that's the first place that commonly women see things are running higher. And if you start to pay attention to your calendar, it will most likely coincide with, that's going to be somewhere about like, three to maybe seven days prior to your period, starting. Some women experience really short lived higher insulin needs. And whether they may have missed a slight nudge up maybe a week sooner. Most of them notice cash, the first, you know, day and maybe the two days before my period, I'm just high, I can't take enough insulin, I dump it all in and I still sit high. Well, next month, you know, if that's the case, and you start seeing higher blood sugars, and you do and you are maybe somebody who doesn't have a regular enough cycle, I would probably expect that this is what's probably on its way, as long as your site isn't bad, you know, all the other variables that it could possibly be?

Yeah, so it's going to be incredibly important for you not to throw your hands up to the diabetes ferry and go, Oh, it's just diabetes, it's happening to me again, like, after it happens a couple of times, you gotta say, like Jenny saying, like, this is what happens. Whether or not I can tell you that it absolutely happens on day, I don't know 13 of my cycle or not, it becomes unimportant, like you, you sort of see, you know, it's not any different than, like, as you're talking about all this and about when people see higher blood sugars, like Arden has this too. But because my mindset is like more insulin pushback, don't let it happen. I can't see it. Sometimes I can tell you that we're bolusing more or that I'm running a higher Basal like profile. But I'm so accustomed to just being in the fight and fighting the fight. I sometimes don't think about why it's happening. I just

right, you just adjust to get it back to target. Yeah. And I think that's, that's okay, as long as you're okay, adjusting that way. And if that works for you, then great. I think that more women especially again, those who are planning a potential pregnancy, are really wanting to track well enough because they're also in ensuring that their blood sugar's are really optimally managed for possible conception, and that thereafter, you know, so if you really do want more consistency, rather than saying, Well, I know how to do more insulin, I do it all the time. I just, you know, adjusted here and take more, they're just back here or whatever. But if you have even those that have a regular enough cycle, it could take some of the like headache out of the salon. Hi again, I know I need more, I'll take more. But gosh, is this happening regularly enough that I could actually figure out how much more do I need on an average monthly change time? Well, yeah, well, that is less guesswork in the moment that

and the reason I brought it up is because the process of getting ready to make this episode with you made me realize I'm going to set up three different profiles for art and because she's gonna go to college. Yeah, I know what I need to do. Her blood sugar is gonna go up and she's gonna be like, this never used to happen before. You know, and she's, you know, not going to realize the thing she's missing is me. Texting, texting, you're going yo Bolus, what are you doing? Cuz because for people who don't like really understand, I know, it sounds like micromanaging to some like newer people, but for people listening to podcasts, I don't imagine it does. Like, I don't like to see a blood sugar over 140. And I act like like, you know how some people might act when your blood sugar is 300 is about how I start feeling at 140. I'm like, yo, what are we doing here? Because in my mind, I'm targeting back to AD in my mind 140 60 points too high. Like get it get it, but the the amount of insulin that it takes to get it has climbed since Arden's been on a birth control pill. So while yes, the birth control pill has regulated artists period, and she's not bleeding to death anymore. Her diabetes has gotten more difficult. Yeah, because and now if you go look at graphs about how it's like, Listen, what I know about birth control is probably not enough. But you're getting you're getting a pretty regulated amount of these hormones. Every day, and that birth control is literally tricking your body into not releasing an egg. I didn't realize that, that the bleed

is keeping you on a one cycle of hormone akin to not needing

ovulation. Yeah. Right. And so you're not nothing's happening. And obviously like the whole process isn't happening actually, I think what confuses people? Is that the bleeding that happens when you're off the hormones and you're on the the placebo placebos is not your period. It's got it's actually got a name. It's, uh, hold on a second. I have so many browser windows open. It's called withdrawal bleeding. Yeah, it's not your it's not the same thing.

Never heard. I've never heard it called that before. Okay. Well,

I was schooled, I recorded an episode about this with a different podcast. I'm going to be on a vagina podcast pretty soon. And that's funny. Oh, it was hilarious. And as I was being asked, I was like, why is this happening to me? But but but people who really take birth control? I don't mean, seriously is the wrong word. But but see it as stuff that maybe, you know, there are people who think you shouldn't do it. There are people who think you shouldn't tell people how to live their lives, there's a lot of consternation around birth control in some circles. And it's important for those people for you to know you're not actually getting your period when you're on birth control. So and I have to be honest, I don't want Arden to be on birth control, not because it's birth control, but because I don't want her to take anything she doesn't have to take right when she was going down. You know what I mean? Like, we were looking at her like, I guess this is it, like, you know, the money, the money we saved for college, we could buy a house with now or something? Well, and

that's I mean, those there are, I think, really, there are really good reasons to utilize birth control all around, there are. But in a case like this, it's almost a necessity in order to get containment of something. Now, the other thing is, you know, is this something that's just, it's just the way that her body is gonna continue to work even into like adulthood, where she continued to have to have this level of birth control, you know, management, so that she doesn't have this problem. That question, you know, I had

constantly like, when do we just like, stop at once and see what happens? You know what I mean? Like, but I don't understand any cause and effect reasons why using birth control for a while, would you know, quote, unquote, regulate things and then you wouldn't need it anymore. Were was this just a cycle of her life, and it was going to pass on its own. And we're never going to know, as long as she's on the birth control pill. Right? I keep saying, I keep thinking maybe, you know, a few months before college, maybe we like, would try to bail on at one time and see what happens. Because when you've done

enough work already to know, I mean, she's used several different types of it. So you also have an idea of what works, what really did nothing good. And what does actually work because there are so many kinds of birth control that are available. And so many mixes of hormones that you could use, or some are single, single hormone, some are a mix of hormones, at different levels. They're taken different ways. I mean, there are

at one point, our our pharmacy benefits changed her over to a generic things were going great. And then they change the generic and it went right back to where it was again. Oh, and then we had to swap her back to another one.

So funny, right? I mean, if it was the same thing, only a generic what's different about it? Right?

I have no idea. This is the this. Jenny in one way or another vaginas are the bane of my existence. They're, they're torturing me from different angles and different perspectives all the time. And, and on the Ardennes period has been, I mean, a roller coaster, it has not been fun for her for the people trying to help her. Well, and I

think you see it from a perspective of you want the best for her. You want her to be healthy and enjoy life and everything's you see it really as a it's problematic, not from a physiologic standpoint is problematic and what it brings into the picture of her management, you know, you may have a very different look on it. If she didn't have diabetes.

Yeah. Yeah, I guess I there's so much about I wouldn't even understand or pay attention to her. Right, Senator. So I, I'm basically having this conversation to tell people that I'm going to start doing what I think you should do, like I'm going to I'm going to set up my own tracking app. And I'm gonna track Arden's like insulin in bushes, Jenny's making a face because I don't,

I'm pretty AMI like, you don't do things like

she's gonna leave for college and either bleed to death or having A1C and the aids like one of the other. Like, it's just one of the others gonna happen.

So and typically I mean that is it's also another piece in the mix too because you brought a lot of things in that could be happening in periods that are mismanaged, right? Someone who has excessive bleeding can bring in a lot of other health risk problems that can also make the diabetes management piece even harder to figure out and manage around. So it's really important. I mean, on average, don't quote me, but I think I read at one point, like the average woman with a normal healthy cycle length, and not excessive bleeding, really only loses about a quarter cup of blood through the whole period, which is it's a tiny amount, right? I mean, if you know what a quarter cup measuring cup looks like. So I mean, if you're saying gosh, excessive, clearly excessive is like lots and lots that shouldn't be happening.

Here's the one measuring stick for you. Arden's ferritin gets down to like the teens, she gets an infusion. They tested again, it pushes it into like the 130s. It gets pretty high when you get the infusion. Yeah, within three months of not being on the period. She was back in the teens again, teens again, yeah. So and just I mean, for people who don't know, anemia, low blood, low iron, whatever, you know, however you get to it. I mean, just can't hardly pick your head up. Oh, freezing feels horrible. You feel like you're dying, the whole time, shortness of breath. You can have heart palpitations. Like, it's not good. You know, you get like pain and you're like muscles and joints and like, it's, it's terrible. So Arden's gonna stay on this as long as she needs to. But yeah, but it's funny, while she was home, aren't chill at home, like when she was going to school from home, she needed less insulin. As soon as she went back to in person I knew her needs, were gonna go up again. And I did the thing, where I was bolusing too much and didn't adjust settings for a little while to like, it happens to everybody, it's sure doesn't not happen to me, because it's my podcast, like, you know, like, you're so used to managing one way. And then this big piece of your life changes. And you don't even realize it for some reason. And that just made me sad, or when I realized that thinking about this, because basically, on your period, your life is changing. Like every couple of weeks, you know, like there's this impact and an end, it might not happen to everybody, there are some women who will listen to this the go, oh, that doesn't happen to me, or, you know, just like, Oh, my God, well, in fact,

I've got, you know, some women that I've worked with, you know, even outside of like preconception planning, just in terms of diabetes management. And obviously, the cycle is a piece that we talk through and talk about, and some women who actually have the higher blood sugar levels during their period. Not before. It's more really an onset, while they're actually having their period, which is not the typical of what I've seen, but again, I've heard it enough that it's also not odd or rare,

ya know, in the questions that I sent to you that that I found online, it was almost like people were like, hey, during these days here, my blood sugar is incredibly easy. And then somebody would come along and say, well, in those same exact days, my blood sugar is incredibly difficult. And yeah, I'm sure if we could, you know, Doctor House, every person in the world you might find, but I don't think that's gonna I used to love that show. I mean, right. sarcoidosis usually. Right? And I don't even know what that means. But, but so did you see anything in these questions that you definitely wanted to go over?

I was just gonna go back to because

because at some point, too, there were a number of questions about menopause, too. And some women are asking about what about when they take hormone replacement? Is it going to happen then, and I don't know, but it seems like the same as taking birth control to me, right your your address, you're adding hormones to your daily intake. 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 how 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.

And hormone replacement therapy is usually for the most part centered around like the menopause kind of time perimenopause, menopause kind of time, it's supposed to help to ease much of the hormonal transition that's creating some of the symptoms, things like the hot flashes, and the energy swings and the insomnia and the, I guess, level of irritation, one woman may experience versus another. Right? So that's supposed to technically, even things out more. And it's a good question to actually ask, if you haven't, and you're considering or already taking the hormone replacement therapy, you know, asking your physician if they know anything, really about that piece in terms of what they should expect. My expectation would be that with the replacement therapy, if it's going well, and the dose is well managed, technically, you should have actually more stability than in how you're feeling, which should also bring more stability to your glucose management, right?

Well, I guess while we're in this area, what about somebody who's had a hysterectomy? Did they lose all of those, that the cycle is just gone? Right? So that is, but it's all the hormones are all the hormones gone to?

So although I mean, there's a good question, because quite honestly, you could have a partial or you could have a, like a total hysterectomy, right? I mean, so there are hormonal imbalances that can definitely happen with partial hysterectomy. It does, for the most part, from what I know cause less dramatic change in hormone levels than a full hysterectomy does. So in terms of that, you know, your hormones definitely shift because obviously, there's nothing there to cause that trend of hormones change, right, there's the period, right disappears. So, you know, overall, while there may be some initial management that needs to be done, I wouldn't expect that there would be as much I've worked with many women who've had hysterectomy. But I wouldn't expect that there to be as much fluctuation, as they probably usually had. I mean, when the menopause obviously is kind of similar in that when that happens, obviously, your ovaries stopped producing enough hormones to continue the menstrual cycle. Right? So if you had a hysterectomy, which includes removing the ovaries, you would then be essentially moved into sort of like a premature menopause kind of time. Right? So

all right. Well, you know, if there's one person that asked such as a detailed question that I think Yeah, way they broke it down might be valuable for us. So her first question was, why does the body become more insulin resistant during different phases of the menstrual cycle? Just the laid out for people now that I think we haven't, but is the answer, just simply there's more hormones at different parts?