Omnipod, Juicebox Podcast, Interview, Type 1 Diabetes, Bold Beginnings Scott Benner 7/1/22 Omnipod, Juicebox Podcast, Interview, Type 1 Diabetes, Bold Beginnings Scott Benner 7/1/22

#711 Bold Beginnings: Terminology Part I

Bold Beginnings will answer the questions that most people have after a type 1 diabetes diagnosis.

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Music - Google Play/Android - iHeart Radio - Radio Public, Amazon Alexa or wherever they get audio.

Bolus - Basal - Honeymoon - A1c - Time In Range - Standard Deviation - Extended Bolus - Algorithm - Non Compliant - Glycemic Index - Glycemic Load - Pre Bolus - Trust Will Happen - Low Before High - Brittle Diabetes - Stop The Arrows - Ketones - Insulin Resistance - Feeding Insulin

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

Scott Benner 0:00
Hello friends, and welcome to episode 711 of the Juicebox Podcast, a special two part episode that concludes on Episode 712, which is available right now to download

Welcome back to the bold beginning series with me and Jenny Smith. Today's two parter happens in Episode 711 and 712. This is bold beginnings terminology part one. In these two episodes, Jenny and I define every word that's available to you in the defining diabetes series. At the time of this recording, there were over 40 definitions. We did a quick definition for newly diagnosed people and left you the episode number. So you can go back and get a more complete definition. If you've just been diagnosed. Or if you're trying to figure things out, it is our estimation that this two part episode, part of the bowl beginning series will catch you up on terminology very quickly. If you're looking for the defining diabetes series, it's available at juicebox podcast.com diabetes protip.com. And in any audio app that you listen in, join the Facebook group Juicebox Podcast type one diabetes to find the lists of all the series in the featured section. This episode of The Juicebox Podcast is sponsored by Ian pen from Medtronic diabetes. And because of the format of this episode, I'm going to put the ad right here for you so that you don't have to take a break while you're powerless running through these definitions. Isn't that cool of impelled to let that happen? Thank you and pen, even though I didn't ask you, but I know you're listening. So just be cool. All right. All right, ready the pen. It's an insulin pen. But it's more than that. Because it's attached to an application on your iPhone or Android phone. This application is going to do many of the things you've heard about people getting from their insulin pumps, you'll be able to see your current glucose right on the screen, a dosing calculator, active insulin remaining meal history, dose history, glucose history, activity logs, and you can generate reports based on your data. Not only that, but you're getting a great insulin pen, everything you expect the cap the needle, the insulin cartridge holder, it's an insulin pen, just like you've come to expect. But it gives you more with this attached app. You can go right now to N pen today.com To find out more and get started. And I'm gonna tell you what terms and conditions apply, but you may pay as little as $35 for the in pen. Medtronic diabetes does not want costs to be a roadblock to you getting the therapy that you need. Within Penn's Access Program. You may pay as little as $35. Where will you find that out? At in Penn today.com. On this site, tons of frequently asked questions that you're going to be interested in just scroll to the bottom. What is the M pen? How much does it cost? Our insulin cartridges included? Does M pen work with long acting insulin? Can I pair more than one M pen to an app? You want to know the answers to those questions? Go right now to in pen today.com and get your answer if you're ready to try the M pen when you're at the link. Just follow the easy instructions it says ready to try you complete a short form. And just like that you're on your way. In pen today.com forward slash juicebox in pen requires a prescription and settings from your healthcare provider, you must use proper settings and follow the instructions as directed where you could experience high or low glucose levels. For more safety information visit in Penn today.com. Just this morning, I put up the conversation that you and I had about this series. So you're gonna Okay, you're gonna find out what it's called for. Right now for the first time. Yay. So what I want to do is I'm going to stay with the naming system. So like there's that defining diabetes, colon, you know, Bolus and there's diabetes, pro tip colon, you know, whatever that episodes about, right? So with for the, for the prefix for this one, I chose bold beginnings. And I went over a lot of things I wanted to Thursday's just like let's just call it newly diagnosed. And I thought, well, then people who aren't newly diagnosed might skip over it. And I think it would still be very valuable for you if you were, you know, diagnosed six months from now, you know, sometimes people are like, Oh, it was six months ago. We're not newly diagnosed. And I thought so I don't want to I don't want to push people away from the content with the name that makes them think this isn't for me. So in the beginning I I mean, when we asked for people, what do you wish someone would have told you when you when you were diagnosed? And that's the beginning, damage any, that's what I'm going with. So

Jennifer Smith, CDE 5:12
it is a beginning and we very much explain. I mean, the title of it is good in terms of the beginnings part of it, because obviously, somebody has who's even six months in who has not put any not that they haven't put work in, but they haven't put the kind of like, evaluate thing kind of work in yet. They need to know some of how to begin.

Scott Benner 5:35
Yeah, I mean, you have to start somewhere you need to, you know, it's so funny as I wanted to call it like, it's funny. I know, it would have been confusing, but a part of me wanted to call it basil, because of it being sort of like, you know, the base. And, and I was like, Oh, that'll be to

Jennifer Smith, CDE 5:52
foundation would be another good word. Yeah,

Scott Benner 5:54
I know. I thought that'll be too trippy. So let's just go with alliteration bold beginnings. Perfect. So today, we're going to talk about terminology. Great. And I have the list in front of me. Do you have it?

Jennifer Smith, CDE 6:08
Let me bring up my notes so that I can

Scott Benner 6:13
we have 14 pieces of feedback that are under the under the heading terminology. I'm going to about you're looking I'll give you the first one person says that all of the terms were so confusing. MDI carb ratio correction factor, Basal Bolus Pre-Bolus. And she says, I really thank God for the defining diabetes episodes. So that's nice. That's not a question. That's a bit of an answer. But we'll talk around terminology for a little bit. Okay, perfect. So what ends up happening, right, you get diagnosed, you're in a doctor's office. They use words, as a matter of course, we all have a friend who's in it, or, you know, a therapist, you know, buddy, and they everyone uses buzzwords. That to them are everyday words, it's, you know, to these people saying Bolus and basil is like you saying, you know, sunshine in the moon, we think, Oh, everybody understands this, right?

Jennifer Smith, CDE 7:11
Or what's very common now, especially with texting are all of the, you know, the three letter means three words of right, those acronyms? Sometimes I have to look it up. Like, I don't know what that was.

Scott Benner 7:24
My wife texted me yesterday. And I said, I will answer you as soon as you tell me what that emoji means. Right? I don't know. And I'm not in a position to find out. So you know, it's so it's gonna happen. You're in the doctor's office? You know, you know, for me, one of the things that I maintain is that when doctors try to tell you about glycemic index and glycemic load, I just think the words are off putting. And they are. And that's why I end up saying, you know, you have to understand the different foods impact you differently, because I don't know, it's just from my perspective, I heard glycemic index glycemic load sitting with the nutritionist at the children's hospital, I was like, this is the part I'm going to ignore.

Jennifer Smith, CDE 8:08
Because it wasn't, well, and I don't want to it's not. It's not saying it mean, but you needed it simpler, right? Those big words can be really scary when you've also just been introduced to something that can be scary, right? Right. So you bring in all of these big words like, what happens with this hyper or situation or this hypo situation, or whatever is going on. And all of a sudden, like, you get these like, this increase in your heart rate, and you're like, what, what, what, what is it?

Scott Benner 8:41
I don't know what I'm doing. And then and then it's juxtaposed against the pressure you feel, to figure it out, and to do it correctly. Because I mean, it's either you as an adult, and my goodness, then you're like, I'm on my own here. And if I don't understand this, there's no one else. Or it's the pressure of, I had it, I had the thought directly in my head, I'm gonna kill her. I know I'm going to make a mistake, and I'm going to kill Arden and that's how it felt when she was first diagnosed. You know, again, here, all the terminology was so confusing. One person said, I needed a way to remember the difference between Bolus and basil. She said she made flashcards for herself. That's not a bad idea,

Jennifer Smith, CDE 9:19
actually. Right. That's not a bad idea. No, not at all. I

Scott Benner 9:23
interviewed a woman the other day. She was wonderful. I enjoyed it so much diabetes for over 40 years. And when I asked her what her Basal insulin was, she told me the name of her meal and some 40 belly. Yeah, yeah. And so

Jennifer Smith, CDE 9:39
well, do you if from the Bolus Basal aspect Do you want to really know the reason for Bolus for food?

Scott Benner 9:47
So I was thinking, do you know it? Well, well, what I was thinking was let's run through these people's thoughts a little more here and the feedback that we got, and if the feedback sticks with just like, hey, I need to know the difference. Maybe we can Do a condensed speed version of defining diabetes and roll. Awesome. Sure. Okay. Okay, as dumb as it may sound, the difference between type one and type two is confusing to me. Another person said insulin resistance, how do I figure out what that is? What is the dawn phenomenon? I think in an episode for being newly diagnosed, it would be really helpful to use full terms for things rather than just acronyms and jargon. And we'll all eventually learn them. That's interesting, too. Okay,

Jennifer Smith, CDE 10:31
that's not a bad. Again, if somebody's asking anyway, and really wants to know, then they will be more informed the next time their clinician says a word. Yeah, they'll actually know what it means.

Scott Benner 10:43
And I think that, well, I think the way we listen, we didn't just make defining diabetes by mistake, like it really seemed the way to go. And people on the other end, have to be willing to listen to it to learn, and they have to know it's there, which is difficult. You know, it's funny, not to take too much of a sidebar here. But the other day, I saw a person talking about the bolusing, insulin for fat episode, and how life changing it was for them, and that they had been struggling for a really long time. And I thought, but that episodes been up for years. And then I remembered, just because I put it up, doesn't mean everybody see. But from my perspective, you're like, I did that already. So I take the

Jennifer Smith, CDE 11:27
especially if somebody's starting with Episode One, and just being very, like just moves through the episode, one episode took a long time to get to the other episodes,

Scott Benner 11:37
this person makes the point that a lot of the episodes feel pump specific, but that most people don't get pumps in the beginning. And it's funny. I want your opinion of it. I don't think the pro tips or pump specific, I think that you could listen to the pro tips and just apply it to a life with MDI. But maybe when people hear it described through pumping, they don't think it would be backwards compatible, maybe.

Jennifer Smith, CDE 12:07
Right? I think the biggest thing that you could learn from the pro tips, if you are using MDI are the strategies for especially bolusing remain pretty much the same in terms of understanding the timing of insulin. It's the delivery of how you would do it with an injection comparative to the fancy features of a pump that might you tell it to do something and then it continuously does it versus on MDI, you may have to feed a little insulin feed a little insulin feed a little insulin, it's the same concept. It's just you may have to do a couple more injections with MDI, to get the same impact. Yeah.

Scott Benner 12:48
Alright, so I'll tell you what I'm gonna do. Because I'm looking through everybody else's information here and overall, around terminology, it's Look, I need to know what this stuff means I need to know quickly and the one woman makes there's, I say, woman, by the way, like 75% of the people that listen to podcasts are women. So I'm just assuming they're women, I guess. But it could be a guy. The one thing that I'm seeing is I was overwhelmed. The default I found the defining diabetes episodes eventually, but it felt like a lot. And I didn't know what to listen to. So I think we're going to do exactly what I just said, Here, we are going to play a speed round of defining diabetes. To an eye, this is gonna be a fun test. Alright, so I have

Jennifer Smith, CDE 13:32
we make this into a game that we can, like, you know, put out there.

Scott Benner 13:36
Well, here's the, you know, we should first of all, and here's the thing, I'm looking at the list. It is. It's long, it's gotta be 40. Oh, my goodness, hold on. I'm gonna pull up Isabel's list. Do you know that every time I make a new episode, that fits on the list is about re does the list and says it's awesome. She's a pretty cool person. So our defining diabetes. Here it is. I wonder if I put it in this document? If you would see it? Does it update in your notes under the Dr. Jack's or diagnose January comment? If not, it's okay.

Jennifer Smith, CDE 14:26
I saw something pop into my notes.

Scott Benner 14:30
Well, I'm gonna I'm gonna look through it. Is it a image? Yeah. Is it an image? It's an image? Was it not coming in clearly yet?

Jennifer Smith, CDE 14:39
Let's see. Oh, there it is. It's under Yeah, it's the Juicebox Podcast defining diabetes series with all of the Yes. Okay,

Scott Benner 14:47
so, alright, so this is what we're going to do and there are 44 terms on this list. So right now the Define diabetes series begins at episode 236 and runs intermittently all the way up to 677 was the last defining we did. All right. Yes. You ready? What do you think? All right, so it's 11 o'clock now we have 30 minutes and 44 things that define.

Jennifer Smith, CDE 15:13
I could actually go a little beyond a little time between between people. So yes.

Scott Benner 15:19
Taking the fun away but I appreciate it. Yes, we

Jennifer Smith, CDE 15:22
will try 30 minutes. Go.

Scott Benner 15:25
Okay, Bolus. You go Bolus.

Jennifer Smith, CDE 15:30
Me to go we'll go. Bolus is the amount of insulin you take to cover food that you put in your body.

Scott Benner 15:37
And if somebody says What's your Bolus insulin, they mean your mealtime or your fast acting insulin? Correct. Some examples might be Novolog, a Piedra fiasco humor LOGG. Did I miss any little jab loom JEV. So those are insolence you use to correct high blood sugars or to cover meals. Correct. That's good. That's what that means. All right, that's what Bolus means Basil is a slower acting insulin. It's either injected for people with MDI. The way I always think of it, whether it's right or not, is that it kind of goes under the skin and a crystal form and then sort of melts away slowly over time, giving you a base level of Basal insulin Basal insulin is meant to control your, your blood sugar away from food. And it if it's dialed in correctly, it should hold your blood sugar fairly stable at a place Basal insulin shouldn't drive you down. It's not its job to overwhelm meals. It's a baseline of insulin if you're using it. Good.

Jennifer Smith, CDE 16:43
Oh, I was gonna say one. In fact, to add on to that once your Bolus is done working, your Basal should hold you where the Bolus left you. If the Basal is right,

Scott Benner 16:54
that's a great way to put it. So Basal insulin is let's see love a mirror Lantis. What are the new

Jennifer Smith, CDE 17:02
Jao? Trust Siba basic lar. I might be missing one

Scott Benner 17:11
you had to pick one if you were if you were giving a person on MDI a Basal insulin. Which one would you pick? I have an answer. What is yours?

Jennifer Smith, CDE 17:18
To in today's world, I would pick receba.

Scott Benner 17:21
Me too. And that's only based on feedback I see online from people.

Jennifer Smith, CDE 17:26
And that's based on my feedback that I see actually from the people that I get to work with. It seems to be much better and in from I know a lot of people probably say Well, is it good for age, you know, a specific age. I have kiddos using it and adults using it and it across the board seems like a very good true 24 hour insulin.

Scott Benner 17:50
Oh, you know what we should do while we're doing this? I'm glad I thought of it after only the second one Bolus. The defining diabetes episode for Bolus is episode 236. The defining diabetes episode for Basal is 238. The next defining diabetes is 241. Honeymoon. It's your turn. Awesome. Honeymoon. Yay. Wait, no, no, no, hold. I did that already. No, no, I tricked myself. Basal insulin in a pump is different. So if you're pumping, right, you don't inject Tresa are another thing. Your pump just takes the fast acting insulin, your NovaLogic for example. And it not only you know, can you tell your pump I just had 30 grams of carbs. And your pump might say to you, well, that's three units and you put it in, but you tell your pump I need 20 units of insulin every 24 hours for as a Basal insulin and it breaks those 20 units down into very small, tiny, like blip pulses. Yeah, like pulses. And so instead of injecting insulin, like you would with MDI, for your Basal, and letting it work on its own, the pump puts in a little bit a little bit a little bit constantly, it creates that baseline. Correct. Right. So

Jennifer Smith, CDE 19:03
and that is the beauty of a pump is also using only what we consider rapid acting insulin or Bolus insulin. Your body doesn't have to sort of figure out the action of two kinds of insulin right? A Basal injected insulin like to receive our Lantis and then a Bolus insulin like Novolog, for example. You should however, always make sure to keep Basal injected insulin in your refrigerator in case your pump fails, right. That's my little educator, thing for you appreciate that.

Scott Benner 19:37
One day, I will actually do that. Maybe when Arden least or college will be the first time we actually do that because that would be a good idea.

Jennifer Smith, CDE 19:45
So when your pharmacy isn't like two seconds away from your house, right?

Scott Benner 19:49
So then once you're in so when you're injecting insulin when you're MDI multiple daily injections, which we'll get to on this list at some point, Bolus is a thing. Like your Bolus insulin is that thing, your Basal insulin is a thing. But when you're pumping their concepts you Bolus because the pump just holds insulin and when you Bolus it puts in insulin, and it also creates a Basal level. I don't know if I'm saying that right. But do you really mean like that it's not as tangible when you talk about it in pumping their functions. And when you talk about an MDI, their vitals, does that mean I think

Jennifer Smith, CDE 20:25
it's because of the difference, as you just said, there's a defined Basal injected insulin. And that's a kind of insulin. It does the same thing as your drip, drip pulses of basil coming out of your pump. But you're right, I guess I never thought about it that way that, you know, pump. It's the same reason for using the insulin, even though you're using two different kinds of insulin to do the same thing. It's

Scott Benner 20:52
almost like the difference between writing on paper and typing on a computer. Like yeah, right. It's a thing is happening when you're on a pump. But when you're writing on paper, you're physically accomplishing it. Oh, I'm good with that one, episode. 241 honeymoon. Sorry, it's your turn. Already six minutes into it, we've only done so

Jennifer Smith, CDE 21:14
we're good. That's okay. Oh, is that phase after diagnosis, where your insulin needs may come down by how much is really, completely individual. It may happen soon after your diagnosis. It may happen a little bit later, like weeks after diagnosis. It may last for a short period of time, short being maybe a week, and it may last longer. Some people it could be an entire year of honeymooning. So it's something that happens essentially, once your body has enough insulin from injections, or maybe you've started a pump pretty quickly. It gives your beta cells a little bit of a break. And so you often get a little bit, outcome, or output I should say from those data's again, they start to help, because they're not as stressed as they were pre diagnosis where they couldn't keep up with such high blood sugar levels. And so you end up having this drop off in insulin need. Some people require only Basal insulin, they don't take any Bolus insulin for their meal coverage. At first, and then some people may take just really tiny amounts of both kinds of insulin, Basal and Bolus insulin.

Scott Benner 22:36
So the way you see it kind of in the real world is the doctor set you up with insulin, it feels like it's working. And then all of a sudden, you wake up one day, and it feels like you don't need as much of it or sometimes at all, or somewhere in that spectrum. The reason it's a term that people know about in diabetes is because it's incredibly frustrating and confusing. Because if you think about it, you've made the decision. I need insulin to cover this food. And then what happens if all of a sudden there's another entity also giving you insulin, your beta cells right now you've got twice as much as you need, your body doesn't see manmade insulin and go oh, no worries, we don't need it. So yeah, right. So two things are happening at once. Is it possible that someone never experiences a honeymoon? Yes, okay.

Jennifer Smith, CDE 23:26
All right, adores that it's so mild and things are not quite contained as much that it may not really

Scott Benner 23:33
notice. That is what I thought when I wrote down to people never Are there people who never experienced it. What I thought was, I wonder if they're just people who never notice it? Because maybe their management isn't even such like maybe put yourself in a scenario where your doctor is like shooting for a 200 blood sugar. Right? And maybe you're experiencing 150 blood sugar because of the honeymoon, you would never know that your pancreas was helping,

Jennifer Smith, CDE 23:57
right? Because you're not necessarily getting too low. So it's not worrisome. Right?

Scott Benner 24:01
Right. It's the outcome that makes you worried about it. Like if you have a if you have a great doc that sets you put your settings together where your blood sugar's 110 all the time. And then your pancreas kicks in and make sure 80 or 70 or 60 that you would notice. Absolutely, yeah. All right, honeymoon episode 241. Episode 243 is a one C. Say the real words. What do they mean?

Jennifer Smith, CDE 24:27
Well, a onesie is hemoglobin a one C.

Scott Benner 24:32
a 90 day that's it. The blood test can be done by a finger stick in the office or a blood draw gives you a 90 day average of what your blood sugar is or was correct. It's weighted differently though, right? Like if you had an average blood sugar of 150 in the first 45 days, but an average blood sugar of 80 and the last 45. It might show lower is that right?

Jennifer Smith, CDE 24:55
That's correct. It's weighted heavier to the more recent timeframe. And the reason is because of the cycle of red blood cell life, of which hemoglobin is a piece of that. And glucose has an affinity for hemoglobin. So the more glucose you have in your system, the more it gets stuck to the hemoglobin. And the life of the red blood cells essentially has a memory, if you will. So, older red blood cells will not be in as large of a concentration or percent as the ones that are closer to the time period where you got your blood drawn, or had the fingerstick done.

Scott Benner 25:37
Okay. Back in the day, once he was the only way that people using insulin could track their successes or or see where they might need adjustments. Today, we don't just talk about a one see their journey. What else do we talk about?

Jennifer Smith, CDE 25:52
We talk about time and rain, I'm in

Scott Benner 25:54
range, which by the way, as I'm looking at our defining diabetes series, we might not have defined. So really, it's possible we're gonna we are making more work on ourselves. So now I'm thinking, so, but But listen, here's why your agency can be fooled. And it's a great measurement. I'm not a person who says it's not a great measurement, I think it's a it's a reasonable way to see where you're at, except if your blood sugar is 400, for 12 hours of the day, and 50 for 12 hours of the day, your agency is going to look lower because of the average. But that is not healthy. And that is not the right way to achieve a seven a one C for example, you can get to a seven the right way or the wrong way. And that's and but but go to Episode 243 For a more complete description of a one C, but find the diabetes pro tip episodes eventually for an idea of how to keep stability so that you can trust the agency that you're seeing when you get it tested.

Jennifer Smith, CDE 26:57
Correct. And I think he was he was one of like the first episodes we did together, wasn't it?

Scott Benner 27:03
Yeah, it was, before we did any series, I asked you to come and talk about it. So there is a there is an all about a one C episode. That's just you. And like a young Jenny and Scott talking. This is a little embarrassing. But the next defining diabetes episode 245 Is time and I looked right past it on the list as I was like, I don't see it anywhere. Go ahead, give them time range.

Jennifer Smith, CDE 27:28
Yes, time and range is a, it's a good visual of a defined bottom and top value that you want to stay within the typical defined time, especially if you're using Dexcom, or many of the other continuous glucose monitors, they have a default of 70 to 180. So if you are looking at your CGM data, especially the amount of time that you spend between that bottom and top is going to be your time and range the time you you know, a percent of the total time in glucose overall, you'll also be given a time above that and a time below range to how much percent some some of the databases also do. Time wise, like how much time did you spend above this in hours or minutes? Which is kind of interesting to define it that way too. But yeah, time and range. I think also, it goes along with what do you want your target to be? So you have to define your target range to be able to then say, Oh, I spend, you know, 90% time in range? Well, that's great. What's your target that you're setting that for?

Scott Benner 28:44
So anyone see time and range, and the next defining diabetes episode, Episode 247, standard deviation, these are sort of the three things you use to measure your actual outcome. You can't just look at the A one C because as we said, it could be fooled. You can't just look at time and range. Because what if you set your range from 60 to 300? And you're like, I'm always in range. That doesn't count. Okay, that's not fair. You got it, you got to play you got to set up some rules, right. So for instance, Ardennes is well, I guess Ardens is 70 to 150. In her clarity report and clarity is just the software that that Dexcom uses to help give you a feedback. And so if Arden's 151, she's high out of range, if she's 69, she's low out of range, if we keep her between 7150 to 24 hours that would say that we were in range for 100% of the time, right so anyway, don't like don't lie to yourself, I guess like like set it up like and so you can see where you really are. I find it incredibly valuable to look at those numbers every other like few days I just pulled up on my phone real quick. I'm like alright, we're where we're at. I expect If it's B or G, something's happening, you know, right. Here's the thing. I'm embarrassed. I need you to explain standard deviation. Oh, because the math thing, I know what it is, I can't explain it. And you're, you're like what?

Jennifer Smith, CDE 30:17
Well, I also think that standard deviation, I mean, well, you can essentially explain it as a math thing. It's similar within diabetes, but you'll also see that value represented as milligrams per deciliter, or for those who are millimole as millimoles, and especially looking at your clarity reports, because they will give you a standard deviation. And really what that indicates is variance. Right? A deviation from, from your average, up and down. Correct? Yeah. So if you're saying, okay, my standard deviation is 60. That means that you're having a wide variance up and down from where your like stable midpoint is. If you have a standard deviation, that's 22, then you have a very small variance up and down from where you're kind of averaging.

Scott Benner 31:16
So smaller, the number of better you're doing,

Jennifer Smith, CDE 31:18
the smaller the number and another one that kind of goes along with it, which we don't have on our defining list. But people consider similarly is the coefficient of variance, right? This is that CV. I mean, that's located within there as well. I think many more people pay attention to standard deviation, though, to try to say, am I improving, and that kind of goes to goes along with that time and range, you know, defining your target range. And let's say you've had it set really high, you've had it set from 70 on the bottom to 250 on the top, and you're looking to improve, you're taking tips and things and you're learning more, bring that top number down, right? And compare time periods so that you can actually see, okay, I had this much time in range, but now I've tightened my, my range, am I actually doing better, even though I've tightened things up, and that's also where standard deviation should come in. Because if you've tightened things up, but your variance has not changed, it's gotten a little bit worse. That's not doing better than

Scott Benner 32:27
right. So that's an episode 247, where Jenny and I do a better job of explaining standard deviation than me just going I don't understand it. And if you want a bonus for that one, episode 343 is called standard deviation and her friends. It is a conversation that I had with a doctor who works for Dexcom, John Welsh, and we do a deep dive into standard deviation, coefficient of variation, a one C time and range and more like we really dig into it if you want to, like do a data geek diabetes. Deep Dive, it's episode 343 on

Jennifer Smith, CDE 33:02
I might have to listen to that. Oh, he was I don't think I've listened to that one. He

Scott Benner 33:05
was very interesting. Okay, Episode 249. To finding diabetes, extended Bolus, I can do this one. Awesome. Alright. So if you have a pump, and you know, you could kind of mimic it in a MDI. But if you have a pump, you could say to yourself, I'm eating pizza, which I think is going to be 60 carbs. But I know that when I eat pizza, I don't feel the impact of pizza in my blood sugar for an hour. Let's just say that that's your experience. It's probably longer than that. But okay, we'll say an hour for your experience. But I do know I need some insulin when I start to eat but not all of it. If I put in too much, I get low. So what I'd like to do is extend my Bolus. So this 60 carbs, I've decided this is let's just say your your ratio is one to 10. And you need six units, what you really want is for, I don't know three of the units to go in when you Bolus, but you'd like the other three units to get stretched out over an amount of time. So you can tell your pomp, I'm going to extend this to three now and do the other three over 90 minutes. And that it will take the remaining three units that didn't put in and stretch it out almost like a really heavily heavy Basal program, like we just discussed five minutes ago, how Basal on your pump is spread out little bits at a time little bits at a time constantly. In this scenario over those 90 minutes, it would take those three units, break them down over 90 minutes and put them out in small boluses over those 90 minutes, and that would be extending your Bolus. Is that fair? Is that fair? Not bad. All right. There's nothing to add to that. I did it.

Jennifer Smith, CDE 34:50
Right. No, you did it.

Scott Benner 34:52
Here's the thing. Perfect. Here's the caveat. They're not easy to figure out. Because if you extended over two hours and you really needed it Over an hour, then you're too weak. If you extend it over, you know, over an hour, and you really need to extend it over two hours, it's too strong. It is a to me it's a trial and error thing to learn how to do an extended Bolus. If you're on MDI, it's not the same, because you can't slowly stretch it out. But in the example of food that is going to cause a rise later, you can Bolus some up front and then inject again, a little later act almost Pre-Bolus thing the rise, which is sort of what you're doing with an extended Bolus as your Pre-Bolus in the next rise that you expect,

Jennifer Smith, CDE 35:36
correct. And a lot of that on MDI. I mean, along with pumping to it takes some analysis of some of the similar things that you've done over and over to see enough of a trend to say, Oh, well, this always happens when we have peanut butter and jelly at lunchtime. So we'll have to try an extended Bolus or we'll have to try a double Bolus sort of plan.

Scott Benner 35:57
Can I do the next one and then you can do the one after? Sure. 251 is algorithm you're going to hear people say algorithm you might think Oh, I hear people say all the time, Facebook algorithm algorithm, it computer program, think of it that way. Right? In terms of diabetes. Let's see on the pod has the Omnipod five tandem has control IQ Medtronic has the 670 G that right there all

Jennifer Smith, CDE 36:26
777 Their newest, and in Europe 780

Scott Benner 36:32
Do It Yourself versions loop. What's the APS one called a free

Jennifer Smith, CDE 36:38
APS, there's Android APs. I'm sure that open APS I'm sure that I'm that there are lots of the APS like little offshoots that I don't really know as much about honestly

Scott Benner 36:53
doesn't matter. The ones Jenny just ran through are literally do it yourself. Someone on the internet made it and made it available to somebody else. Some people choose to download them, you put it on your phone as a as a program, as an app, I guess would be what the young kids would say. And you're somehow this app, I'm not a computer person talks to your Dexcom CGM, for example, and to your pump, and it makes decisions about insulin dosing and handles those decisions, the algorithm is handling those decisions, whether it's on a do it yourself unit, like the loop which Arden uses, Jenny uses Jenny loops, or it's on the new AMI, pod five, or control IQ from tandem or any of the others the algorithm is just the computer, program app, whatever you want to think of it, taking in your data, making decisions and then telling your pump make your basil higher, make your basil lower, we need to Bolus here, that kind of stuff.

Jennifer Smith, CDE 37:54
Correct. And all the algorithms, they're a little bit different for each of the different system. Right? So swapping from one to another, you may have some reworking to do. And or that really starts with relearning this system versus the system that you're coming off. Yeah.

Scott Benner 38:14
All algorithms are settings based if your settings are bad algorithms are as useless as you not understanding where to Bolus if you're on MDI. But that's what algorithm means specifically, can you do episode 253 non compliant?

Jennifer Smith, CDE 38:29
Oh, this is such a word that I, I so hate this, this one. But yes, I can do it. So non compliant, if we look at it just as a simple non emotional, this is what non compliance specific to diabetes and or really any health condition means, right? You are intentionally neglecting your own care or your child's care, right? That you're really refusing to take good steps to do better to remain in the target that you've been given to aim for. That's non compliant, whether it means not taking your medications, just not appropriately managing and covering for food that you're eating, or you're missing your doses or whatever it is a I don't love the word non compliant. In fact, I really hate it. Because I don't think I don't think 99% of people are willfully choosing to do themselves harm, right? I don't that would

Scott Benner 39:40
be my that's my experience from talking to people. What I see mostly like, I'm not going to tell you there aren't some people who just have breakdowns and just like I'm not going to be diabetic anymore, which gets you to the hospital in a couple of days. But mostly most of the time what I see what happens is, the doctor gives orders to the patient The patient either doesn't understand them or understands them, and they're not good orders. And then you come back to see the doctor three months later, your numbers in close aren't where he expects him to be. So the or she so they make the assumption that you're not doing what you were told, and therefore they believe you to be non compliant. That's pretty rad. Yeah,

Jennifer Smith, CDE 40:20
exactly. And, and therein lies I think a big, big problem really is. There's a rabbit hole here. But in many office visits, there's a limited amount of time that can be spent in discussion, and really digging into what the data is showing. And when you only really look at data, and you don't ask more about what's happening in the person's life. You may certainly think that somebody is quote, unquote, non compliant. Yeah, well, maybe this big life, upheaval ended up happening. And that doesn't mean that the person doesn't want to take care of themselves. It just means that something has happened that is sort of taking over and they're trying to do their best. So yeah,

Scott Benner 41:07
here's, here's, what I would say is if somebody's calling you non compliant, and you and your heart are like, No, I'm really trying, you can express to them. I'm doing what I've been told it doesn't seem to be working. Can we try something different? You could run into a doctor who's like, yeah, great, let's make a change. You could run into an ego that says, oh, no, no, no, what I said to you was right, you must not be doing it. That's them. And that does happen, I'm sorry to say, but that's them, not knowing what to do next. So they just push it back on you. Correct. There are even people who will go listen to these defining diabetes episodes, they will listen to the Pro Tip series, they will show up with an A one C five, five, and the doctor might say to you, that's too low, and call your non compliance because they want you to be at six. There's a lot of self care in diabetes. And if you ever experienced any of these things, you're going to realize that you need to be the arbiter of what success is for you that you're not, you're not noncompliant if you're trying. Can we move on? Do you want to say more? Yes. Episode 255, the famous glycemic index and glycemic load. And by the way, by the way, Isabel, if you're listening, you have misspelled glycemic on my list. I want it fixed immediately.

Jennifer Smith, CDE 42:27
Because probably an honest little mistake. On the see on the keyboard right next to each other,

Scott Benner 42:34
fired, fired this lovely woman who makes these lists for free out of the goodness of her heart, she can't do it anymore. Episode 255, glycemic index glycemic load? Go ahead.

Jennifer Smith, CDE 42:45
Yes. So glycemic index is the first, glycemic load takes it a little bit further. But really, glycemic index tells us with diabetes, whether a carbohydrate containing food or not, how quickly it's going to raise your blood sugar. That's really it. So white rice versus green kale leaves, they both are carbohydrates, they both have a certain amount of carbohydrate in, you could eat the same amount of carbs in both of them. 10 grams, 15 grams of both, and they're going to have a different impact on your blood sugar in terms of a timeframe. Okay, so the slower or the lower glycemic sort of numbered foods are going to have a slower overall impact on your blood sugar in a defined time period of about two hours.

Scott Benner 43:39
Take off, take a bite of pizza, and it's three carbs of pizza, your blood sugar rises at one rate, take a spoonful of sugar that's three carbs or sugar, it will rise much quicker. Correct? Exactly super important to understand when you're boasting for your meals glycemic load is

Jennifer Smith, CDE 43:55
glycemic load is the amount of that food that you eat at a given time. So honestly, glycemic load is the bigger impact. In my opinion. If you look at portion, a good example is watermelon. Watermelon has a really high glycemic index somewhere in the 70s. Anything above 70 up to 100 is very high. So if you take a small half cup of watermelon, compared to four cups of watermelon, they have the same glycemic index. But the load effect of the smaller portion is going to downplay its impact on blood sugar comparative to the four cups of watermelon, which is going to have a very large impact on your blood sugar.

Scott Benner 44:45
Okay, so the the load kind of a way to think about it is so the glycemic index is how quickly it punches. The load is how much it hurts.

Jennifer Smith, CDE 44:57
Yes, yeah, yes. Okay. All right. Yeah. That's a good way to explain it. Yes, I like that.

Scott Benner 45:03
That's how I got the podcast. Okay, so that's 55 Pre-Bolus. I'll do 258 is Pre-Bolus. It's just the idea that man made insulin even though Jen Jenny hates if you call it fast acting insulin cuz she doesn't think it works fast enough. And she's right, it does not work quickly enough. But in, in, depending on your situation yourself, how hydrated you are in a million other things. Insulin begins to work slowly, right. So when you put it in, it's not like it's doing its full job. Immediately, it takes time to kind of ramp up the best way I can explain it very quickly. It's like watching a locomotive pull away. It's putting all of its energy into it, but it's not going 100 miles an hour, it takes it a half an hour to get up to speed this this locomotive I'm making up a number. I don't want to train people calling me going it takes a locomotive 23 You know what I mean? So you put,

Jennifer Smith, CDE 45:56
I'm sure that there are people with diabetes, who are locomotive drivers, who probably would know the direct answer. So

Scott Benner 46:02
it's occurred to me as I said it so. So you put the insulin in, you sort of let the Pre-Bolus you Bolus before the food, pre the food, so that when the food starts impacting when the glycemic index of the foods starts slamming into you, at the same time, the action of the insulin is also occurring. And that there's a great episode in the Pro Tip series that I'll talk about tug of war and all this stuff, and you will understand Pre-Bolus And when it's done, but as at the definition Pre-Bolus Is the idea of putting in your insulin before the food so that the impact of the food and the action of the insulin can happen at the same time. Correct? Right. I think I'm gonna have to do the next one.

Jennifer Smith, CDE 46:44
Next one. Because it's your

Scott Benner 46:47
term, yes, please do episode 260 is called trust will happen. And it exists because because at some point, you'll get to believe that what you know is going to happen is going to happen. And it's a big deal when you're using insulin, like we just talked about when you're putting something in your body or your kid's body that could make you so low that you could have a seizure. And you're trusting that the Bolus will start working when you think it will and that the food will hit when you start when you when you know it will. And even though you see it over and over again, it's it can be difficult to give yourself over to it. So I like to tell people that eventually you'll, you'll trust it and trust will happen. And what you know is going to happen will happen and it's a it's convoluted, but if you listen to it, it's a it's actually a big deal. Because otherwise, you can't do it. It's it's like I guess the simplest ideas. If you're parachuting, you can't jump out of the plane unless you believe the chute is going to open. Correct. Right. So trust will happen. All right, Episode 269. lobe Oh, Jenny, sorry, hold on. This is gonna be me talking for a while this is another episode 269 is called Low before high. Super simple. I'll give it to you in two sentences. When I wake up in the morning, every day, and I think about diabetes, I have a mantra, I would rather stop a low or falling blood sugar than fight with a high one. It is a staple of how I keep my daughter's blood sugar down. It's just a theory. It's a way to think the minute you start accepting the higher blood sugars, things get out of whack. So you're shooting for low understanding that the old make a mistake at some point. But fixing that mistake is far, far more palatable than fighting with a high one. Okay, and then the next one is episode 284. Jenny brittle diabetes.

Jennifer Smith, CDE 48:56
Yeah, that's another good thing. Like give me the nasty one. That's not very fair.

Scott Benner 49:04
This is like when you make the nurse give you you know how the doctors make the nurses do the shots and they leave the room. So the kids of course, yeah, I'm doing that with you right now.

Jennifer Smith, CDE 49:12
Right? Yes, exactly. That's not very fair. So brittle diabetes. Again, it's it's a term that is really an older term. In my professional opinion. It's meant to describe somebody who appears to really have very difficult to manage glucose numbers, where there are very severe swings up and down, and nothing seems to be able to contain them. And that essentially is Bertel diabetes. Yeah. Is it? Is it really a thing that is truly yet to be defined in terms of research urge, I mean, brutal diabetes, if it is truly happening, somebody should have worked through all of the pro tips. And said, I've, I've done all of these steps, I've gotten help from somebody who really has spent time with me. And I still have these time periods where I just don't know why it's not working. Right, right. And I think that many times brittle is being it's defined in a clinical setting, to somebody who hasn't had the greatest

Scott Benner 50:40
assistance whose blood sugar's look very variable for no reason. Correct. Right. But I generally believe there's a reason you just don't know what it is.

Jennifer Smith, CDE 50:51
I generally really, really, really Yes, believe that there is a reason and some of the meat the some of the reason may also be undiagnosed other conditions, that nobody's taken the time to ask enough questions to the person to say, Well, hey, this is happening. And it started happening about here, let's take some lab work. Let's look at your digestion. Let's you know all of these other pieces that could actually be creating this variability. I would say 9.9 times out of 10. You don't have brittle diabetes, right? There's, there's something that needs more assessment. Yeah.

Scott Benner 51:29
So if I was I, at some point, in these episodes, you'll hear me just say, you know, the worst thing I think you can do is just throw your hands up and go, Oh, that's just diabetes, you know, my blood sugar falls out of nowhere. It's what happens. Usually, it's because you didn't Bolus for a meal correctly. You got your insulin out of balance with the food you drop really quickly. And then doctors look at that, you know, think about 20 years ago, versus now even you still have trouble getting people understanding how insulin works, even at the physician level, but 20 years from now, they're like, I don't know, you're fertile. Like it just it to me, it seems like an answer out of the 1940s. You know what I mean? Like, like, Absolutely. Like, like, I don't know, like, like, put yourself back in that time. Right. And, yeah, there's a man and a woman and they're married, and the man does something terrible and the lady gets upset, and they go, Oh, she's, that's how she gets, you know, they mean, like, you know, it must be her time of the month, like just these general throwaway bullshit answers. I didn't mean to curse during this, that that are, the way I hear them is I don't know what's going on. So I'm just going to say that this is something unforeseen and uncontrollable. And it's just the way of the world but might not be the truth. Someone's calling you brittle at this day and age. Go listen to the Pro Tip series. Oh, okay. Here's another one for me. Episode 286. Stop the arrows. Again. It's just a theoretical thing if you have a CGM. I prefer to say that sometimes we all get stuck wondering what's happening, instead of just stopping the arrows, right? Like, well, my blood sugar's jumping way up. I don't know what and then the people sit back and they go, Well, I guess I Bolus that this time for this while you're talking to yourself, your blood sugar is shooting up, right? Just stop the arrow. Again, in much more detail in the episode, we don't need to spend a lot of time with it. I'll talk about like keeping your car in a lane and stuff like that. You'll love it. It's going to be great fun for you. So 288 ketones, not as easy as it sounds, Jenny. So I'll give it to you. Again. Nice, hard one.

Jennifer Smith, CDE 53:33
Yes, no and ketones specific to diabetes now, right? Because that's what we're talking about. They are chemicals, if you will, that the body makes when it breaks down fat to use for energy. So could you have ketones and could they not be dangerous? Yes. You could, in fact, have any people wake in the morning in a fasting state and have what are overnight sort of fasting ketones, right? Those are not the dangerous ketones that we think of when you get diagnosed and you're told all about all of these things. And one of them is ketones. Watch out for keto.

Scott Benner 54:23
You're in DKA, diabetic keto ketosis, right. So, right.

Jennifer Smith, CDE 54:29
So I mean, DKA, those types of ketones are very different ketones and those are not the ketones that you want. Obviously, that is a very serious complication. That occurs essentially, when your body has a very high glucose levels and not enough insulin. Then you could very easily move from high ketone levels into diabetic ketone. acidosis which

Scott Benner 55:00
is life threatening, so it's a big deal. Yes. But it doesn't stop it from being true that if you eat a low carb lifestyle, you might see some ketones. Correct? Yeah. Okay.

Jennifer Smith, CDE 55:11
So and that's actually a good point to make in terms of like a little clarity, I should say. The level of ketones very much defines DKA versus nutritional ketosis, which is really what if you're on a low carb or a ketogenic diet? It's really what you're aiming for. Your goal is to get your body burning fat for energy instead of carbohydrates. Okay,

Scott Benner 55:37
yeah. So, alright, Episode 295. And by the way, there's a really deep dive ketone talk in the defining and in other places in the podcast, so it'll get explained much more episode 295 is called insulin resistance and over Bolus, now these two things aren't the same thing. It's just, we set out to make a defining series about insulin resistance, and we started talking about something else, so much so that it belonged in the title, but let's just stick with insulin resistance here. I'm going to ask you to do that one, too, because it's a term I rub up against, and then I get on a soapbox, so I'm just going to let you do it.

Jennifer Smith, CDE 56:16
Sure. I mean, insulin resistance really is the body's inability to utilize insulin at a silly cellular level. At a certain amount, so you need more insulin to overcome the cell's inability to recognize and allow insulin to work. Okay, and there are many, many reasons for insulin resistance to happen. So, I mean, I don't know how much more Yeah, we can't sanative definition.

Scott Benner 56:52
Go listen to the episode, because you're gonna hear it like, if you have type two diabetes, insulin resistance is different than if you have type one diabetes. Right? It's not different. But structurally,

Jennifer Smith, CDE 57:06
it's the same reasoning. I mean, if you have insulin resistance, whether you're type one or type two, insulin resistance is there because your body is just not using insulin the right way? Quite honestly. Could you be? Could you be a lean individual and have insulin resistance? Yes, you could. So I think that's a hard one, especially in terms of defining between type one and type two. Insulin resistance is just you need more insulin to overcome your body's inability to use what it should metabolically be able to use. At a lower amount.

Scott Benner 57:41
I think you should listen to the episode because the words can be used as a crutch with bad settings. So Correct. Yeah, insulin resistance is exactly what Jenny said. But what if you're your ratio, carb ratio, right? Your one unit per 10, carbs should really be one unit per five carbs, and then your blood sugar goes up, and then you correct and your correction ratio is not right, you won't come down, the doctor sees that and goes, Oh, you're insulin resistant. You're not insulin resistant, you're not using enough insulin. So right, so anyway, there you go. episodes, yes, Episode 344 is called feeding insulin. And in my recollection, you have two minutes, I have two minutes. In my, my recollection, that is about when people have too heavy of a Basal profile. And you find yourself constantly feeding the insulin, meaning you're getting low, and you have to keep putting in food to bring it back up. So you don't want to be feeding your insulin. You want the insulin to be set at a place where it works without needing to be offset with carbohydrates.

Jennifer Smith, CDE 58:44
Correct. And you could also feed Bolus insulin. I mean, the first idea is evaluate basil. Absolutely. Especially if you are without insulin on board and you're constantly nibbling to keep your blood sugar up. That's a first analysis Basal. Absolutely. But if you're feeding yourself and snacking, without having to Bolus again, after you've Bolus for a meal, and there is insulin on board, then you're probably feeding your rapid insulin or your Bolus insulin. And that would be an analysis point

Scott Benner 59:18
don't want to feature so So Jenny, we're gonna stop here. The next time we record we're going to pick back up with 347 Bumping nudge. I've loved this. I think this is terrific. So we got through a number in we got through about half of them wasn't Yeah, it did a good job. There was a couple of times I was like, we're just getting chatty. But but but we didn't. We kept we kept it really short. I think this will end up being an episode about an hour and a half long. That will do exactly what all of those people who talked about terminology wanted. So right, excellent. All right. I'm sorry, go live your life and you know,

Jennifer Smith, CDE 59:49
that's okay. I've just got a patient I have to get run. And so anyway, I'll see you next time. Awesome. Thanks. Bye.

Scott Benner 1:00:00
are a huge thanks to Ian pen from Medtronic diabetes for sponsoring this episode of The Juicebox Podcast. Head over now to in pen today.com To get started. And while you're doing that, go download episode 712. To hear the second half of this conversation, Jenny and I pick this conversation right back up the next day, and we finish strong. Hope you're enjoying the bold beginning series. If you are gonna look for other episodes that you think you might also enjoy. Jenny Smith works at integrated diabetes.com In case you want to hire her, and I'm gonna leave you a little bit of information there for the music, about how you can find out more about the podcast, subscribe, and other such things. Alright, some quick stuff you'll want to know. The private Facebook group now has 26,000 people in it Juicebox Podcast type one diabetes, people using insulin, you can hang out, watch what they're saying talk, ask questions, pick brains, or just lurk whatever you need. It's there. Juicebox Podcast type one diabetes, including lists like the bowl beginning series, defining diabetes, the diabetes protip episodes, diabetes variables, all listed in the feature section of the Facebook page Juicebox Podcast, type one diabetes, it's a private group, so you'll have to answer just a few questions so that we know you're a real person. Everything else you need to know about the podcast can be found at juicebox podcast.com or diabetes protip.com. If you're looking for a great endocrinologist, we have a list at juicebox Doc's dot com. It's curated by the listeners, doctors who are down with how people who listen to the podcast they care their type one. You want that part to be easy to write juicebox docs.com completely free. Everything is free by the way, find me on Instagram, find me on Facebook, find me somewhere. If you're enjoying the show, please leave a beautiful rating and review in whatever app you're listening in. Like five stars. This is amazing. And then give a really great description. So the next person who sees your review will know that it's worth listening to. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast and don't forget that episode 712 The second half of this episode is available right now in your podcast player or at juicebox podcast.com.

Test your knowledge of episode 711

1. What is the main topic of Episode 711?

Insulin management tips
Terminology in diabetes management
Carb counting techniques
Diabetes complications

2. What does the term "Bolus" refer to?

A long-acting insulin dose
A short-acting insulin dose
A basal insulin dose
A blood sugar test

3. What is "Basal" insulin used for?

To cover meals
To manage blood sugar throughout the day and night
To correct high blood sugar
To test for ketones

4. What does CGM stand for?

Continuous Glucose Monitor
Carbohydrate Glucose Measurement
Constant Glucose Management
Continuous Glucose Management

5. What is the purpose of a CGM?

To measure blood pressure
To continuously monitor blood glucose levels
To measure insulin levels
To monitor ketone levels

6. How often should you check your blood sugar with a CGM?

Every 5 minutes
Continuously throughout the day and night
Once a day
Only before meals

7. What can a CGM help prevent?

High blood pressure
Low and high blood glucose levels
Ketone production
Weight gain

8. What is the defining feature of the Bold Beginnings series?

Detailed medical advice
Personal stories from newly diagnosed patients

#706 Bold Beginnings: Adult Diagnosis

Bold Beginnings will answer the questions that most people have after a type 1 diabetes diagnosis.

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:00
Hello friends, and welcome to episode 706 of the Juicebox Podcast.

Today is going to be the second installment of the bold beginning series. While you're listening to this episode, 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. If you're a US resident who has type one diabetes, or is the caregiver of someone with type one, please consider going to T one D exchange.org. Forward slash juicebox. To take the survey, the T one D exchange survey benefits people living with type one diabetes, it's incredibly easy to do and will take you fewer than 10 minutes, T one D exchange.org forward slash juicebox. Also, today, you're going to hear Jenny Smith, Jenny is a CDE. She has had type one diabetes for over 30 years. And she works at integrated diabetes.com If you're interested in learning more about what she does.

Jennifer Smith, CDE 3:12
Correct. And that's in a I mean, what you just said is also in an environment with doctors who really are thinking type one thin, normal size looks, you know, like they maybe are an athlete or something like that. I'll actually say I mean, I've got a number of people that I've worked with over the years that are athletes, like I've worked with a couple endurance athletes who were initially misdiagnosed in the emergency department, as type two and sent home with completely a lack of information and a prescription for oral meds that were not going to do anything for them.

Scott Benner 3:54
Yeah. Yeah. You'd be surprised how many people I've spoken to who are dismissed at their diagnosis because the very next statement here on in our questions is, when I was first diagnosed as an adult, I couldn't get in to see an endo for a while because I wasn't quote unquote, critical and I wasn't hospitalized for DKA. And one of their first questions was, how do you even know I'm a type one. And you know, nobody does antibody testing right away for you. And this person says I just wish I would have known to ask for a C peptide test. When this was starting. It is not uncommon at all handful of metformin get home, take these come see us in a month, let us know how you're doing except you don't have type two diabetes. You have type one diabetes, and that's not going to help you. So and then you are in a real you're at a risk then a significant risk. Yeah.

Jennifer Smith, CDE 4:48
Yeah, absolutely. And I think that the issue there too, is adults. We're we're very misinformed when it comes to our education system. All right, we just we really are in terms of many health conditions, but diabetes included, there's still a lot of really good misinformation out there about diabetes. And so as adults, if you have all these symptoms, and you have no knowledge of diabetes, no personal history from family member or friend or anything, you may go to the doctors because you don't feel very good eventually. And then you get diagnosed, we are told your type two diabetes, well, maybe you don't even know there's type one diabetes, or you don't even know that you should ask to say, Well, gosh, this doesn't seem to be what I you know, what, what I would fit into for a diagnosis? I think so I think teaching is important. Yeah, it's

Scott Benner 5:48
important to know that you can be thin and lean and healthy and have type one or type two diabetes. Correct, right? I mean, and there's just so many in here, like I was diagnosed a month ago, at age 55, a week after my birthday. How was that possible? No one in my family has this. I was 50. My first question was, what the this person is obviously shocked. And then the next thing I want to get to, which I think is super important is, and I won't read the whole thing, but diagnosed at 47 years old, full time job, fast paced lifestyle. They can't get started, really, they don't know anybody that has diabetes, they're busy, they get up, they go to work, they're counting. They're I mean, people end up being hopeful, right? Like this person probably lived their whole life, you get sick, someone gives you a medication, you take two a day for seven days, you feel better. That's that, right? What you expect when this happens. And then when that's not the case, they say, look, it's almost five years later, I still struggle with my Basal with my Pre-Bolus times, this person doesn't know what they're doing. And so

Jennifer Smith, CDE 6:47
and I think a big thing of it goes a little further than not necessarily knowing what they're doing. One, I've found, definitely, that adults diagnosed with type one and absolutely with type two, are very poorly educated from the beginning, in terms of what to do, but along with that is they've already had a life and a schedule and a structure to that life, adding in something that they haven't been given the right information many times from the get go. And now they have to disrupt a lot to learn how to fit this in, to what their schedule was. Whereas kids are, they're different. I'm not saying that it's not difficult, but it's different, because who's helping the child

Scott Benner 7:43
write it because when you're diagnosed as an adult, it's on you, it's on you. And when your diet when a child is diagnosed, some person I mean, hopefully, right? A caregiver basically stops the rest of their life to figure this thing out, because the diabetes is really a newborn baby, all of a sudden, correct can't help itself. If you don't know what you're doing yet. And it's a it's a very slow process and a scary process and, and a process where you feel like you're about to drop the baby every five seconds. And, you know, you just sit on the sofa. But, you know, it's funny to piggyback on what you just said, and the next question, somebody said that they got a ton of code, they got a ton of information in their education at the hospital, but none of it's happening in their real life. So what they, they felt like they left completely prepared,

Jennifer Smith, CDE 8:29
which is great to hear that yay for whoever educated you.

Scott Benner 8:35
And then there you go, you shop at home. And there's nothing there, the person actually said I had to start listening to the podcasts and reading posts in the Facebook group, but that they still feel out of control. You know, please do a show for older diagnosed people, a different issues like work pressure schedules, exercise, cycles, evening events, etc, etc, all these things, and it's very liquid. It's very true. I mean, Jenny, you know, like, if my daughter runs on a schedule, I can run her blood sugar, like it's nothing but if you start throwing in a bunch of different problems, ya know, and variables like this adult issues, it changes and I never go ahead and say that, you know, Sam, so no, I

Jennifer Smith, CDE 9:16
was gonna say you're AB you're absolutely right, adult issues are your own to manage to begin with, and many, thankfully, there are a good number of people who have a very supportive, significant other spouse, or a really good friend that, you know, gives them some support or help. I think one of the, not everybody has this option, but I've had a couple of people who've actually after diagnosis, they actually decided to do the best they could for themselves to really get an idea. They took one or two weeks off of work. And they said I am I'm just gonna I mean if I'm going to really nail understanding this as much as I can, and then I'm going to add this other variable back into the picture. I'm going to add work back. Now I'm going to add exercise back. It's but there are a lot of adults who don't have that option, you don't have the time you can take off. So you have to do diabetes, along with what was already in your life. And it adds a layer. I mean, I can say, as somebody who had had diabetes, long time before I had kids, adding kids into the picture has added a layer to my management that is very different than I did before.

Scott Benner 10:28
Yeah, I saw a woman walk out of an elevator yesterday with a libre on her arm, and she was lugging a baby, and had a four year old behind her. And I thought, oh, that's different than just walking off the elevator. It really is. You know, it's, there's this this next person said it this is very interesting, because I brought it up in the honeymoon episode for newly diagnosed but this person says, I thought I was doomed. I was in denial. And I spent days researching articles about potential cores, cures, excuse me supplements to prevent disease progression and everything. So they fell down a rabbit hole. Then they said they went into a depression, hopelessness. And on top of all that, blood sugar is all over the place. Yeah, yeah, let me keep reading, I kept calling my doctor when numbers didn't make sense. And they repeatedly told me it's okay, if you're 180 to 200 for a few hours after you eat, you're not damaging yourself unless this occurs for long term.

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Jennifer Smith, CDE 14:06
Right, but how do you stop it now? Like if it's occurring, and it's damaging long term? Well, then tell me what I should do. So I can stop it from happening long term. Yeah, excellent. Right. Like it's

Scott Benner 14:17
like, they feel like they're like, you could do a little math, you'll be alright. But that leads to a meth problem. Right, right. And it really is the same thing. Like I didn't I'm sorry, it's such an odd if anybody has a math problem, I'm so sorry. But like, I mean, it's just like, that's how it seems to me. It's just like, Absolutely, Hey, it's okay. Don't worry about it. But it's okay. Don't worry about we have so many episodes where people say, listen, they told me it was okay if I was up to 180. And then one day it was 190. And I thought well, that's only 10 More than one ad and then 200 was only 20 More and then 250 was only 50 More than 200 and I was okay with 200 Before you know it, blah blah, blah, blah, blah. Right and it's not it doesn't help you in this moment when here you On your house hopeless, alone, feeling depressed, unable to manage diabetes? I think the one of the, you know, I'll tell you a genuine I don't know if I would have said this five years ago, but having that Facebook page really teach me like you have to go find other people. Because for a little while, you need to know that other people live with this, and they do a good job.

Jennifer Smith, CDE 15:23
Because I was gonna do the same thing. Yeah, yeah, hope is incredibly

Scott Benner 15:27
important. And I'm not saying you got to go to some like type one retreat with people or something like that if you want to you can but but just knowing it I, I interviewed a girl this morning. I see if I can tell this really quickly. Last year I ever interviewed a girl from Canada who was allergic to insulin. i Yeah, figured it out. A doctor in Texas heard the podcast, she had a patient who was going through something similar. The doctor called me I put the doctor in touch with the person from Canada. conversations went back and forth. Long story short, the girl in Texas started using a Frezza. And she's doing much better now. During the conversation that I just had with her the girl from Texas, which is in the podcast summer, like go find I think it's called allergic dance on Park.

Jennifer Smith, CDE 16:20
All right. That's my alert that I should have turned off for going to pick my child up from the bus stop, which is not my job this afternoon. That

Scott Benner 16:29
kid can wait, Jenny, we're making a podcast. Wait, tell him to stand there a little longer, he'll be fine. But in the course of interviewing this girl from Texas, the mother spoke about how this is such a rare thing. But that she found a Facebook group with seven people in it who are allergic to insulin. And it was everything to her. Yeah, everything to find those other people, right. And I just think that it's not. For some people, it is not going to be intuitive to go look for other strangers and find comfort in them. But I am telling you, I've been doing this a long time. And not nearly as long as Jenny has been. And it's incredibly important.

Jennifer Smith, CDE 17:12
No I and I wouldn't 100% agree with that I would include for adults specifically too, don't be afraid to reach out for some type of mental health support to there's a lot that you have to navigate and it really helps to have somebody to even maybe help you get some structure or an idea of how to restructure things. I asked an adult as you said from a touch point, I I did not have diabetes friends, really, until I was an adult. I didn't. I had the people that I got to work with on a clinical bases. But I really didn't have anybody I connected with until I went to a diabetes like athletic training camp. Right.

Scott Benner 18:09
And you met people there

Jennifer Smith, CDE 18:10
and I met you it was it was like diabetes disney world to me. Everybody was beeping and buzzing and complaining about blood sugar's and how are you going to adjust before the five mile run? We're going to go on? I mean, it was I smiled the whole time that was there. Because it was exciting to connect.

Scott Benner 18:31
As as crazy as this might sound. I know this is a weird statement. But for you personally, if everyone in the world had type one diabetes, that would be better for you. You'd,

Jennifer Smith, CDE 18:43
right? I mean, the whole the whole world would just, it would just understand it wouldn't be a oh, well, you know, I'm gonna bring that special dessert for you because you have diabetes, kind of like the weird comments that you end up getting, right? No, just you don't understand. So sometimes that is even off putting for you as an adult to try to explain to somebody because there's so much missing that you can't explain in just five minutes of why you could actually eat the regular dessert if you wanted to. You just don't bother and you're by yourself. And then you're by yourself. And

Scott Benner 19:23
listen, I only have the context of a parent but I can tell you that when your child is diagnosed, you have no recourse you're not you know, I'm not I'm not I'm not dropping her in a in a basket or a fire station. She's my kid I'm gonna figure this out right

Jennifer Smith, CDE 19:36
she's not Moses you're not gonna let her go down the street

Scott Benner 19:42
I'm not very religious Jenny So I don't know that whole thing but it did pop into my head about should I say I didn't float it out or stream but I couldn't remember the whole parable. Anyway. The it slowly you understand it? And you don't you don't you give yourself over to it. It's a life change. As much as you won't want it to be at first, and you may do a really good job of giving diabetes, a lower impact in your life, but it's going to have one of the only, like, the only thing I can say is, you know, when you get a bad cold, and for three days, you just the world understands, you're going to lay down, you're going to be sick, and nobody's going to hear from you. And you find a way to make that time you do that when you're the parent of a child, you okay? Well, we're, you know, as an example, we were in the we had just renovated a portion of our home when our son was diagnosed, we'd done it, and we had it broken into two phases. For five years, while I learned about diabetes, my children had to jump out the front door, because I didn't have steps. And that is one, that's great. Yes, that is one of the things I put on the back burner, while we were figuring out diabetes, for Arden. And but when you're going to be an adult, and this is going to happen to you, there's no one there. I mean, maybe you have a spouse if you're lucky, right. But you'll be surprised at how many adults I see who try not to share their diabetes with spouses, which is a personal decision, you know, so you're going to have to say to yourself, I got to look at this 24 hour clock at this seven day, calendar this 30 day month, and find some time in here to just learn about this, and find a way to incorporate it because unlike a bad cold, it's not going away, but it will get you know, if I if I had something hopeful to say I would say that diabetes doesn't get easy. But sometimes you get so good at it that it can feel easy, some days. And those days sometimes grow into weeks, where you just go, oh, this was an All right, you know, you're gonna have to make that time in your life, you can't just put your head down and run through it, because it's not going to work that way. And you

Jennifer Smith, CDE 21:45
can start in from an adult perspective of a major change to your structure or your day schedule. Even if you just start with a basic of kids, then given this medicine called insulin, and I was told to take it, here. And here. If that's where you start, then that's That's it? Yes. Just take what you were told to take. And then moving on, you can kind of build on that. Especially if you've got technology, I would say that's another big one that adults should definitely ask about. I know, parents are definitely the ones to beat down knocked down camp outside the doctor's office until they get the products and the technology that they want. Adults do the same thing. Yeah, I asked for a CGM right away on diagnosis, you know, ask for a pump. And or start the discussion sooner than later, depending on you know, what you think you can handle

Scott Benner 22:46
to, to use a phrase from the podcast or something else, you should dictate the pace? Don't Don't let a doctor say, hey, we'll look at it three months back. No, no, let's do it. Now. You know, I want to get an insulin pump. Let's start that right now. I don't want to talk about it three months from now, you know, the other thing is, too, is you know, I tell people all the time, you might get a clunker of a doctor. Don't, don't don't suffer with it if that happens, right. And it's you know, I have a note here to myself, that children get treated better than adults do in medical situations. And it's because in my mind, it's a business. And if and if I see you treating my kid poorly, I don't want to come back here. So everyone's very nice and accommodating. It's how kids get treated adults, do not get treated that way. And by the way, if you are if your husband's a doctor, or your wife's a doctor, or you're a nurse, even if you're like you know, an OB nurse and know nothing about diabetes, your doctor is going to assume you know all about it. Yeah, and not tell you anything, because you're gonna think other nurse they know. And we know that's not true, too. So,

Jennifer Smith, CDE 23:55
in fact, in hiring my own Endo, or endos, you know, in over the past years as an adult on my own. I think since I've been in the profession of diabetes education. I've had more doctors who seem they seem almost standoffish, kind of scared to suggest and or talk about things. I'm usually the one to bring up the questions or hey, look at this. I'm thinking about this. What do you think about this? And I don't, I don't want that I'm paying you to help me. I don't want you just so you can write my prescriptions for

Scott Benner 24:36
me, I still need help with just a guy with a podcast. And every once in a while I get that I get the like, Well, what do you think I'm like, you saw what I think like that's the best I can do. What do you think? I'd love to hear what you think? Let's collaborate a little bit. It's it's not undoable. And I would I'd want to I'd want to finish this up by saying that I've interviewed you Dozens of people diagnosed in their 30s or 40s, their 50s and their 60s. And they're doing well. It's so possible to do. I would. I mean, listen, I'm biased. I'd find Juicebox Podcast type one diabetes, the private Facebook group and just lurk around and watch people talk. You can learn a lot that way. If you have a question great, if not just sit back and watch. And the Pro Tip series from the podcast that begins at Episode 210, with an episode called newly diagnosed or starting over, I think if you listen to the Pro Tip series that Jenny and I put together, it's absolutely free. I think you could get your a onesie into the sixes pretty comfortably. If you need any help find me and ask and I will absolutely ask. And if you're really, really lost, Jenny works at a place called Integrated diabetes, and it's at integrated diabetes.com. So you could

Jennifer Smith, CDE 25:48
thanks yeah, I was actually going to bring in the the fact that you've got a really wonderful list of endocrinologists. And I think there are even some diabetes educators within the list on the website on your website, right?

Scott Benner 26:01
juicebox, Doc's dot com.com Voc acids a list. It's curated by the people who listen to the podcast, who say that my doctor is cool with how I manage. I manage through, you know what I've heard on the podcast and you know, so other people can find them

Jennifer Smith, CDE 26:19
and you have some pretty good connections in a good majority of the states and bigger cities

Scott Benner 26:24
is getting bigger and bigger. It's not. It's not not worth your time to go check it out. You might find something near you for sure. Yeah. Okay. All right, Eddie, thank you so much. Thank you real quick when you get a dog.

Jennifer Smith, CDE 26:35
Oh, we've had a dog a long time.

Scott Benner 26:36
I know. I thought you have cats. Oh,

Jennifer Smith, CDE 26:39
well, we have a zoo. We have two kids. We've got a chocolate lab who's like 85 pounds. We've got two fish. We got two cats.

Scott Benner 26:48
I'm still recording, by the way, but I did not know your dog.

Jennifer Smith, CDE 26:51
Oh, yes. We've got more hair like floating around.

Scott Benner 26:56
That dog bark and I went, What the hell is Jenny dog sitting? I've never heard a dog barking all the time. I've talked to you.

Jennifer Smith, CDE 27:03
I know. Usually. In fact, I've heard your dog's bark before. And I'm I am surprised that in all the years he has not ever bar

Scott Benner 27:13
I swear to you, I thought you were dog sitting with that happen. I was like, although true.

Jennifer Smith, CDE 27:18
We often we most often do these more in the morning. And usually if we're getting deliveries, which I expect, probably something came and somebody knocked on the door, they usually come in the afternoon. So that could be why today

Scott Benner 27:33
you and I almost never do this in the afternoon, actually, that ever is the big deal. Sorry. Well, it's it's a holiday weekend. So I hope you have a great time. Thank you. New episodes of the bulk beginning series will come out every Friday. Thank you so much to Ian Penn from Medtronic diabetes, for sponsoring this episode of The Juicebox Podcast. Please remember to head over to in pen today.com. If you'd like to learn more about that insulin pen that talks to that app through Bluetooth. I'd like to remind you again about touched by type one, it's touched by type one.org. Of course, Jenny Smith works at integrated diabetes.com and bold beginnings episodes. And all of the episodes of The Juicebox Podcast are available at juicebox podcast.com. And in any one of your favorite audio apps, like Apple podcasts, Amazon, Music, Spotify, and stuff like that. If you need a list of apps that are free to use, by the way, I also have those at juicebox podcast.com, where you can head over to the private Facebook page for the Juicebox Podcast. It's called Juicebox Podcast type one diabetes. There are links there to all the series, tons of questions and answers from people living with diabetes, and links to audio players. If you're enjoying the podcast, please hit subscribe or follow in whatever audio player you're using right now. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.

Test your knowledge of episode 706

1. What is the main topic of Episode 706?

The Bold Beginnings series installment
Insulin management tips
Carb counting techniques
Diabetes complications

2. What common issue do newly diagnosed adults often face?

Misdiagnosis as type 2 diabetes
Lack of access to insulin
Immediate DKA hospitalization
Over-prescription of insulin

3. Why do some adults fail to get immediate testing for type 1 diabetes?

Misbelief that type 1 is only for children
They have a family history of type 2
Lack of awareness about diabetes
Early testing always confirms type 1

4. What type of test is often missed at diagnosis for adults with type 1 diabetes?

HbA1c test
Blood glucose test
C-peptide test
Ketone test

5. What advice is given to adults newly diagnosed with type 1 diabetes?

Start with basic insulin management
Avoid all physical activities
Immediately use an insulin pump
Follow a strict diet plan

6. What did Scott and Jenny recommend about diabetes technology for adults?

Delay using technology
Ask for a CGM and insulin pump right away
Use technology only if necessary
Avoid using CGMs

7. What is a common feeling among newly diagnosed adults?

Denial and hopelessness
Immediate acceptance
Confidence in management
Lack of concern

8. How can newly diagnosed adults find support?

By attending type 1 diabetes retreats
By joining Facebook groups
By isolating themselves
By avoiding discussions about diabetes

#702 Bold Beginnings: Honeymooning

Bold Beginnings will answer the questions that most people have after a type 1 diabetes diagnosis.

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:00
Hello friends, and welcome to episode 702 of the Juicebox Podcast.

Today is the first episode in the bold beginnings series. While you're listening to this episode, 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. If you're a US resident who has type one diabetes, or is the caregiver of someone with type one, please consider going to T one D exchange.org. Forward slash juicebox. To take the survey, the T one D exchange survey benefits people living with type one diabetes, it's incredibly easy to do and will take you fewer than 10 minutes T one D exchange.org forward slash juicebox. Also today you're going to hear Jenny Smith. Jenny is a CDE. She has had type one diabetes for over 30 years. And she works at integrated diabetes.com If you're interested in learning more about what she does.

This episode of The Juicebox Podcast is sponsored by Ian pen from Medtronic diabetes in pen is an insulin pen that talks to an application on your smartphone and gives you much of the functionality that you will get from an insulin pump. In Penn today.com. The podcast is also sponsored today by us med. Don't just get your diabetes supplies from anywhere. Get them from us med Call today for your free benefits check 888-721-1514 Or you could just go to us med.com. Forward slash juicebox. Us men always provides 90 days worth of supplies, and they give you fast and free shipping us med.com forward slash juicebox. So we did this little episode recently where we talked about we're going to go through the steps of the questions that people sent in about being newly diagnosed. This is going to be our first episode about it. We have it broken down. It's not really it's still it's gonna be a lot of episodes, but we haven't broken down to honeymoon. What it's like to be diagnosis and adult. different terminology. highs and lows, the 1515 rule long acting insulin, fear of insulin, range and food choices Pre-Bolus ng carb guidelines and impact of food stalking, flexibility school exercise guilt, fear and hope. Podcast the community medical care team journaling, technology and supplies, insurance. And that's it. So that's it. That's it. I have it narrowed down to like I don't know, 15 or 20. Yeah, so we're gonna go through and have these conversations. So you and I put these in order, and we thought honeymooning went first. So we're gonna have to feel our way through this a little bit, because we've never done this before. In the past, I just started the conversation. And then we chatted to where we wanted it to go in the in the in the pro tips. But this one, we have questions from people. So why we thought this was important, is because going into the Facebook group with 25,000 people on it and asking them, What do you wish you would have known or someone would have told you when you were newly diagnosed? So under the heading of honeymoon, the first thing that we have here is a better explanation of the honeymoon phase would have been helpful. Let's talk about what that is.

Jennifer Smith, CDE 4:09
Yeah. Better is is a it's like a rabbit hole of consideration. Right, though, like, better explanation kind of starts with Well, how was it explained to the person or to the majority of people to begin with? Yeah, and I do think it's a concept that's really it's a gray area, have known, honestly. Because it's a time period, essentially, where after diagnosis, you've got some remaining beta cells, at least many people do. Not everybody but many people do. It seems like the sooner you get containment of the blood sugar levels, the more likely you are to have if there are remaining betas, their assistance and they come I'm back to help and that may eventually reduce your overall insulin needs. I mean by how much again, this is a person to person, you may need less overall dosing for mealtimes. Maybe just Basil is holding things really, you know, tight for you in that honeymoon phase. But I think a good word to go along with honeymoon is unpredictable. Honestly.

Scott Benner 5:29
So, the, you know, let me jump to another question, because I think it'll pull the conversation together, right? This person says mi honeymooning, how will I know. And I think that's such a good point. Because you really don't know what diabetes is to begin with. So whatever it is for you on day one is how you imagine it is and a lot of people get caught up in thinking, well, this is it. You know, and someone can tell you in the moment, hey, you might experience a honeymoon, and a honeymoon is going to be, you might have some beta cells that are still helping along with insulin production. That might be great. Because if it's stable, then we'll use you know, less insulin. But it also could wax and wane. It could be one day, you're getting help. And the next day, you're not the next day you are and you know, especially you're probably going to be MDI at that point, right. So you've got to for the most part, right, you've got a fixed amount of insulin in us a basil. And then one day, you're, you know, your pancreas is like, I'll help and no thanks. I already put the insulin in today, and you're feeding insulin all day. So it's a lot.

Jennifer Smith, CDE 6:34
It is a lot. And I think a misconception too, is that it shouldn't really be mistaken. And it could be easy to think, Well, gosh, maybe i i was incorrectly diagnosed. Right? Maybe I am really getting better. Maybe I was just sick or something was going on this downplay in insulin need. Especially being tested. I mean, most people who are who are diagnosed with type one, or assume type one, get the antibody testing and all those things that we've already talked about to to really give a positive diagnosis. But once that's there, even if your insulin needs go down in this expected honeymoon time period, you're not you're not getting better. And that's sad to say it is

Scott Benner 7:27
because it'll hit you that way. Because it happened to me. Yeah, there was a couple of days where art in just out of nowhere did not need insulin. And or at least that's how it felt like, you know, my memory on it could be, you know, right. I'm getting pretty old those long time ago. But right, my recollection is there were two days where Arden didn't need insulin, and I and I've told this story before calling our pediatrician who's a friend. And I preface what I said by going I know I'm wrong. But I have to say this because it feels imperative that I tell you that I don't think Arden has diabetes, somebody made a mistake. Right? And he sat very quiet and sad and said, she asked diabetes, this could happen. You should call the endo and talk to them. And I was like, okay. Yeah, but the problem day to day and why the question gets asked by people who are like, you know, when you ask somebody, what do you wish you knew? I think first of all, you need to know what could happen, you need to know it might not happen. Correct. You know, you might catch diabetes very early. And then your honeymoon might be longer, you might catch it later, it might be shorter, and 1000 other variables that could influence if there's a fluctuation, and if there is how big it is. This person says the lows were horrible. And we had a scary middle of the night, barely conscious, 32 blood sugar, about three weeks after diagnosis. So this is a person who didn't have this information was never told.

Jennifer Smith, CDE 8:51
Right. And that's I guess it also brings in a timeline of when, and that's a that's a major question that's also often asked is, well, how long can I expect this to last for? It could be a week, it could be a couple of days, it could be weeks, it could even be years. And for the most part, the years that length of time in honeymoon. I more often see in adults who are diagnosed who research has has shown as an adult diagnosed you more often have a reserve of betas after diagnosis that's a little bit larger than really young children or even kids or teens really. In fact, there's there are a lot of good studies for kids diagnosed under the age of five. I believe that actually so it's that the onset of type one is much more rapid and much more aggressive. And that there is more likely that there's less or almost no beta cell action left in really little kids were diagnosed very quickly. Yes, yeah.

Scott Benner 10:02
Artem was to and, you know, besides those two days, well, here's the rest of me right. Besides those two days, I'm going to tell you that I didn't notice. But I also was a guy holding the meter and a handful of syringes and a vial of insulin right? There were no CGM, I couldn't see anything happening. And these people who are listening very likely are not being handled a CGM right away either.

Jennifer Smith, CDE 10:26
Many of them are not I've had, in the past couple of months, I've had a handful of people who've actually left the hospital with a CGM on their child. Okay, well, that's fine. But again, that's it's a small percent, but it is encouraging to see how that's progressed in importance for visibility. And or they've left with a prescription to get it within a week or two after leaving the hospital or after diagnosis, which again, is, in my opinion, pretty quick turnaround,

Scott Benner 10:57
the context that the the glucose monitor line gives you, it's just, it's different. Because otherwise, in your mind, it just feels like the blood sugar is coming in and out of hyperspace. Like, it's you know, it's 78. And then the next time you look up, it's 250. And without context for how it got there, your brain struggles to make sense of it, you know, especially when it's very likely that the doctor has given you basic ideas of what to do count these carbs. Use this, you know, use this formula, inject this insulin, if you're lucky, you got that right information. Right. And because we're talking about newly diagnosed and not just children, I've interviewed a number of adults, you know, you know, over and over again, but lately, one that's sticking to my head where they just told her like your take 10 units of this and eat. Yeah, that was it, you know? Right, right, exactly. consideration about carbs or anything. Honestly, it's more

Jennifer Smith, CDE 11:55
than for adults, I've seen many more adults being diagnosed, let's say correctly with type one, but given more of a really old school, way to dose insulin, and prior to giving them any, you know, real information or education, if you will, it's like you said it's eat your meal, take 10 units of insulin, take it three times a day with each meal time and go about your business until you actually see an educator or somebody who can help adjust this for you. Where again, that's it's that's really old way to dose.

Scott Benner 12:34
But you're seeing it more and more you're saying.

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Jennifer Smith, CDE 16:41
I see it, I see it often enough that it sort of frightens me, given all the technology we have today. And the types of insulin we have today and the way that they are meant to work to specifically especially our rapid acting insulins to mimic sort of digestion for the food that it was formulated to cover which is carbohydrate. So why don't we just educate people? Well, give me an idea what your meals look like. I mean, this is pretty easy question to ask people upon diagnosis, okay, your meal seemed to be this. And as an educated clinician, you should really have an idea about how to carb count, especially if you are in the profession of diabetes. And that's you should be able to say okay, let's start easy and just say, for every 15, you take one, right, at least

Scott Benner 17:36
it gives people context,

Jennifer Smith, CDE 17:38
something's starting to work with a starting point, even if it's completely wrong, and they need to be a one to five, at least, then in a couple of days, you can say, well, that's clearly not working, let's adjust it, but they already have the concept of counting and dosage.

Scott Benner 17:52
Your, your your story makes me think that maybe at diagnosis, people are like, well, they're gonna get great technology. And then now this is going to matter. So I'll just say something that won't kill them today, then they can go to the next person, and the next person will do a better job of this. But your point is, I mean, listen, it's not a brag, but I think you could bring me up to any person using insulin. And I think I could probably ask them four or five questions and make a pretty educated guess about how to cover their meal. Yes. So absolutely. Yes, it just doesn't it's not I hate to say it's not that hard. But you know, it shouldn't be if you're a clinician, I guess. Just this next thing here says, What do I need to know, during the honeymoon stage, you really have to put yourself in the position of a person who's just been whacked over the head with a shovel while someone's yelling, you have diabetes. And they're like, wait, what she's she said before they teach carb counting. Like when do I know if it's a true DKA? Or hold on a second? These are broken up questions. So let's skip the car panic and go. When do I know if it's a true DKA situation are just part of the honeymoon stage? What do you think they mean by that?

Jennifer Smith, CDE 19:01
Well, high blood? It's a good question. Because if high blood sugars are just sustained high,

Scott Benner 19:07
and then they again, do ketones because somebody told them if you're over this for a certain amount of time test your ketones, right. And they're fresh from a traumatic moment in their life where these kids had or they had a high blood pressure and they were in the hospital for it. Right. Oh, I see. Okay.

Jennifer Smith, CDE 19:22
I mean, that's what I that's what I would certainly expect but it is it's a it's a good question. But I think it's a pretty complex question. Because if you're in this window where honeymoon could be the case, and all of a sudden you're running high blood sugars, okay, great. Go ahead, do the steps. You know, test for ketones. dose, call your call your doctor and say, Hey, we've been running higher all of a sudden, it seems like without visible illness or stress or anything in the picture. Seems like you're likely at that point then coming out of honeymoon and you actually need To increase your doses, potentially basil to start, maybe the doses that are covering mealtimes, especially if they've been very, very, very conservative. But I mean with high blood sugars, regardless of what point of diabetes diagnosis you're in, if it's a stain high test for ketones, right, good first step.

Scott Benner 20:20
You know, it's funny, I always think about these things, all these topics about I think of them as like, if we were in an elevator for three minutes, and you said to me, Scott, honeymooning, what do I do? I think, and I don't want to give away that I've watched more than one season of Big Brother, which I'm embarrassed by, but I think you have to expect the unexpected. Like, if Thank you, if you just need to live in the in the reality for a little while, that things are going to change more frequently. Or they could change more frequently, I should say. Then you hope and right. And that's where you hear people online, say stuff that I don't like that they say, but I understand where it comes from, like, you know, carbs, times this plus this equals elephant, you know, or when they say like, nothing makes any sense, right. But if you expect it to be varied, then it does make sense, but it's varied. Right, you know, if you if you put yourself in a position where you say, This is what should be happening, I did what the doctor told me, I measured it correctly. This is wrong. None of this makes sense. I give up. You're gonna, you're gonna make yourself crazy. Right? Yeah, you just have to stay very flexible in the beginning.

Jennifer Smith, CDE 21:29
And I think that the flexibility and especially in terms of what people should know, after diagnosis around honeymooning is that expect that it may be in the picture for you at some point, sooner than later after diagnosis. And that once you're exiting the honeymoon, it doesn't necessarily mean that you're doing anything wrong. Right? This isn't it's not really, it's not your fault, that you're coming out of the honeymoon time period that you need more insulin. It is what it is. Yeah. So I mean, there's a lot of, I mean, in the grand scheme of diabetes management, there's like, a lot of psychological stuff anyway. But I think this is a, this is a period where you may feel really, really confident. And honestly, during a honeymoon time period, it may seem a lot easier for some people because they have these really tiny insulin doses is they're only on basil. They feel like oh my gosh, I'm an eating and checking my blood sugar looks like it's in this target range. And they may not even be dosing mealtime insulin, maybe Basil is just cutting it for them, right? And then it starts to inch and creep and change. And that's where again, like that psychological piece of management kind of comes in, because a lot of people think, well, well, maybe I need to cut back. Maybe I'm doing too much, maybe I'm eating too much. So I'll just eat iceberg lettuce. And that means it's okay.

Scott Benner 23:04
It's such a good point that in the beginning, you're very likely using such a small amount of insulin and it can make you feel like I've got this it's so easy. But if your Basal is point one an hour, and you know your whole meal, insulin is like a unit for a meal or something like that, like, I'm not belittling, it's hard, and it's scary and everything else. But you're basically playing wiffle ball in the backyard with your dad, you're not hitting up a Clayton Kershaw right now, yeah, go crazy. When you put the ball over the hedge line, you know, they may just say, okay, and to me, it's all experiences. I mean, I don't know how many times I could talk about it, but you have to do a thing. You have to see how the thing works out. And then you decide, do I need a little more, a little less, a little sooner? A little later? How does this insulin work? And you do it again, and again and again, until one day, it just makes sense every time you do it? And? And the truth is, is that, you know, in the beginning, you do have more going against us than just understanding that you have the other parts, the psychological aspects of it, and what could really be, you could be suffering with depression at that point, or, you know, there's a lot happening. I interviewed an adult recently, she's in her mid 30s. And she said they were explaining to her about her diabetes, and she just sat there thinking I don't have diabetes. Like she wasn't listening to anybody. You know, she's like, a young fit person. And she's like, I don't this is wrong. Like she couldn't get past the I think they're wrong about this. You don't know how many important things were said to you. While you were staring at the wall thinking, hey, what was wrong? Yeah, what the hell just happened to us? Yeah. Okay. Yeah. Is there anything here we're missing? I do want to go to one more question here. But I want to make sure you have everything out that you want to say.

Jennifer Smith, CDE 24:49
Um, I don't. I don't think so. I mean, outside of just one other question that I think has come up in conversation in discussing with some newly diagnosed people that I've worked with, a lot of people end up asking, is there anything that can sustain this honeymoon? Right? And there's, there's only one study that I know of, and it was done in adult men. So not even a broad spectrum of, you know, gender or anything. But it showed that exercise in newly diagnosed men proved that the honeymoon lasted a fair amount of time longer than those who didn't include exercise in that time period post diagnosis.

Scott Benner 25:40
I wonder why that is. So

Jennifer Smith, CDE 25:43
again, I mean, something like that, certainly, you need to study it in more people more, you know, kids, teens, women, but at least it was a good visual that there is that one thing that was shown that could potentially prolong it, and I would, I would expect, it's just from a sensitization standpoint, right building muscle making the muscles work, which makes your insulin work better. And if your body is more sensitive, your pancreas also doesn't have to work as long so maybe it preserves the beta cells longer, right would be my expectation

Scott Benner 26:17
what let's put this part in here to like, so we know about like Tomislav, for example. Right. There's that drug trial. Yeah, about a long gating people's honeymoons? What's the real benefit of that? For the patient? Beyond that you don't need to use insulin, and you don't have to have diabetes, as soon like, I mean, the lesson to think of put off three, four years, then hey, you know, I'm saying, that's amazing. But if I'm just doing something that's going to extend my honeymoon by a week, or a month or two, like, what's the real benefit of that? Is there one?

Jennifer Smith, CDE 26:50
I guess the benefit to me especially would be for if it's even keeping people from some type of diagnosis, you know, in those who are tested with antibodies and are given the drug in order to extend the time without diabetes, any years without diabetes are definitely a benefit.

Scott Benner 27:10
I get that one I'm talking about, like, if running around like a lunatic makes it take three less. Like, if it gives you three weeks back, you know what I mean? Like, like, you've had diabetes for over 30 years? Yes. Would it be any different if you had it for three weeks less? No, no, right. But I would not, but three, three years less, God bless we would like that. Right.

Jennifer Smith, CDE 27:33
Absolutely. Three years less. Absolutely. And, you know, from the standpoint of ease to the body and whatnot, I think more information needs to be gathered as to people who were diagnosed without use of something like this. What type of outcome with control, like healthy management long term? What was their end outcome compared to people who got the use of this drug and had an extended let's call it honeymoon time, where their body was allowed to help them a little bit more. They had to use less injection, less pumped insulin less, right? What did that bring in down the road? Did it improve anything down the road? And that's going to take years to look at differences

Scott Benner 28:26
from I think, from my perspective, from a person who talks to a lot of people. When I hear about people wringing their hands about honeymooning what I really hear from them, mostly, they just wanted to stop. They just they just like, can we just get to the part where this is reasonably predictable? Please? Like, like, what what is happening, Jenny?

Jennifer Smith, CDE 28:46
I don't know. That's not me. It sounds like you're getting a weather. Emergency weather alert.

Scott Benner 28:51
Maybe a tornado here. Oh, great. Now live, you're gonna ever hear this episode? Scott, he's on his way up.

Jennifer Smith, CDE 29:01
I was gonna say do you need to go to the basement? I don't live

Scott Benner 29:03
in that kind of an area. This is the kind of an area where people go like, why don't we get these tornado alerts. But But, but to go back to my thought that was very odd. They just, I mean, listen, if it's a situation where one day your kid can go to baseball practice and the next day, they can't because one day the pancreas isn't doing anything and the next day it is. It's it's it makes you nuts. Like it just does. And I you mostly hear people say I just want to get to the next part at this point. All right. And I don't you know, I don't not understand that. I think but but this person asked this last question that says they're talking about a two year old who overnight is experiencing lows with no insulin at all. And they say he can hover at 90 for hours and then slowly creep down to 70. But here's the thing. Isn't this interesting? If Jenny's blood sugar would hover it 90 For hours overnight, and then slowly creep down to 70. She would text me in the morning, a picture of her CGM ago, look how good I am at this. And that's the thing you don't have context for when you're looking at your two year old baby who's had diabetes for two months. Right? That, you know,

Jennifer Smith, CDE 30:19
there's not enough history to it for it, this example, this family, this person, there's not enough. I, I have a sense of, of what that means to me. I also have a sense, if I got an alert overnight, and I saw what was happening. Even without using the system that I'm using previous to this, I would have a strategy that I 99% of the time would have worked, right to say, Okay, it's drifting, this is happening, this is what I need to do, or I can go back to bed, because I know that it's all gonna be totally fine. Right? So knew there are, there are a lot of kids, especially kids that I work with, who are still using multiple daily injections or MDI. Because once that Basal injection is there, you can't take it away.

Scott Benner 31:09
Yeah, this is an example from someone who obviously pumps because they were able to turn their basil off off, right? If they were MDI, they would continue to get low. It's funny, yes, I just was explained to somebody the other day, a person who just doesn't know anything about diabetes, and we're talking about low blood sugars. And they said, Why does it keep getting low? And I said, well, the insulin is dumb, it doesn't know. I think that the insulin is pulling glucose out of your blood, pulling it out, pulling it out, pulling it out, it doesn't get to a number and say, Oh, good, we're done. It just, it will continue to take glucose out of your blood until the power of the insulin is gone. And it doesn't care that you are where you want to be too low, having a seizure doesn't matter, it's going to does taking

Jennifer Smith, CDE 31:52
correct. And that's, you know, on pumpers if it was happening enough, again, in this particular example, you could say okay, well, this has happened night after night, I've had to turn the basil off. But if you've got a pump, you can program it just program is zero basil from this point of drop to this point of leveling out and and take care of it. You know, but on again, injections, it's it's really difficult. And so often, what we end up having to do is really make sure that the morning is when the Basal is adjusted, assuming that the overnight lows in this case, and assuming it's honeymoon in this case, is the pancreas is just kicking out at this point. Yeah, this is where it's taking most of its action. And so you don't need any injected or pumped insulin here, because your body is helping.

Scott Benner 32:39
And then the last question that people constantly ask is, How do I know when it's over? And yeah, that one's easy, because you need a lot more insulin,

Jennifer Smith, CDE 32:48
your insulin needs go up. And it's again, this is a visible Okay, was it today because it was a birthday party or a cookout or something? And so we just had a lot more that was different, or is it ongoing in the next? Okay, this was today, tomorrow looks similar. The next day, it looks similar By day three of needing more insulin and nothing else has really shifted or changed. You're probably getting to that point of honeymoon is ending

Scott Benner 33:15
experience after experience day after day showing the same thing. Yeah, you're probably not being helped by your pancreas anymore. The other thing too, is I don't want to be like ham fisted about it. But you know, when you have type one diabetes, and you're not getting any help from your, uh, you know, the way I used to explain it to one of my daughter's teachers when they wouldn't understand I said, Look, here's Arden right now, her blood sugar is perfect. If I take this pump for her, take it from her, just she got no more insulin, and we give her a half a bite of this cookie. She's going to be dead in four days. And you're like, I'm laying there like what? And I'm like, Yeah, her blood sugar is going to continue to rise and there is nothing her body can do about it. I said it will put it into decay, it will end her life a bite of this cookie without insulin. And so you can see it. When you don't have insulin, your blood sugar wants to go up. And if you you know if you can, you know, if you have some stability, say you are using a CGM and you have some stability at 120 and then you eat something and you know, you Bolus for it and three hours later, you're 120 Still but then it keeps rising and keeps rising and keeps rising. Your Basil is probably not strong enough. And then you need to probably go over and listen to the pro tip episodes about how to get going and taking care of your blood sugar. So alright, did we do it? Is this good?

Jennifer Smith, CDE 34:29
I think this is pretty good. Yeah,

Scott Benner 34:31
I you know, every time we do this, I wait for you to look at me and go, Dude, you're so wrong. Stop talking.

Jennifer Smith, CDE 34:38
I don't think I've ever said that to you.

Scott Benner 34:40
You just keep there's that little kid inside of me. It's like I'm gonna mess up eventually. And Jenny's gonna be like shaking her head at me and be like, What are you talking about? Stop but I think

Jennifer Smith, CDE 34:48
the only one time that I did correct you is when you told me that I wasn't nurse and I'm like, Yeah, I'm not a nurse, dietitian.

Scott Benner 34:55
I misspoke and there's the truth right now. We're still recording she would stop me if you I misspoke one time in how many years have we been doing this together? Oh my god, you're like, I'm not a nurse. Oh my god, I felt like I was married to you for a second. I was like, Oh, she finally got me he's so excited

new episodes of the bold beginning series will come out every Friday. Thank you so much to Ian pen from Medtronic diabetes, for sponsoring this episode of The Juicebox Podcast. Please remember to head over to Ian pen today.com. If you'd like to learn more about that insulin pen that talks to that app, through Bluetooth, I also want to thank you s Med, and remind you that you can get a free benefits check right now at us med.com forward slash juice box or by dialing 888-721-1514.

It would be a great companion to these episodes to become a member of the private Facebook group. For the Juicebox Podcast. It's absolutely free. But it's a private group so that you can feel comfortable speaking openly with other people who are living in a similar situation as you it's called Juicebox Podcast type one diabetes, you'll just have to answer a couple of questions to prove to that Facebook algorithm that you're a real person, and then you'll go right in to a space with over 25,000 members. There's so much activity on that Facebook page every day, there's bound to be a conversation. That's about something you've wondered about something you're experiencing, or something that you know enough about to help someone else with Juicebox Podcast, type one diabetes on Facebook, in that same group, at the feature tab at the top, you'll see lists of other series of the Juicebox Podcast, like the diabetes pro tip episodes that have been mentioned, or the defining diabetes series, which will also be mentioned here. If we haven't already, everything you need to know is it juicebox podcast.com are right there in that private Facebook group Juicebox Podcast type on diabetes. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Let me just remind you again, before we go that Jenny works at integrated diabetes.com If you're interested in hiring her, she's interested in helping you. Also, for US residents, T one D exchange.org Ford slash juice box, it really is a valuable thing for you to do to complete that survey. And it genuinely helps people with type one diabetes, and it supports the Juicebox Podcast. So if you can spend just 10 minutes today taking that survey, I would just greatly appreciate it t one D exchange.org. Forward slash juicebox. I've seen listeners of the podcast be involved in a number of different trials around diabetes, they got the opportunity from the T one D exchange. The one that comes to mind right now is that there was one person involved in a new adhesive study for the Dexcom G six. But there are many other opportunities. So beyond answering the questions in the survey and helping people with type one by lending your your data to the T one D exchange and I don't mean like super personal stuff. I mean simple questions about type one diabetes, which by the way, are HIPAA compliant and anonymous. Anyway, by by answering those questions in the survey, you will also give yourself the opportunity to hear about trials and studies. T one D exchange.org forward slash juicebox

Test your knowledge of episode 702

1. What is the main topic discussed in Episode 702?

The Bold Beginnings series introduction
Insulin management tips
Carb counting techniques
Diabetes complications

2. What is the purpose of the Bold Beginnings series?

To address questions and concerns of newly diagnosed type 1 diabetics
To promote new diabetes technology
To share recipes
To interview celebrities

3. How many topics are covered in the Bold Beginnings series?

Around 5 to 7 topics
Around 25 to 30 topics
Around 10 to 12 topics
Around 15 to 20 topics

4. Who is Jenny Smith?

A fitness trainer
A nurse
A nutritionist
A CDE with over 30 years of type 1 diabetes experience

5. What is the honeymoon phase in type 1 diabetes?

A time when diabetes symptoms are most severe
A period after diagnosis where remaining beta cells still produce insulin
The initial shock period after diagnosis
A period of denial about the diagnosis

6. What can influence the duration of the honeymoon phase?

The type of diet followed
The initial insulin dosage
The level of physical activity
The timing of blood sugar containment and the remaining beta cells

7. What is a common misconception about the honeymoon phase?

That it is a permanent state
That it means the person is getting better and doesn't have diabetes
That it requires no insulin at all
That it happens to everyone

8. How should you manage insulin during the honeymoon phase?

By stopping insulin completely
By maintaining a fixed insulin dosage regardless of blood sugar levels
By closely monitoring blood sugar and adjusting insulin doses as needed
By only using insulin for meals