#330 T1D Exchange

David Walton (T1D 24 years) is the CEO of T1D Exchange

David (T1D 24 years) is the CEO of T1D Exchange, a population health organization focused on improving care for people living with type 1 diabetes, primarily through the creation and use of real world evidence.

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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, everyone, welcome to Episode 330 of the Juicebox Podcast. Today's show is incredibly conversational, I don't want to break it up. So I'm going to put the ads right up front here. Today's guest is David Walton. He's the CEO of T1DExchange. And I expected to have a more technical conversation with my guests about what T one D exchange did. But instead, we ended up having a multifaceted conversation around Type One Diabetes that I enjoyed so much that by the time I got to an hour and a half, I realized I had to let him go. David and I are going to speak today about the research that T Wendy exchange is doing with the COVID-19 virus. And then we get into his diabetes, his life, his management style, concepts about how to help people with type one. I just really enjoy talking to David, I think you'll enjoy listening to him talking to me, and me enjoying talking to him. And I guess hopefully him enjoying talking to me. But that's an assumption on my part because I didn't ask him anyway. ads are up front. podcast in the back. Was that party? What is it? What was that thing he used to say about mullets, business up front party in the back. That doesn't apply to this. This episode of The Juicebox Podcast is sponsored by the Contour Next One blood glucose meter and touched by type one. It's also sponsored by Omni pod and Dexcom. Everyone's got a blood glucose meter. And since you have to have one, you should probably have a great one. And you will, if you go to Contour Next one.com and find out more. The Contour Next One meter is multifaceted just like this episode. And not just because it can speak to a contour app on your phone, iPhone or Android By the way, and help you make sense of the data that's coming back from your meter. But because it's easy to use, easy to handle has a terrific test strip that will allow Second Chance testing like if you touch the blood, don't get it right, you can go back in without wasting a test trip. But the accuracy of this thing is just otherworldly. Arden has been using it for well over a year now. maybe longer, and it's absolutely the best meter she's ever had. As far as accuracy goes, and portability. I just love it. Anyway, if you go to Contour Next one.com there's a button at the top where you can find out if you're eligible to get the meter for free. And if you're not, you can still have your doctor write your script for it or pick it up at a anywhere Honestly, I guess pharmacy once people are allowed to go to pharmacies again. Anyway, this meter is worth looking into Contour Next one.com. After that, please check out touched by type one.org. The people that touched by type one are dedicated to helping those living with Type One Diabetes to excel. And they have a dance program for children actually have a dance studio, you got to go check it out touched by type one.org. If you're interested in finding out more about the Dexcom g six continuous glucose monitor, you're going to want to go to dexcom.com forward slash juice box. And to get a free no obligation demo of the Omni pod tubeless insulin pump sent directly to your home. My Omni pod comm forward slash juice box there are links to all the advertisers in your show notes. And they're also available at Juicebox podcast.com.

Not gonna argue with you You went to Princeton? Is that a burden, but by the way we're recording? And by the way, is that a burden?

David Walton 3:52
No, it's not a burden.

Scott Benner 3:55
But does everybody say it to you at some point?

David Walton 3:58
I definitely get it once in a while. You know, interestingly, I have a I have a twin brother and he went to a good school Gettysburg College. But every time I would go visit him there. It would just be nonstop comments from his friends about you know, why didn't he go to Princeton and you know, various jokes and things like that and but I you know, once I acted stupid and silly, he they realized I was just like, everyone took care of that. Hey,

Scott Benner 4:26
you know, you might be the first person I say this to who genuinely understands what I'm saying. My son goes to Dickinson.

David Walton 4:33
Oh, really? Yeah. Yeah, I have a friend whose daughter plays basketball there.

Scott Benner 4:38
Oh, no kidding. Yeah, I am probably a 10 minute ride from Princeton University. So, you and I overlap a little bit but that's gonna be where that ends educationally. Because my son's the bright one, not me. And I think our our overlap around education will probably end right around there.

David Walton 4:56
I actually live about 25 minutes from print. In right now, I'm in Pennsylvania.

Scott Benner 5:02
Oh, no kidding. I grew up in Bucks County.

David Walton 5:05
In bucks. Yeah. Yeah, yeah, I'm in New Town.

Scott Benner 5:08
Oh, okay. Oh, so let's start over. I was born in New Town. My parents moved into lower Southampton, we lived there for quite some time. My wife got a job in Manhattan soon after we got married, put us into the Princeton area just to be near the train. And we've kind of kind of stayed since then. But not right. in Princeton. If you don't mind walking over some water, you've walked over before, how old were you when you were diagnosed?

David Walton 5:39
I was older. I was 24 years old. I had, I was in business school at Penn. And notice the symptoms that ironically, I knew about because I had, in my very first job at a college, I worked in a consulting company that did work for pharmaceutical companies and the diabetes, the dcct, the diabetes control and complications trial had just findings have just been released. And everybody was talking about, oh, we need to do tighter glycemic control. And one of these pharmaceutical companies hired us to help them come up with a program. And we essentially designed like a

kind of a

patient compliance program, it was discovered a reward system for people if they did the things that were beneficial, like testing your blood sugar, and exercise and so forth that it was for type one and type two, okay, this program, but that they would get points and we developed like a point system and worked with lifescan, who had the blood glucose monitoring, they were one of the partners, we were talking to gyms, etc. So anyway, I did market research and heard from doctors talking about both type one and type two and the symptoms for newly diagnosed. And so I learned a little bit about it. And then fast forward. Two years from then, you know, I'm in, I come back for the second semester, my first year, and I'm going to the bathroom more frequently, I can't quench my thirst, I started losing some weight. And I just started dating my now wife, like a week prior. And I'm telling her that this isn't normal. This isn't how I normally AM. And ironically, she had worked for Eli Lilly as a sales rep and a managed care rep and sold insulin. So she knew a bit about it. And she didn't come out and say it sounded like it. But I asked some doctors who are also in this Healthcare Management MBA program about the symptoms. And I said, it sounds like type one, doesn't it? They said no, you're too old for type one. And you're not really a candidate for type two. So then my vision got blurry. And I went into the student center that day, and read off the symptoms to them. And they kind of looked at me and said, well, let's just test your, your blood sugar. We sure and then I was put in the hospital for a couple days. And you know, off we go. There was no family history. Although subsequently, I have a my sister son, at three years old was diagnosed with type one that more recently that that was more recently and

fortunately, my twin brother and I are adopted.

But we met our biological family when we were 18. So we were adopted at birth. Our parents were teenagers, biological parents. They ended up getting married and then had a son and daughter that our full fledged, you know biological brother and sister. And it's my biological sister whose son got developed type one. So I think we have that that genetic predisposition runs

Scott Benner 9:03
through there. You've brought a lot of things up I have to ask you about so a and this is just gonna be odd. I'm adopted. B are your biological brothers and sisters. I don't know how to say this. Maybe you're not going to answer I did. They go to great schools to

David Walton 9:21
my twin brother biological and grew up with me, Brad. So he went to Gettysburg. My both my brother and sister went to Florida State. They grew up in Tallahassee, and my sister still lives in Tallahassee. My my younger brother, ironically moved up to Boston. And so he and his wife and his two kids, they they live now out west work again to end exchanges up in Boston. So I go up to Boston almost every week for a few days. And every once in a while I get to see him because he's out in the suburbs. But there's no other family history there had there was none private My diagnosis, right? And since my diagnosis, just my my nephew again at age three. Yeah. So I joke if you add us together our ages, you're pretty close to the median age of diagnosis for type one. But I was a little bit older and he was a little on the younger side. And I know you've you've got experience with a young young child. I really do.

Scott Benner 10:24
Let me ask you one thing real quick before we move forward if you're on an Apple Computer, right?

David Walton 10:29
Yeah, I turn notifications off on Outlook, but I guess my yahoo email, don't worry,

Scott Benner 10:34
I know what to do. You're in luck, the apple in the top left corner System Preferences, System Preferences. Okay. The speaker that says sound. And then under the sound effects, tab, alert volume play sound effects through drag the alert volume all the way to the left. But leave it open. So you remember to drag it back to the right when you're done.

David Walton 10:59
You're saying on the output volume?

Scott Benner 11:02
Sound Effects? Not output. So there's sound effects out?

David Walton 11:06
Yeah, I'm on sound.

Scott Benner 11:09
No sound effects sound effects at the top. Yep. And then alert volume. There's a slider bar you run all the way. And then that one,

David Walton 11:16
I'll just keep it off. I don't need to be alerted.

Scott Benner 11:19
Like, wow, I wish I would have known that years ago.

David Walton 11:23
I thought I saw this with turning I look off that.

But I my Yahoo emails. Okay, now that email

Scott Benner 11:28
really wants you to know that you're there. While we're taking a break, I'm gonna have my daughter bolus something she's downstairs

Unknown Speaker 11:39
for school.

Scott Benner 11:42
There. Okay, cool. Well, that's interesting, has nothing to do with what you're on. But it is really incredibly interesting. And I just picture you in, you know, in business school trying to impress a new girl and you're just running to the bathroom constantly. That must have been a that must have been a big a big rock the drag up the hill, like I'm cool. I swear I am I gotta pee again. I'll be right back.

David Walton 12:02
Yeah, yeah, no, I don't normally go 20 times a day. This I'm telling you, this is an aberration, I swear. But thankfully, again, we were in a health care program. And I'm I was, you know, as casual as you could be about, you know, it happening in the diagnosis after I mean, I didn't freak out. I kind of tried to attack it rationally. But I, I was pretty fortunate that I had a little background and I was older. And you know, I was a college wrestler. So you know, I was thinking, wow, what if this had happened earlier, like it would have totally changed probably what I did or how I did it. But ironically, in the in the Penn hospital, I received a call the first day from a woman who I dated prior to dating my now wife. And she said, Hey, I just wanted to let you know, I heard about the diabetes. And if you ever want to talk to someone about it, you know, you can always call me I know what it's like to live with it. I said, What are you talking about? I've never saw you check your blood sugar or given injection, you have type one? And she said, Yeah, I'm pretty private about it. So often would go to the bathroom. And that's where she tested and, you know, right from the get go I it kind of gave me an appreciation for the fact that there's a spectrum of how people kind of deal manage their diabetes, how they think about it. I was diagnosed in a very kind of,

Unknown Speaker 13:35
let's say,

David Walton 13:37
out front manner, people people knew, like, why is Dave in the hospital here? So and I was older, and it was just a different thing versus you know, if someone's a teenager or someone's younger, you also

Scott Benner 13:49
you also did like a group thing. thing to figure out if you had it, you were talking to people and ask

David Walton 13:54
people they could and they knew about it, and there were physicians that kind of thought but maybe not and then just in general I that's often you know, I that's often the way I you know, think through things that I don't know, it's like, let me talk to other people who may know information that will be helpful.

Scott Benner 14:10
Yeah, well, that's a smart way to figure anything out. I'm now fascinated that you dated a person who had type one and you didn't know it, how long were you together?

David Walton 14:19
Less than two months? Okay, like

Unknown Speaker 14:21
totally

David Walton 14:22
as you're as you're being interrogated in the hospital and I think I was I had every resident intern med student, you know, come through because it's an academic, you know, Medical Center teaching hospital. I got asked the same question you know, any relatives this out of the other? I had several people asked me to knowledge Have you been exposed to a virus in the past six months, and I said, I don't really have a virus meter. I don't I don't know if I if I have been or not, but there was one incident with Taco Bell where I was violent. sick with a stomach virus that happened a few months ago that I guess it's, it's possible. I was just attributing it to bad a bad burrito, but perhaps that was a stomach virus. But then I said, Well, is it possible that this this woman I dated, had a virus and I caught it, I had the same reaction she did, like, Oh, that's crazy. You can't catch diabetes, right? Like, well, I'm not necessarily saying I can catch diabetes, I'm saying, could I catch a virus and we both had a reaction to a virus that was, you know, this autoimmune thing. And they, they kind of treated me like I was the dumbest idea they'd ever heard. And granted, it could have had nothing to do with it. But there weren't a lot of other great theories they were proposing. So I just figured I'd throw that out. I want

Scott Benner 15:45
to tell them I went to Princeton. So David, you're it's only April. But if we give an award this year, for the most organic and natural segue, you're going to win. Just so you know. What? Okay, yeah. Why don't we tell people a little bit about what the T one D exchange is doing? By the way? I don't know. Did we even say that you're the CEO of T one, the exchange, it's not important. It'll be in the title. Anyway, you are? And what are you guys doing right now? based around COVID-19? Sure.

David Walton 16:18
So first of all, it is a very, very high level, we do a lot of kind of what we call real world evidence, doing research and gathering data from things like electronic medical records, for people with type one diabetes. And the goal is to help improve care to work collaboratively with hcps, and researchers on that. So we have diabetes centers across the country that participate. Yeah, through that effort, this quality improvement collaborative we have with different centers, this topic came up regarding COVID, from some of the researchers to our team, that, you know, there's just not a lot known out there, you know, people are, you know, the early information that was coming in, you know, a couple months ago, was, oh, diabetes as a risk factor people, people with diabetes are getting COVID-19. And, as, you know, some of these researchers were looking into what data was really available about type one versus just type two, or overall, just having a diabetes diagnosis, there really wasn't much known. And a couple of things came from China and Italy that we saw that suggested it type one was not a risk factor in and of itself. But that later, we, you know, it seems some indications that poor blood sugar management are probably more indicative of or have more of a causal role in getting infected or having a severe reaction to the infection. So we said, well, we are set up to gather information from different centers on, we're not going to be able to do this automatic kind of poll of data from the electronic medical records of different hospitals. What if we set up a different system to gather data on this from like a survey Type Tool and have a point person at each one of these centers? Just document the cases of COVID that have come in? and answered about we have about 30 questions in the survey, that will give us some idea about the symptoms they had about what their blood sugar control had been previously. What type were they using an insulin pump or CGM? If they were using a BGM? How often were they testing? what medications were they on? and gathering this information? We, you know, had a few goals of trying to characterize does it appear people are being diagnosed in any different rate than either people with type two diabetes or just in the general population? If they are when they are being diagnosed? What is it? How is it presenting? Is there any pattern to the symptoms? And how is it progressing our people? What type of outcomes are they having? It is our are there more instances of DK for these, these people. And so the goal was let's get as many centers as possible. We started with the ones that we work with, which was a about 15. But quickly, other centers were interested and we were started talking to people at other diabetes centers and we saw what was going through on Ada websites and newsletters and things. So we've gotten it up now to about 65 centers. Wow. And and the goal is to get up to 150 to 200 cases documented so that we'll have some ability to draw some insights and conclusions that we can disseminate out spread to the to the medical community and to the patient community, about you know, understanding it better Who knows what some of it is going to be? Interesting, what do we find, and then others we might try to, you know, confirm some of the thinking that we do have, which is that just having a type one diagnosis is not, does not put you at higher risk for getting a covid infection,

Scott Benner 20:19
have to tell you, I'm thrilled to hear that because a friend of mine, who is a physician, by the way, went to Penn, really you and I might be friends, we don't know it. And he's been on a couple of times, through the first six weeks of you know, Cronin, we talked very much at the beginning. And then about three weeks later, and he'll come back on again, as things continue to morph and change. But that really was the consensus, you know, that the best defense for a type one against you know, COVID-19 is being healthy, as healthy as you can be. And in all the ways that that means. And that, you know, he couldn't, you know, early on, figure out how someone with Type One Diabetes, just just by virtue of having Type One Diabetes would be more susceptible to it. Anyway, so since you said that it makes me feel comfortable that about what we talked about?

David Walton 21:13
Yeah, yeah, absolutely. And there are some, you know, some other I've heard Dr. Peters talk, and Dr. Mark Clements, who's at a children's hospital in Kansas City and involved with us. And they've essentially said, that's what the research at this point indicates. Right. And again, it is possible that as you get more information, maybe we will learn something about a certain segment or slice. Sure, you know, we're gathering some other information that could characterize this, but from all the, you know, what we've seen so far, and we're still early, we haven't, you know, analyzed all that, you know, we have about 60 cases documented in the system, by clinicians, but we haven't analyzed all that yet. We just started to do the first 25. And there's a manuscript being written as we speak, because, again, some of its doing the work and some of its getting it out there, yes, and helping to disseminate it and provide it so that other people that are looking for it, you know, have access to that knowledge. And a lot of I've had a lot of parents that I'm in touch with just in the community where I live, who know that I work in the arena. I've reached out to some proactively and a couple of others had, I had some inbound questions, you're wondering, you know what the situation is. And that's basically what I've, I've told them, it's like, we'll learn more. But at this point, we don't believe there's a high risk, but the best, the best thing to do is to keep your blood sugar. And it's tightly controlled as possible, because we know infections, like sugar, right? And if you keep your blood sugar controlled, and to the lower side, it likely will will help about a medical provider. So no, but

Scott Benner 22:56
I have some questions that I don't know if you can tell me from what you've learned so far, maybe you haven't. But first thing is about 60 people from about that many locations was where their hot zones are, was it fairly well spread across the 60?

David Walton 23:11
Yeah, so you know, there's a bit of when you look at the the data coming in, we still have some places with a lot of cases in New York as an example that haven't pulled there. They joined later to the effort. So they're just going through their administrative process, that they're that they're center before they submit the cases, but that should be coming within a week or two. Within two weeks, we should have 100 cases, I believe. We know that there's one one hospital in New York, you know, said that they have about 15 cases. Mount Sinai. Mm hmm. But we haven't seen that yet. That was very got that that. But but they're looking to to put that in, but someone had done someone had quickly looked to see through their systems. And so they haven't entered that in but they told us that they think they have 15 cases. Another another one? I believe NYU said they may have eight cases, or there's some

Scott Benner 24:08
hospitals that are on your list that have not reported back at type on case.

David Walton 24:14
Yes, there are some that said we went through and we had no cases. Gotcha. So yeah, so that's what we need to get more of the information. We can draw conclusions about prevalence from what the numbers that we have, but it is interesting we've seen and our centers may have 1000 type one people in that come to their center routinely. So some of them are decent size, we even have some that are bigger than that, that are 2000 or one that's 5000. So we expect to see some cases just if you think about general population and whatnot, you know, one in 200 people has type one diabetes in the us so

Scott Benner 24:55
well, you know what I find doing the podcast and maybe you know a lot of people with type one as well. I see, there's two, you know, listen, everything's not black and white, but you meet people with diabetes who are either very just micro about it, they're very on top of it, they're a onesies are in the fives. If they get into the sixes, they're, you know, they feel like they've done something extraordinarily wrong, which of course, it's a little silly, but that's what they're that's what they're thinking. They're always well within control. And then you'll see other people who, you know, just having this conversation with someone last night, who asked me, could you interview more people who don't have technology, but who are doing well? And I said, Well, that's, you know, subjective, like what is? Well, first of all, and so the person said, you know, I'm looking for somebody, you know, like you who, you know, whose daughter has a one C and the fives very consistently, I wanted to hear from someone who doesn't have a CGM, you know, doesn't have a pump and is doing that too. And I said, Well, I, you know, I can try to find someone like that. I said, but you'll never know if they're achieving that a one see through protracted lows, you know, they don't have that data. And also, when I've interviewed a lot of people who don't have, you know, any kind of technology that's moment to moment, and I asked, How are you doing, they always say, Oh, I'm doing great. But then they'll very frequently Tell me about an agency that's in the high sevens or in the low eights. And then I realized that their threshold for what great means, you know, is subjective. And for them, I don't pass out during the day and I'm not dead. My doctor says I'm okay. So I'm great. And and it's, you know, there's, there's an interesting swing between, you know, how people manage, and I'm not saying one's better than the other. I'm saying that all those people exist, and then they end up in the hospital. It's funny, because I think that people who are in tighter control lose some of their control in the hospital. And I think people who are in looser control probably gain better control in the hospital. And I'm wondering if there's, if that's being tracked, as you said, we know what were your blood sugar's like prior to being in the hospital? And gap? Do you know what I'm getting at?

David Walton 27:03
Yeah, now a couple of interesting points that you brought up that I could maybe expand on, please. Because here we are, we are collecting the most recent a one see the date and what that was prior to them coming in. So that will give us an indication of where their blood sugar has been, and what their control has been. So that that is part of what we endeavor to look at. You know, we'll get something around that if that, that that role that you mentioned, you know, in terms of the technology, it's, it's funny, I, you know, I came along this, this trajectory, like anyone else, I mean, I feel like I was in a healthcare MBA program. I was very educated.

And I had very good insurance.

I worked at j&j for 11 years. And yet, in my early part of j&j in the early 2000s, my blood sugar control was not that good. And I was only testing with a blood glucose meter, one and a half times a day. I would test every morning, and then either at lunch or dinner, and it was almost, yeah, I've never had an endo say anything different. My Awan sees would go between mid sevens to low eights. But I never broke seven. And, you know, I had moved in a new job, new house, kid, you know, you're busy with life, I was just doing injections and using a blood glucose meter. You know, I decided I'd learned a little more. And I'm like, I really should be doing a little better. My Yo, my endo might say you should test more. But they never said my ANC was a problem was a problem or that I could be doing better. Yeah. It kind of suggested if you tested more, it'll be easier to to stay in tighter control, which is absolutely true. All the data shows that but i was i was a little lackadaisical about it, then that I you know, I decided I want to go on a pump and see because I had a friend who was on a pump. And, and her ex husband worked for a pump company. So I got on the pump. And I saw a little bit of improvement. still didn't break seven on day one. See. Then I joined an insulin pump company in 2006. Right. I was at j&j, they acquired animals. So I went over, and I had to, I was leading strategic marketing, which was looking at new products and what was going on with competitors and all the emerging technology and clinical data. It was a great, very interesting job. And I I, to orient myself, I read through some presentations on advanced pumping by john Walsh on San Diego. And it was a great PowerPoint that went through all the ins and outs of using it and but through that I realized, wait a minute, they have these formulas for how you dose insulin based on your weight and your total daily dose and these rules of 1800 and 500 You divide your total daily dose into those numbers to get your correction factor and your carb, insulin to carb. And I realized mine were seemed really out of whack. I was taking one unit of insulin for 25 milligrams per deciliter to correct and I was taking one unit of insulin for 15 grams of carbs. That's what the educators put me on when I was diagnosed. Nobody ever looked at that no one ever suggested that might not be optimal. What have you, yeah, I start reading this presentation and realize that those numbers don't seem to fit with the way Big Data Analysis would ever suggest, or these formulas and clinical studies that were out there with suggest would be in a kind of a stable adult kind of ratio of those factors. So I just changed them on the fly. I looked at my total daily dose, which is like 53 units of insulin that was in my pump. And I divided it in I just instantly changed my my correction factor to one to 35, I think and my insulin, the carb to one to 10. And next day, when c 6.8. First time I cracked said, Yeah, so I didn't need necessarily the pump to deliver the insulin, but the pump tracked my total daily dose for me accurately. And all I had to do was go through the little cap the history in the pump, and I was able to calculate it. Yeah. And that little formula that had been derived from some people, I think, down in Atlanta, and but it was all over the education and diabetes sources. So for 10 years, I was on the wrong dosing. And it's easier to find issues like that if you're using technology and you're collecting data and then even have have, you know, analytics run without you having to do it, like download reporting now and tools that are out there will do this automatically. But I had a you know, I saw great endos one worked at Stanford, one worked at Novo Nordisk that they didn't. I had no hypose to speak of. So they weren't really acutely concerned about anything, and they wouldn't see a 7.6 for someone with no lows and seems to be doing okay, he's busy. That wasn't, you know, they've got other more problematic situations to deal with. But yeah, that wasn't hitting the target. And I had every other thing at my disposal, great insurance, j&j covered all of our supplies for diabetes. So I, I had no excuse. Once I got in better control. I'm like, Wow, it was positive, that positive reinforcement of, well, now I'm taking the right amount of insulin. And, you know, and I was frustrated, it wasn't brought up sooner. But I was pleased that I finally figured out one of the things that was frustrating me, yeah,

Scott Benner 32:35
no, I'm glad. I'm glad you had that feeling. And you didn't just you weren't angry about it. Because I've I've met people who are so angry after they find out that it's hard for them to get past. You know, I've lived my whole life like this, you know. And I heard, I heard a podcast and my agency went from, you know, 8.9 to 6.9. In three months, how could nobody have told me that? It's sometimes it's hard to get past? Yeah,

David Walton 32:59
no, absolutely. And I also benefited from being around a lot of people with type one, I picked up some tips that after that, so then it was like sustaining that my agencies just got a little bit better. And then we're consistently at those, you know, positive levels. And because of that, that education, and then the technology, and then certainly CGM coming out. And I think I first tried it 2007. And it didn't work very well. It was the first gen of Dexcom. But then 2008 when I tried the next one, this the seven Yep. And that that worked better still had some issues. But you know, wow, the insight of seeing how you spike after breakfast, and you know, all the all the various things that come with CGM. One last point on what you just talked about the hospital though, cuz I think that's a very interesting point that it should be pointed out from some of the data that's coming out. And there was a study done by glide tech on just anybody with diabetes, or any high blood sugar they saw in the hospital, a pure hospital study, that it's clear if you manage blood sugar, and if the healthcare team manages blood sugar, more tightly in the hospital, people do better. In a lot of scenarios, after surgery, getting out sooner, and if they're dying, they have diabetes, and and, you know, they were in for some other condition. If you keep their blood sugar and control, they have better outcomes with that other scenario. That's not what's happening right now. Because of COVID. There are healthcare teams that understandably, are trying to minimize contact with patient and blood sampling and they're busy and, you know, being tapped, you know, the bandwidth is being challenged. Yeah. And what that this One study showed is that, you know, David Kahn off was the author that that People aren't doing as well, there, there are a lot of people. And again, this was a lot of type two diabetes. But you know, we're certainly interested in the type one angle, and we are going to be looking at that potentially with with them. And this is data that comes in from all these 300 hospitals that that they work with. And it's, it's fair to say that there are people that get frustrated when they go to the hospital, if they've been managing their diabetes, well type one. And then they're told they can't use their pump, you know, they can't be doing it themselves. And I know the number of hot there are hospitals that will defer to the patient preference, if they've been self managing all this time. And if what they're in for the hospital for is such that they can be lucid and clear their decision making, then let them keep doing it because they have been doing a great job of 24. Seven outside. So why are we going to change that because we're a healthcare team that doesn't know their body as well as they do and so forth. But that's a, you know, if you can see, it's a challenging problem to know, what's that threshold for a hospital say, No, we've got protocols for our quality, and we don't want to get sued. If something happens, we have to follow certain rules. And, you know, there's it, I can understand both sides of that equation. But clearly, I know people that have gone in to the hospital and said, I'm keeping my pump, you're gonna have to rip it off me, I do a good job with this. I don't want this being mismanaged. And I your point. Some people might be a little over the top with that, but you understand where they're coming from, because you know, they're a little anxious about what's going on. And they know they can do it. But if they pass out, or if they're given, you know, medications that change their thinking that, you know, you've you've got concerns there on the other side. So

Scott Benner 36:50
yeah, we we do a, we do a series inside the podcast called diabetes pro tip. And I do it with Jenny Smith, who works at integrated diabetes. She says, Oh, yeah, she has a CD, she's had type one for over 30 years. And there's, I don't even know, at this point, there's probably like, 20 episodes of it. But we very recently went over emergency room protocols, and how to handle yourself during an illness and injury or surgery. Because it's just so it just it, it's not something that would occur to you, you get into a hospital in a position of thinking, well, these people know better than I do. And you just kind of hand yourself over to it. And it's very infrequently with diabetes, the case, you're often you know, the best arbiter of what's going on. And so I think that's, I think that's incredibly important. Also, I want you to know that when you reached for the word lucid, and I did it exactly the same time, it made me feel like I should have tried harder in school.

David Walton 37:48
One thing my mom, who I grew up with, right, as I mentioned, I was adopted, she was a voracious reader, and a stickler for grammar and vocabulary, right. And just because she read so much the words that she would use around the house, some of it I just picked up, because I didn't like to read that much. Certainly, I, like twin brother, and I played sports constantly, in a way with typical boys. And sitting down and reading was sometimes you know, like, just couldn't be done. But I read in school, certainly, and all that, but she's responsible in part for sometimes I would, you know, use use the dsat words, and then I did some sap tutoring after college, on the side, right, make much more money. And I had to learn extra vocabulary so that I could make sure I knew what I was talking about when I tutored some of these kids when vocabulary was a bigger deal on the LSAT. So yeah, it's it's purely there. The circumstances that exist sometimes explain, you know, explain things more than any other, you know, innate as my grasp of vocabulary is probably the same as anyone else.

Scott Benner 38:59
I got my vocabulary from Howard Stern. So

David Walton 39:01
I got into the radio interviewing

Scott Benner 39:06
podcast, there are times when I think I'm probably only halfway good at this, because of how much of that show I've listened to. There's just a, I have a timer in my head. And when my timer gets bored, I just, I move it along. And I think that's a helpful thing. Okay, so interesting. I want to kind of just hit one thing, and then I want to ask some more questions. But, you know, I don't know that people think about it, because you get diagnosed, and then you're sort of frozen in that time period, right? That happened to you, you were diagnosed, this was the level of care and then that just became what was and as the world moves forward around you, your care doesn't always move forward with you. And that makes sense. If you're with the same doctor for too long or you're not around other people with type one and you don't say to yourself, like how come that guy gives himself insulin before we go to the cafeteria and I'm doing it after I eat, you know, like, like those small idea. And we also all sort of sit back, traditionally, and we wait for the a DA to tell us what our agency should be. Right? That happens historically, over time. The a DA says, this is your goal. And then technology gets a little better than the a DA says, you know, we've done some research. And the problem is, is the research started 10 years ago. And now they're rolling up in 2020. And telling you, here's what you're able to see should be. But you know, I did some research to it was called, I took care of my daughter and figured out how to use insulin, it turns out, you can keep your Ebensee lower, if you have a handful of, you know, tricks in the bag that you can, that you can use for the lack of a better term. I call them tools on the podcast, usually, but they're just simple ideas around using insulin to keep your blood sugar in a more stable and lower place. And so I understand completely the need for the diligence, you know, looking at that over time to come to a conclusion and tell somebody something, don't get me wrong. I'm not, you know, I shouldn't be listened to like the a DA should be their, their their information is vetted. But that vetting process takes time where my vetting process is faster, right. It's it's Yes, anecdotal at first, but then eventually, it's experiential, and then it then it's provable. And I'm a firm believer that I think it's nice when people in the diabetes community say things like, you know, your diabetes may vary. And, you know, your, your experiences with diabetes may vary. I don't argue with that. But the way insulin works, that doesn't really vary. That's pretty scientific, you know. And so the way you use it, or what you eat, or your activity level, or all number of other variables, variables could be different. But at its core, and I say it constantly, I don't think I'll ever stop saying it. type one. diabetes management is about using the right amount of insulin at the right time.

David Walton 41:49
Absolutely. Like I couldn't I couldn't agree more. I the, and again, I worked at an insulin delivery company, animus I mean, what was the point of wearing this, this pump 24. Seven, it's to give the insulin in a better way. Because if you give insulin and and the optimal fashion, you will have great results. It's just very hard to do. But if you pick up all of these, all of these little tips that you're in scenarios about the you know, the first thing people discovered was CGM. I heard Dr. Bruce Buckingham mentioned this, it's Stanford a lot was

Oh, if you

once you put CGM on someone, the first thing they realize is how much that oatmeal causes them to spike. And they don't, their blood sugar's high for three hours afterwards. So people start switching the bacon and eggs, you know, like the carbs in the morning when you're insulin resistant. That that that hyperglycemia contributes, you know, a decent amount to people's kind of above target glucose throughout the day. That dosing formulas that I mentioned, I mean, those Yeah, not everybody is going to fall, right, exactly the formula, it just so happens, I do. I'm like, literally, it worked out. Right on those that it just it fits and my weight, you know, the amount of insulin I use a day is almost exactly half of my weight in kilograms, which is what one and Joe had mentioned to me that that's a good rule of thumb. And it turns out, I get pretty good control, you know, in the sixes, mid sixes to high sixes, depending. And now with control IQ that I use, it's, you know, I'm more in the mids. And I'm not having to, you know, I love that, and we can talk about that later. But, but that aspect of the of the dosing. I fall Exactly. on that. And so I know there are people that have that don't fall right on that, you know, and that average comes from, you know, distribution, a number of people, but when you're way off of that average for no good reason. Or you're doing a number of things like it certainly should give someone pause to think maybe there are some things that aren't tailored to me that maybe I do need more Now, a lot of people don't take enough bazel insulin and so they're putting a lot of insulin to correct for these excursions they have these highs that because, you know, if you're if you're not taking a bazel it's like you've already kind of lost the battle so hard to recover, to, you know, given how long it takes insulin to work. So,

Scott Benner 44:24
David, you would like this podcast?

David Walton 44:26
Yeah, I definitely agree. But one thing I do want to say about who can who's able to figure that out on their own? You know, there is this, it's no

Unknown Speaker 44:34
one

Scott Benner 44:34
it's because the life man because you're busy living here's how I was able to figure it out, right? I don't have type one. It's for my daughter. And because it's for her I feel an incredible responsibility. Right. And I was and continue to be to some degree, a stay at home dad while she was diagnosed, so I had nothing to do but stare at her and and figure it out and and and go through the the Real defeating moments and realize, like, I can't let this be her life, like, I have to figure this out. Like, it must be doable. Some people are doing it, but nobody could explain it. You know, on a side, I got a note yesterday from someone that said, hey, there's someone with an Instagram account ripping off your ideas for the podcast, but trying to put it in their own words. And it's, it's funny. And so I went and looked, and sure enough, there, it's ripped right out of the podcast, and that's fine, you know, whatever. But my point is, is that they said it in their words, and it doesn't work that way. And so there's something about my specific experience and who I am and how I communicate with people. I'm telling you, those those pro tips, it, you know, the other day, I put a website up for, because people were asking, so I made diabetes, pro tip calm, just so people wouldn't have to, you know, go through the entire podcast podcasts if they were just looking for management, because it's interesting. Some people are very interested in community. And some people are very interested in management, the community, you know, just regular interviews with people with type one, and not even like hooked in people, like, people you don't know, they don't have a podcast, they're not online. They're just people with type one, I try really hard to keep those interviews to people like that, right? Those are the most popular podcast episodes. But the people who care about management are fervent about the management. It's It's interesting how some people want the community and some people want the management. But anyway, I put up this thing just yesterday, I said, hey, I've got this diabetes, pro tip calm now. Here's the link, if you could help me in the comments below, just if the podcast has been valuable to you, could you share here, and you know, so people who are coming on new kid could you know, figure out what to expect. And I didn't even believe some of this, this, there's I'm just looking now, my four year olds, a one C is down from 97259. From the diabetes protests, my husband's is down to five, six. And it just it goes on and on. It's it's fascinating. And so I'm proud that I found a way to talk to people about it, because once I could do it, I thought, well, now how do I replicate it for everyone? You know, like, how do I make it as mass market appeal as possible, the idea of, you know, how we manage, and I just broke it down and kept breaking it down and distilling it until it's just the simplest ideas. So that while you're busy living your life, and you know, you're worried about getting COVID-19 and whether or not you can afford your groceries and how you're going to do it your job. And you know, all the other things that people worry about when they start noticing a trend up in their blood sugar that they don't have to go back to a book or go to a doctor's visit, like what what one sentence, can you kind of say to yourself, that'll bring it back for you. And I tried to do that with all the tools. And I think I have. And and, and it's interesting when I used to wonder out loud, like, why can't doctors do that. But now I realized that my whole life's been about communicating with people. That's not what a doctor's life is about. Like, they know the idea, and some of them are terrific at it, don't get me wrong, but a lot of them aren't. And, you know, like, you know, or a lot of them are just like, oh, David's fine, he doesn't pass out. Because they once he's not too high. There's bigger problems here in the practice. So

David Walton 48:26
I'll go I think on the adult side, you know, you find this more, I mean, think about, you know, an adult endocrinologist. How many people with type two is he seeing and, you know, in general, people with type two diabetes are not as engaged and don't spend as much of their mindshare on their diabetes as those with type one do right. Now, it's obvious with kids, I mean, usually people don't have another condition. If they do, it might be asthma, or it might be something else. But diabetes, and with their parents also there, the amount of collective, you know, mindshare, that's focused on that and the importance of that and so forth. Different so you can imagine these endocrinologist who are just beating their head against the wall because they've got type two diabetes patients with multiple chronic diseases, they're not taking their insulin for getting to take their insulin, they're not taking enough insulin, their numbers aren't getting any better. And then if they're worried about a low because of it, I, my endocrinologist mentioned this to me that, you know, when he's had low blood sugars, and some of his older patients, it's when he has their adult child, ensure that they take their insulin every night. And then they get a low because he's been adjusting their insulin up based on the based on that hazard way they use it the way they use it. And so that's part of their skittishness or like, because they don't want to, you know, do no harm they're afraid to, yeah, give them something where an older person who's not used to hypo, that's the thing that happens with tattoos. That they have many more cardiovascular issues. Heart attacks occur when they're not accustomed to having a low blood sugar, and they end up having it at, you know, when they're 65 to 75 years old, it can be, that can be very dangerous. So having spent some time also in the type two space and looking at smart insulin pen caps to try and track that data, so we could try to attack that problem. It's a huge problem. And it's, it's overwhelming, and certainly for primary care, that's taking care of those. Yeah. You know, it certainly can be that well, the percentages,

Scott Benner 50:32
I see them here, because there's, there is no more popular type one podcast than this one. And I know how many people listen to it, versus how many people have type one diabetes. And the percentage of people who, you know, are looking for this kind of information is still small compared to how many people have diabetes, there's, there's far more people who fall through cracks, for you know, the reasons you mentioned, and many, many more than then who are going to have the wherewithal and the and the drive to figure the rest of it out?

David Walton 51:04
Yeah. Well, you know, interestingly, throughout, you know, I've worked in health care for 25 years. And before I was in the diabetes field, you know, I was a consultant, working with health plans, and with pharmaceutical companies. And I remember looking at a segmentation, consumer segmentation, and what are the different kinds of types of behaviors and a couple of these different analyses show that there's like this 15 to 20% of the population, that are the proactive segment, they're the ones that are going to go research, they're going to go take control of things. And if you ask them, How do you approach care? Do you? Do you research it and then go ask your doctor? Or do you wait for your doctor to tell you because they're the trusted health care professional, or somewhere in between. And when you look at that, it's, you know, 20%, maybe 25, depending, are in that proactive kind of thing. And I saw it in oncology, they saw another company had done this, and the people who are the passengers and people who are the drivers, and then people that are, you know, something else. And that unfortunately, like a lot of the digital health tools, and a lot of things they get built, get built for the proactive segment. But we only address that only that kind of population takes full advantage, it's very hard to get to some of the other people, or you have to do more to, to, you know, bring them along that journey to educate them, you know, etc. And this, this is one of the the challenges in healthcare across a number of different conditions. But Type One Diabetes is certainly in that, you know, in that same in that same vein, yeah, that there, you know, you can go online and look at influencers and so forth, and you see certain profile of people, and they're, they're the ones that are have this, they want to share with what they know, because they've seen it work. And they're like, why aren't more people doing this, right. But there are a lot of other people just living their life who don't aren't connected to people, they don't know about things. So awareness is some of these things. You know, it's tough, like I've been at dinner tables at a restaurant. And I'm adjusting my pomp and telling someone where my friends about it, like they're asking what I'm doing. And the table next to me, a woman leans over and says, I'm sorry to butt in, but my boyfriend has type one, and he just doesn't want to listen to me. Could you talk, literally

Scott Benner 53:29
asking me to tell him why you should test more and all this. So I, I understand that and I, I try to massage the situation. I mean, this guy does not want to be told by a stranger what to do in a public place. That's not the way to handle it, but she cares about them. And she and she's frustrated, she can't make an impact and, but people are all over the place. And that's because I did a lot of market research at atomists and surveyed thousands and thousands of people at a time and, um, you know, it's, it gave me a real appreciation for that spectrum, just like when I was diagnosed. And I mentioned, you know, the previous ex ex girlfriend who took a different approach to her Type One Diabetes than I did once I was diagnosed. And that's perfectly fine, that people are different. And you know, the way people these different personality types and so forth. It transcends the Type One Diabetes diagnosis, it's not naturally going to change someone. So understanding that people are different and that different approaches are needed to get people into the education circle. For me, I realized that everyone's life is gonna take a different trajectory, and their level of you know, how much they want to put into their health on many different fronts is is personal. And I'm okay with people making those decisions for themselves, as long as they know what their decisions are, are going to bring, like, as long as they understand, it's okay with me. I don't know if that makes sense or not. But if you want to get your car and drive it into a wall as long as you understand the car is going to you know crushing the law and you're gonna die right on you, you've got free will, you can do whatever you want. You know, and so I just want them to know how insulin works. I think once you understand how insulin works, then the rest of the things that, you know, quote unquote, are happening to you, you can start to see causality for and then you can make your own decision, like, do I want to Pre-Bolus? You know, I think Pre-Bolus thing knocks a point off of a one say,

David Walton 55:24
yeah, it's absolutely. And again, I mentioned that Buckingham comment he made in 2007, at an at a conference, it just struck me, you know, at the time, and if, if you were to think about and we actually came up with a list of these for insulin pumping, when I was at atomists, I remember, you know, this concept of so many people say if they just could share what they know, or they wish they knew this earlier, right. So the idea is, let's get more people to understand these things. And so, the basics of Pre-Bolus, the basics of how much it should be roughly for the carbs are to correct based off your weight. And based off, you know, trial and error sometimes helps you but you have to get that right. If you're if you're you know, and I was I was, again, I was taking too little insulin for what I ate, and then I was taking too much to correct it, I had this little yo yo thing going on. But you know, given that it takes insulin a while to work. And I don't know, four hours is probably an average duration. We know some people go five or six, and some might be within three, three and a half. But that's about as fast as the rapid acting's go. Now you have ultra rap backing, I guess that can be a little faster. A frenzy, you know, inhaled insulin, that could be certainly faster to bring down high spikes, but that gets, you know, that's a that's like the Masters level, like the introductory level, you're talking about. Having just, hey, if you if you did a handful of things, like the Pre-Bolus, that right amount, to avoid Lowe's, you know, you did what's necessary, whether that's if you have a pump, you can do something if you don't, you're on injections, you do something else by eating right. But the timing of your when you take your long acting insulin, and there certainly are better ones now than there used to be. So if they're more forgiving, but they used to be that you needed to get that right, you know, you couldn't miss the time window too much. So that would be a problem. So you go through, it's not a list of 50 things. No, right? Here it

Scott Benner 57:25
is, your Basal has to be right, that's First, if your Basal is wrong, nothing else works. And the things you're seeing are ghosts, because they're not real. And you don't you don't know if that low what that's from, you know, when I do a talk in person. And I explained to people that if they're bazel should be, you know, two units an hour, but it's a unit an hour, then they're a unit deficient every hour, then all of a sudden they come along, see a meal. And I said I always say like, let's say that God himself has come down or herself has come down and told you that this is absolutely 60 carbs, and that your carb ratio is 100%. Right, you can definitely trust that you count the carbs, you put the insulin in your blood sugar shoots up. That's because most of your bolus is really just making up for the job that the bazel was supposed to be doing. When you say something like that to people the look of all on their face is is fascinating. Like, why would no one tell me that? And it's because no one knows how to tell you how to adjust your basal insulin. And so I figured, you know, I figured out a way to talk about that. I was like, look I talked about based on some like volume, I'm like, you turn it up until it's as loud as you as you can stand it. And then if that makes you a little too low, then just turn it down a little bit. If you had a pump David, and your anybody and your basal insulin was wrong, I could spend a half a day with you and fix your basal insulin. Yeah, it's not hard.

David Walton 58:48
I, I absolutely believe that. And we, again, design these download reports for clinicians to download the pumps, and then with CGM data as well. I mean, that's often You're the ones who are really good and used to doing data interpretation to help patients out. That's the first thing. The first thing they look for is, are they having a bunch of they're having lows. If they're not having the lows, then it's let's, let's go. And even if you're having lunch, it could be the bezels wrong. But usually people are under bazel. That's fine. So that's your point. It's the number one thing from a percentage of the time it's wrong. Like that's where you go first. You have to get that right. Because then, like you said, Why worry about your attempts at trying to fix your bolusing and all that the timing and the amount are futile, because you're you've got the wrong background that you can't operate. And so I I totally agree.

Scott Benner 59:41
I practice, not on purpose, but I practice for this podcast by talking to people privately. So try to imagine never meeting someone before having a phone call with them that lasts less than an hour and figuring out their issue and pointing them in the right direction. Not being able to see anything except for what they're telling you. So you have to learn how to ask the right questions. And then you have to learn how like what the path is for them, like, where do they start? And eventually, during that conversation, they'll feel a little emboldened and say, okay, so around my meal, and I always say, No, your meal is all wrong. It's not even work. I know, it's frustrating, but everything you've been staring at trying to figure out around your meal. It's all meaningless data. It's not real, because your bazel so far off, and I said, so you're gonna have to forget everything you've seen before and start over again. It's just, you know, I don't know, man, is it frustrating and not uplifting?

David Walton 1:00:36
What you just mentioned it brings up to two thoughts first, I you know, I just was talking to some people at at t Wendy exchange about this, you know, we have new people come in, I've started giving a diabetes one on one presentation that kind of updated an older one we had and put additional content in there for my experiences in industry and so forth. And

you know, it's it's interesting

Unknown Speaker 1:01:03
that

David Walton 1:01:05
Oh, God, I just lost my train of thought, because someone's banging outside my door. You don't hear the banging. I don't hear the banging. You need to

Scott Benner 1:01:11
get out of the building. First.

David Walton 1:01:13
decks getting prepared. Oh, okay.

Scott Benner 1:01:16
You said you redid the diabetes 101 that you guys had?

David Walton 1:01:20
Yeah. So so we we give that education everybody about? Yeah. So they have some some, you know, baseline understanding about, you know, what's taking place and one of the things we were talking about, and I mentioned was, you know, people counting carbs incorrectly. And Bolus Bolus calculations. So it turns out there are lots of studies that show that people consistently under dose their bolus insulin Yeah. And and the thought and Howard Wolpert when he was a Joslin did a nice study with a 30 gram apple and showed, most people guessed it was 10, or 20, or 15. And that correlated with having a higher agency, and the people that saw it 30 or 35, or 40, which were fewer, their agency was better. And so the idea was, if you're better at carb count, you're more accurate at carb counting, you're going to have a bit it correlated with a better agency, is it? Is it causal? Or is it Who knows? But certainly, it makes logical sense that if you're better at that, but the reason people are consistently under is because they have a fear of hypoglycemia. So are they really? Do they really think it's only 10? Or 20? Or are they nervous about giving too much insulin and getting a low blood sugar. And so we did some research with with a, an insulin maker, about this fear of hypo issue to try to understand some of the aspects of it, and the severity and so forth. And we were going to be doing a broader survey, and there's some things that we're going to be teasing out, but it does, you know, brings up that interesting point about you know, there are there are reasons, sometimes you can think the answer is we just got to hammer people with carb counting, let's give them apps, let's give them flashcards, let's, let's get a picture of the the food they eat and send it to a reference database and tell them what it is, you know, I've seen a couple of these apps that you can scan the photo and or scan the food plate, and it will give a reasonable estimate of the carbs. But it turns out, people may actually have some intuition about what the number is, but they're downvote out adjusting because they're nervous. And so that's the first point. Yep, the second would be the potential and promise of Finally, good closed loop systems, or hybrid closed loop systems in the market. And, and, you know, I'm, I'm a little biased, because I used the tandem with the control IQ. But, you know, this promise that we've been hearing about for at least 15 years since I've been working in the diabetes industry, it's right there talking about closing the loop. And now, some of these issues that do exist, where you can say, Is it an education? You know, can we help people understand this better and train them better on these things? Or can we use technology to handle some of the challenges that just only some people have been able to master themselves? Right? Some people just won't. And there's a spectrum there. And, you know, the power of this with the time and range that, you know, we're seeing with people, and that's the thing I'd point out is my agencies haven't improved that much since going on this, but I have no lows. So you know, I like zero will be my top my time and range will have zero sometimes you'll have 1% I used to be at seven or 8% consistently. And that's that to your point in the beginning about there are some people that keep a when C's down in the fives, but you know, but they've got some real significant blood sugar, low blood sugars at times. I used to have more I never, I've never passed out. I've never had something bad bad but I certainly had a lot more lows and I'd have to, you know, go run, get something to drink and whatnot. That just is much less and that's because of the technology. You know, nighttimes being much better. So that whole issue of what are some of those tips, there are tips that you still would need to do even with these kind of systems. But then there are things like, overnight control can be drastically improved. Because I can't think and do things at 3am when I'm asleep when the system can

Scott Benner 1:05:20
Yeah, I started off all my talks by talking about fear, first, you have to get rid of your fear of insulin First, it just, it has to be, you know, if you're going to be afraid of this, it's not going to work out. I talked about, you know, when you're asleep, it's a third of every 24 hours, basically, right? So it's free a one seat time, think of it that way, you know, and, you know, and then, you know, the Pre-Bolus thing and readdressing blood sugar's when they don't go the way you want. My daughter's not, you know, low, you know, a scary amount. I mean, everybody has a scary low once in a while, but it's not not a monthly occurrence or anything like that. Her a one seat is just cemented at five and a half. And she has no diet restrictions, and only we had Chinese food for dinner last night. And you know, and then she worked out afterwards, like, it's not like, you know, it's a regular life. And her a one C has been between five, two and six to for six years. And it's just doing the things that I talked about on the podcast, and it's being it's understanding them, and they don't get me wrong, like after you have some experience with it, it does become second nature, you know, I don't look at an elevated blood sugar for an hour and a half trying to figure out if this is the right one to put another unit on or not, you know, like, it comes to me pretty quickly. I'm still teaching it to her. But the other part of me believes that closed loop systems are going to keep her from really needing to understand all of the things I understand. And you alluded to it, I'm happy about that as a parent, like if my daughter can, my daughter is not the, you know, she's not the sounding board for the rest of the world. She's a person who's going to try to live her life. And if she can live her life without the burden of knowledge about how insulin works that I have, that would make me happy. You generally mean and and I see it too, like, you know, it's it's obviously here, no control, like who's here, horizons gonna be here. Before you know it. I'm assuming Medtronic will figure out how to make that other thing work better at you know, you know,

David Walton 1:07:24
no, absolutely. The next version of a tronic will be better. You mentioned that those are three closed loop systems. And there are four other ones that are in development, right, and will be out within a couple of years. So that's correct, you know, super excited separation of these different systems. But you I think, the point you made, like, even when you're using the systems they'll handle they'll help take over certain issues or problems or, and make certain things better. But you have to have a base understanding of how it's working, and what to do when, oh, wait a sec. I ran out of a supply or my cartridge, something malfunction, I'm getting an alarm here. And they have they have some technical support, you can call it but there are times where some things have happened where I had to improvise, and not understanding what to do, you know, understanding how insulin work when I was traveling five years ago, and I had an empty vial of insulin in my carry case, and I went to go fill up my cartridge in my pump into Oh, I don't have any insulin. Yeah, this is that you know, what midnight, and places are closed, what am I going to do, and I found a 24 hour pharmacy, and then I go and they can't get the prescriptions not on file. So they could give me regular insulin. And so I got a premix. And I just kind of guesstimate of what I should do based off of what I knew and how much I knew I took for long acting and short acting, I divided it up and turns out it worked reasonably well. But like, if I couldn't have done that, what a scary thought if you were by yourself traveling somewhere in a different city, and you don't have anything like what are you gonna do? These these things happen. I mean, I, everyone's gonna have a moment of absent mindedness or forgetfulness, or, you know, unexpected, you know, something came in and took change your plans and you weren't preparing for that. And, you know, I joke to my wife, you know, going for a walk right after I took a lot of insulin, it's just a walk. But it's amazing how that my blood sugar will go down and I just, It surprises me every time and it shouldn't. It's like I'm just walking. But it's insulin, and I play basketball on the weekends and I you know, lift and workout. I'm relatively active, walking right after insulin. It's amazing how my blood sugar drops. And certainly when I you know, I've ran a couple marathons a way back when I learned how my how to balance the insulin. I take any insulin on board relative to how long I'm running for how hot it is. I'm a big guy. So like, you know, I think it's even more drastic, so I would have to drastically cut back my insulin. Yeah. You know that that was trial error that there wasn't a simple formula I could follow. I talked to people who also ran and but I was a little different and you know, you learn these things, how to tips from other people. So I do think that other people with die with type one can be the best source of information, provided you can kind of take it in the right context. So you'll learn a tip or two from somebody But no, they're like, someone else responds differently to oatmeal or to steak than I do.

Scott Benner 1:10:39
Oh, yeah. Hundred percent or younger people like coffee, half the balls for coffee and other people don't have to for the Exactly. I'm

David Walton 1:10:44
wanting to ask the Bolus, right. I don't drink Starbucks often. But my kids love it. And I get the sugar free. I get you know, and do it that caffeine and why? I have to take four and a half units. If I get a venti

Scott Benner 1:11:01
macchiato. Yeah, we've been we've been doing a great

David Walton 1:11:03
Diet Coke with caffeine, you know, nothing, not profitable, in fact, so it's,

Scott Benner 1:11:07
yeah, sometimes sodas make my daughter's blood sugar go up. And I

David Walton 1:11:11
yeah, and I've heard people talk about that. And like, I drink so much diet soda. And like a lot of people with a one and zero impact like I've, I've looked at this I've watched and see because people will tell me, oh, your body treats diet just like regular nice. Well, your mind doesn't?

Scott Benner 1:11:26
Yeah, you're different, right? Your stuff. We've been doing it, we probably have a half a dozen podcast episodes now about algorithm based pumping. And there's more and more coming because I have to tell you, from my perspective, it's my belief that for the great many people who will never find a podcast like this or find community or talk to somebody or live with another person who has type one diabetes and get a tip from them, you're gonna slap this algorithm on them. And with a, you know, hopefully a little bit of guidance there a one C is going to improve their lows are going to improve, it's going to make their life better. Absolutely. You know, and that that for and there and then there'll be people like me and others that will manipulate the algorithms at times and get it to do more of what we want. And that to me is that's the future. Honestly, I I would give everyone a dexcom if I had the power to do it. Yeah, yeah. Well,

David Walton 1:12:13
I certainly I've heard more and more examples now of endocrinologist putting CGM on right away. Yep. to people and after a diagnosis. And it's it's interesting, because I remember this discussion coming up years ago, and people saying, you know what, you know, pumps are put on sooner than CGM a lot of the time, just because they've been around longer. And there's more familiarity with them. But as the familiarity has increased, and they've gotten simpler and more accurate, that has shifted over the last few years now. So I think if if given a choice, and you told people, you had to have either CGM or a pump one or the other, you have to choose Yeah, I think most people are going CGM. Now,

Scott Benner 1:12:58
my daughter has been using wearing on the pod every day since she was four. And she'll be 16 this summer. And they are sponsors of the show. And I am a huge fan of Omni pod in a million different ways. I know people there and I know good people who are working behind the scenes. And same with Dexcom. And if you held a gun to my head, I'd give my daughter's pumped back if you made me you know if you put me in an either worse situation. I right. I'd rather have a seat. Yeah,

David Walton 1:13:22
no, absolutely. I think, you know, you do have studies like the diamond study that showed you can do very well CGM and injections. Similarly, as you could with a pump. I do think you know, the pump has certain advantages. And then there are certain drawbacks to wearing wine. Well listen, once you see

Scott Benner 1:13:41
the data, in my opinion, then you're gonna want a pump. You're gonna just be like, Oh, I would love to use an extended Bolus here or Temp Basal.

David Walton 1:13:47
Yeah. So like there's that. Absolutely. But you mentioned earlier about some of your listeners being interested in those that technology is funny, because so there are three people, you know, that I know from high school that we all have type one, only one did at the time, two of us got diagnosed as adults. And you know, I won't name her but you know, she has done very well. She was diagnosed in her mid 30s. Very well, just on when she was on a blood glucose meter and injections, okay. They wouldn't see in the low sixes. She's very athletic. But she did. I talked to her a couple times. And you know, I showed up told him what I did, but I'm like, hey, you're doing great man. I you know, enjoy, enjoy that like you're you've got good results. There's not necessarily need to do anything. But then you know, I think some things changed a little and she got out of the habit Libra and think, Wow, this is so much easier than I thought it would be. And I didn't realize like it's kind of cool seeing my body the way it reacts to certain foods. Like Yeah, let's that's the benefit of CGM. And now you know, she's like an advocate. But she was she, not everyone needs the technology at that point in time, but there There's no doubt that a technology like CGM can absolutely give you insights and help make things easier and more and help you do a better job of controlling. Right. You know, and and she's now a convert. So that's why we're getting up into this. I think the estimates are about 4035 to 40% of type ones might be on CGM.

Scott Benner 1:15:26
It's getting there. You know, it really

David Walton 1:15:28
worth that level. Yeah, depends. Depends on what denominator use, I use 1.6 million. But some people use different numbers. I think that's pretty close. That's what CDC came out with recently. So

Scott Benner 1:15:42
yeah, I hear you, I think it's, uh, I mean, honestly, you'd be hard pressed to see the data coming back, like the, when I make an ad for Dexcom, it makes itself data comes back, you get to see what the insulin impacted what it didn't, how you can next time, do a little sooner, a little later, a little more, a little less, you know, do things like I talked about, you know, there's, there's, some times people have meals, they're like, no matter what I do, if I put too much insulin up front, I just get low later. And so we start talking about bigger ideas like getting the insulin up front through a bolus and extended bolus, you know, even attempt bazel increased it to really force the insulin on the place you need it and then create a I call it a black hole of bazel later, just make a void of bazel later, so that when the the harsh bolus you made tails, it tails right into a black hole where there's no bazel. And then that tail just acts as the bazel instead of a catalyst to drop your blood sugar. Yes, it's Yes. It's not as hard as it sounds. Don't even say if you talk if you have a cup, if you talk it through a couple times and understand the timing that your insulin hits, and you can create those sort of, you know, those really kind of what feel like advanced ideas. And you know, I couldn't do that without a CGM. You think I figured that out before Arden had a dexcom? You're out of your mind. So

David Walton 1:17:04
yeah, yeah. Now that that whole concept of like, you know, the Super Bolus, right, that was the concept of pumping A while ago, that much better now, when you have CGM combined with it that, you know, if you're, if you're high right now, you could take even more Bolus and turn your bazel off and get that to get to, you know, try to really bring this thing down faster, right. And like I said, when it's coming down, it's some of it's replacing the bazel deficit. And so you get that softer landing. And so these different ideas, it, you know, because there's a danger element to it, it's not something you enter into lightly, because if you overdo it, you could have a, you know, a bad low. But how nice to have a warning system and alarms go off, if you are coming down fast, and you are cutting below a threshold. Yeah, I mean, that's, that was the early stage of CGM just having that alarm. Like, and yeah, I'm one of those people that doesn't wake up all the time when my alarm goes off the middle the night, which is why control IQ has has helped on the overnight. But that early experience of finally having something it's an early warning system, immensely helpful. And so if people are fear of hypo, I'd say, you know, CGM can be unbelievable in that regard. Now, you have to be okay, and realize you're gonna have some alarms. And those alarms can be annoying at times. But it's kind of a necessary evil I'd much rather have an alarm than wake up in an you know, profusely sweating you know, and, and anxious, you know, in a panic, not know what's going on. And

Scott Benner 1:18:35
I'm hoping you do the right thing that you don't fall back asleep before you figure out if you're okay, and yeah, all the

David Walton 1:18:41
trip down the stairs as you're going because you're a little a little off balance. And, you know, just all those things like, you realize the way we were acting when the technology wasn't as advanced that let's let's take advantage of technology making my life better and simpler. Oh, you only

Scott Benner 1:18:55
you only have to find one person who's had diabetes for 20 years to tell you a story about the time they woke up in the morning and it looked like a bear attack their kitchen and they don't have any record. no recollection of it whatsoever. You start thinking you're gonna call the cops, somebody's broken into your house, but that was just you looking for frosting. You know? It's it's an interesting, it's a really interesting, David, I have to tell you, I mean, this genuinely. You would love this podcast. It hearing you talk. It was interesting for me because I don't come through academia and I don't have type one diabetes, right. I I had a daughter. She got she got diabetes when she was two. I was immediately the person who was you know, with her constantly. Two years into it. I was just still a wreck and everything wasn't going right. And I really felt like I was killing her most of the time. I'd started a blog in 2007, the very beginning of 2007, which sounds cute now but there were only maybe three diabetes blogs. Then, and I wrote about diabetes for such a long time. And then, kind of Luckily, I guess, I wrote a book about something different. And during my PR tour of all people, Katie Couric told me I was good at communicating with people verbally. And I just assumed that everyone was good at that. But she stopped me and told me, no, she's like, you're really interactive. You're moving these people like, Don't you see like your, the way you're talking? They're following along with you. And it was such a nice thing she said to me, about a year later, when blogging seemed to kind of tail away. And it wasn't the thing any more people didn't like to read, I guess. I didn't want to lose the impact of that I was seeing myself have on other people's lives with type one through the blog. And so I started this podcast, which is now 240 episodes, or 340 episodes deep.

Wow. It's crazy, right. And so

when I start talking about what I was blogging about, I realized I could explain it. And then I was getting feedback from people. And they're like, hey, my agency's dropping from listening to the podcast, and it built and built. And then suddenly, I realized that I had a system that I developed an actual system for managing diabetes that I didn't even realize was a system. So I kept distilling it down into t shirt slogans, like more insulin, be bold, Pre-Bolus, like just little stuff, you know, like, just right down to the basic concepts. And what used to be an email or two a month through the blog, like, hey, this blog is really helpful to me, it's now become about a half a dozen notes through different like emails and social media a day, Hey, I just wanted to share with you, my agency came down a point, my agency is down two points, you know, my variabilities, like, I just had a guy the other day show me his, um, his standard deviation was like, 22, from the podcast, which is just crazy, right? Like, I can't get my daughter to 22. I don't know how he did it. It's amazing. And seeing that this was the way that it's repetition, even though it's not your repetition, someone comes in talks about diabetes, I interject a little bit with what I would do there, they tell a story that makes you more comfortable that diabetes is normal. You hear different ways of managing ideas, suddenly, you start seeing, you know, reflections of your own life in these conversations, you make little adjustments, and before you know it, your life suffer. And that was not my intention, I just didn't want to lose my blog. Like that was really it, and that it's turned into what it is. It fascinates me. Because the truth is, is that it's elevated my understanding of diabetes, it's this podcast is much more helpful to me than it is to the people listening to it, I guess, is my is my point. And I've gotten to the point where I've spoken about it so much and broken down so many people's lives with type one, that, you know, I have experiences where I go to, you know, jdrf events and speak and three days later, someone's sending me a 24 hour graph that's never over 120 and never under 70. And they're like there's, you know, there's ice cream in here. Can you find it? I'm like, No, I don't. You know, and, and not that everyone needs to live like that. And I don't mean to say that my daughter's blood sugar is always at five. Because it's not. We're just very reactive to spikes. And we're able to get them down without creating a low. And but but the point is, is that it's there for people and it and it works and to have you come on I mean this with with the with reverence, I really do have you come on and you don't know me, I don't prep for these things. So five minutes before you and I started talking. I had no idea about you, I jumped onto your bio real quick. I was like I went to Princeton, and Penn Oh, this will be fun. And and for you to say things that so closely mimic the stuff that we talked about on the podcast, it made me feel good. It really did. Like it made goods not the right word it It made me comfortable. You know, because there are times where you're saying like, anecdotally I saw this thing, and you're saying it out loud. And you know, when you're blogging to a couple hundred people or 1000 people, which you know, at some point, it became a million people, you know, the stakes are higher, and you realize your responsibility in this podcast has almost 2 million downloads. And so, you know, like, you start realizing like I'm saying something, I better say it right. And it better be universal, you know?

David Walton 1:24:26
Yeah. And so anyway, you know, interestingly, I mean, I'm proud of my Ivy League degrees, but they really don't help with this nothing to do with my diabetes knowledge. And I would tell people, when I got to enemas I didn't know that much. I knew basics of type one diabetes and you know, someone I'd read articles about new products coming out and whatnot. But you know, I, I had to do research to get up to speed and like, I would go to these conferences and just go to the poster sections where all the clinical research are outlined. It's like mean, ridiculous, hundreds and hundreds of yards of posters, you know, on different aspects of diabetes, and you could spend all day in there reading them. And I immersed myself to understand things because I wanted to feel like I was very knowledgeable since I was making decisions about what product we go with next, and what features should be in that product. But I learned so much from talking to people who've been dealing with it, and the the power of experience, and cause and effect, and like being able to figure out what you can use from what someone did. And you know, some people, like you said, with coffee have different, different experiences and reactions to it. And that's something just knowing that that's the case, and that you can't just jump on something because one person told you that's, that's also an important thing. But when someone has gone and talked to a bunch of people, and then curated that and given you a perspective, that's where it's valuable. So that's the role I would play. I used to get frustrated, like people would say, oh, what do people with diabetes? Think about this, Dave? What do they think? As if not asking me because I surveyed 1500 enemas users? Because you haven't been asking me because I was Dave Walton, the type one right, you know, and that type of thing. You know, happened a fair amount.

Scott Benner 1:26:19
Yeah, no, I hear I don't like I don't pretend that everyone's life is the same. I don't think that I just think there are basic tenants about how insulin works. And I think that there are a lot of similarities to people's lives. Like, for instance, one thing I tell people all the time, like, well, how am I ever going to know how to bolster all these meals because we don't count carbs. So we Bolus historically? And how do you learn how to do that? Well, some of the truth of that is you don't really eat that many different things. You don't I mean, like you maybe have 10 favorite meals or, you know, there, it's not like one day you're having, you know, truffles, and the next day, you're having chicken and the third day, you're gonna like give me like, you just eat what you eat. And so I started telling people, like, Look, you can look at that plate, and say, I don't care what the carb count says, this serving is, you know, the outcome of this meal taught me that while my pump said this was five units, it was really seven. If I come around and make this meal next week, and don't put seven units in, I'm an idiot, you know, like, like, I don't just why would I count the carbs? Gonna go five units, just like last time? Like it didn't work

David Walton 1:27:22
last time? Yeah, absolutely. My my diabetes educator in, you know, at the Pet Hospital, when I was diagnosed, said, after the carb counting lesson, eventually, you'll probably get to a point where you don't do the calculation, you just immediately gravitate to the end, you go to the end result, which is this food means, you know, this granola bar means 2.5 units, right? or what have you. It's not that you're, you're just going to jump to that know that association and not go through the math directly. And so like I see pepperoni pizza, which I don't eat that often. But when I do it's three and a half units a slice with a combo bolus, which is what you know, or extended bolus 60% up front 40% later done over about two and a half to three hours. Right. And that's how pepperoni pizza works for me if it's the right size, the right not to thicker crust, whatever. What when it deviates from that, yeah, I'll be a little bit off. But generally speaking, I go right into it. Let's pepperoni pizza. Here's what I do.

Scott Benner 1:28:22
And if it goes wrong, you're not flummoxed.

David Walton 1:28:25
know exactly how you'll spend the next six hours. Okay, right. I'll monitor and say, wait with my insulin. Do I need to give a little extra was a little under was just a little heavier in carb than I thought. Yeah, absolutely. All the time. Chinese food. You mentioned pizza and Chinese food were two of the problem. foods for a lot of people to usual suspects. And the Chinese I never eat the rice, but manage the sauces and any kind of you know, reading they put it on certain things. But I try to be mindful that I swear I still always get it wrong.

Scott Benner 1:28:57
Yeah. Oh, it gets in there with the fat man. And it just stretches out over hours and

David Walton 1:29:01
hours. Now you see that stuff in the refrigerator and the next day you realize how much fat is in the corn starch or this whatever is in there to make it taste good? Is this big jello? It just congeals in the refrigerator, you realize that's what the chicken egg carry on was?

Scott Benner 1:29:19
I have to tell you last night, my we were finished. And my wife's like here put this away. And I'm like, throw it away. And she goes, What am I gonna keep that? And I was like, Yeah, I mean, I'm not eating it again. Just so you know, like the heat was the only thing making it palatable.

Yeah. Anyway, David, I've learned I can talk to you forever. And I've kept you much longer than you. Then I told you, you're gonna be on. Here's the funny thing. Did we finish what you want to say about what's he when the exchange is doing for people with COVID-19.

David Walton 1:29:47
We know we talked about COVID. I think the last thing I'll wrap it up with is that so we are going to be presenting results along the way. So think of it as the cases come in. We analyze them so Yeah, the first 25 cases, we started to do some analysis, draw some, just just to characterize here's kind of what we're seeing. But you can't really draw too many conclusions from the first 25. But we'll be communicating this information out on a regular basis. So I think, by the end of the first week, in May, well, probably the first time we just talked about that. But we've got 60 cases, and now we'll have 102 weeks. And then there's going to be a lot more and it'll be growing. And we're working with the researchers, these clinicians, you know, Todd Alonzo, at the Barbara Davis center in Colorado. So it's a, you know, a big, one of the biggest in the in the country in terms of taking care of people with type one. And Mary Pat Gallagher at NYU, that they're kind of leading the research along with this Dr. asagi, the cozy and who's at t Wendy exchange. And he has a wife with type one. He's got a lot of great experience working in the type two diabetes and HIV arenas before he came to us as a consultant, and then as a full time doctor, clinical researcher, so those results will be coming forth. We are talking about additional studies, there's a lot of interest. And I talked about the hospital, we may do something looking at just hospitalizations because of some data that this other company has. They want to work with us potentially. But there are other aspects of the what we've done. So that's our big focus now with COVID. But in general, this collaborative we have, we're focused on improving care. And we work collaboratively with leading diabetes centers. And we're growing that and so we'll be at over 20 centers that do this regularly with us picking out topics like how do you drive CGM uptake? How do you screen for depression more consistently, right? Because these things impact care. And the are collaborative, we help do the data analysis and share it with them and work with them hand in hand on how can we get us all to a better spot. And we're all collectively focused on let's get people in better outcomes with Type One Diabetes. That's our that's our mission. That's that's their, their mission. They just happen to be providers of care at diabetes centers, and we happen to be a not for profit in Boston that works with them and does a lot of data and research as part of it. So I love working at that T Wendy exchange. And, you know, I think we have gotten more focused on near term impact and near term, how can we help other organizations and whether that's a healthcare system or another, not for profit, improve the situation for people living with type one. And, you know, I think we're we've had some, some good progresses here, and more people are interested in joining this collaborative, more centers, and we want to get that bigger, so the knowledge is shared amongst all of them. We don't have situations where like I was describing, I'm on the wrong insulin dosing ratios for 10 years. And that was such a simple fix to take off, you know, at least half a percent, if maybe pi more like point 7% off my agency, right? That those kind of things should be done more routinely. And again, we work with some great centers that do a lot of great things consistently. But part of their interest in the collaborative is they're learning from the others. And so they may have a lot of people using CGM, but they may not be screening people for depression and realizing Wow, so that's how you guys are doing it with your, with your medical record system, and how you're getting counselors and social workers connected with patients so that they can deal with these tough problems and challenges like oh, okay, and so it's a it's witnessing it is it's awesome.

Scott Benner 1:33:40
How do you take once you learn something from, you know, you gather the data, and you you sit down and you make sense of it? And you find a, you know, something that that's fallen through the cracks? How do you? How do you put it into practice? Because that's, that's, that's really, you know, great question. Yeah.

David Walton 1:33:59
And I'll tell you what, so this is I won't go deep into quality improvement methodology, because that'll cause some snoozing potentially with some listeners. But there are things called change packages that we helped create working with the Diabetes Center. So it's kind of like an implementation plan. And here's how you do this now. So like we know with CGM usage, look, there are things you can do to make it easier to start someone on CGM. There are also things you can do to make sure that the reimbursement exists. So in Texas, the Texas Children's Center that we work with, they've done a lot of great things to drive up CGM use, but Medicaid wasn't paying for reimbursing CGM for people with type one, right. And they've actually I think, been pretty successful in working with Medicaid to get one off approvals and maybe get a system wide kind of change for that reimbursement well by sharing some information and approaches used by others, centers and other states that helped their cause. But they took a kind of a leadership thing, like they recognize the importance of it, and we help support them with data. You know, we have a portal that we provide that they can do some reporting themselves and look at things. But we also do analysis and provide them with with things so. But the idea is, there are these change packages that we help roll out that's like the implementation plan to do it. And then there's measurement. And every month, you can see how things are going. So are you seeing the CGM usage going up, just like we they look at a one C, we have several years worth of a one c values for all type one patients at these centers, they can see what's happening there, they can see what's happening in their high risk group of people without a one C of nine or above. And so by tracking it, and really, it, you can't manage what you don't measure. And unfortunately, we've lived through that as a country with with COVID. Diabetes is the perfect example of that, when you do a good job of measuring it, it really helps to manage it. And that's something that we're kind of, we help drive that change with these centers working kind of hand in hand, and we're lucky to have a great starting set of centers, and we're looking to add a lot more so we can have a bigger impact. So you know, 1.6 million people, you know, we've only got about 25,000 patients so far in our, in our system, the data from from those EMR, those centers, we're hoping to, you know, drive that number up over the next couple of years. So we have a much bigger sample to work with. And it's, and we're touching more people at those centers. And then other people can learn from that we'll put publications out, a lot of the researchers that work with us at the Centers are putting abstracts out at the ADA conference, European conferences, trying to even share it learn from people, you know, in Europe and elsewhere. So there's so much that can be done on that knowledge sharing and getting it into the hands of gay I'm working with organizations like ADA, and at CES, the new diabetes educator name. And then patient organizations to like, we'd like to get the word out there. And so we've had good work with jdrf and beyond type one and TCL ID and children with diabetes. You know, a lot of great organizations there. We're all trying to figure out how to help each other kind of just complement each other not overlap too much. And that's a big part of what we're

Scott Benner 1:37:25
doing. Well, I'm really pleased that you came here to share it with me so I appreciate it. Thank you for coming on. I know I kept you long. You know to find out more about T one D exchange you can go to T one d exchange.org. Huge thanks to David for coming on and sharing I'm pretty confident he's going to be back at some point I really enjoyed speaking with him. I want to thank also the Contour Next One blood glucose meter. Of course more information about that can be found at Contour Next one.com there's links in the show notes touched by type one is that touched by type one.org please go check them out. dexcom.com forward slash juice box for more information and how to get started with the Dexcom g six continuous glucose monitor. And of course, a absolutely free no obligation demo of the Omni pod tubeless insulin pump can be sent directly to your door by going to my Omni pod.com forward slash juice box. Have a great day.

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#329 Denying Diabetes

Julie is Abigail's Mom and this is their type 1 diabetes story

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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 everybody, welcome to Episode 329 of the Juicebox Podcast Today Show sponsored by Dexcom. And on the pod, you can get an absolutely free no obligation demo of the Omni pod sent directly to your door by going to my Omni pod.com forward slash juice box. And to find out up to date information about the Dexcom g six continuous glucose monitor, you just go to dexcom.com forward slash juice box.

Today's show features Julie now Julia's Abigail's mom, Abigail has type one diabetes. Julie is a 911 operator, and Abigail was diagnosed at the same hospital that Arden was. And that's not even the tip of the iceberg about today's show.

Hey, there's some new stuff in the Juicebox Podcast merge store. For those of you who have been bugging me, I think literally for two years about the tug of war graphic with the insolence having the tug of war with the apple and the hamburger and the milk. I finally found a way to make that image printable. So there's a coffee mug, a neck Gator. If you don't know what that is, you should go check it out. That has that and a white t shirt with it on the front it is adorbs as the girls would say in 1987. A couple other items are on sale. Anyway. Juicebox podcast.com you'll find the link at the top saysmarch. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise please always consult a physician before making any changes to your medical plan or becoming bolder than I made it.

Julie 1:49
Hi, my name is Julie. I'm Abigail's mom, she's 11 year old, he one day diagnosed. It's been a little over two years now. And we've been working with it ever since.

Scott Benner 2:02
All right, Julie. So Abigail is 11. So she was diagnosed at nine. That's two weeks or her birthday. Two weeks I'm sorry. Prior or before.

Julie 2:13
After, after after,

Scott Benner 2:14
okay. Two weeks after her birthday, two weeks after her ninth birthday. That must have been unpleasant. And we're the were the decorations still up somewhere in the corner.

Julie 2:26
I'm pretty sure but yeah,

Scott Benner 2:28
we just like Oh, good. Now I can go clean both streamers up. And now you're it's funny. You're I don't want to say exactly where you live, but because that wouldn't be right. But I believe you may live somewhere near where my daughter was diagnosed?

Julie 2:45
Yeah, yeah. I mean, I'm fine with it. We I mean, we live in Franklin, Virginia, but close to Norfolk. Okay, where she was taken to ch Katie.

Scott Benner 2:55
And that's the tell me the name of that hospital. Children's Hospital King's Daughters of the king's daughters. That is where my daughter was diagnosed as well. We were on vacation at the time. And okay, at the beach. And it was, it was interesting, because I woke up my friend who is also my kids pediatrician. You know, like one in the morning, I said, we're taking you to the hospital. And he said, Where are you going? And I told him, he's like, that might not be right. And I was like, what he goes, there's some hospitals that are more, you know, they have like children's I didn't know back then they have like children's wings for diabetes. And some people have like specific diabetes care, the other hospitals don't say. So my pediatrician who is also a friend ran to his computer, because this is before, you know, phones that did great things. phones, it did anything. I wonder if young people are like wait, phones didn't always do things, but no phones used to just make phone calls. And so there's my my friend, my pediatrician in his underwear, booting up his computer? And he said, No, no, I'm gonna let me give you an address. I think you should go to this hospital instead. And it turned out to be the hospital that you were, you were diagnosed that as well. So that's interesting. And we have that in common among a lot of other things. I think So tell me a little bit about that time. Was it a surprise or do you have diabetes or in the family?

Julie 4:25
No diabetes? Well, I mean, we have type two, but not type one at all. A lot of intercurrent issues in the family, thyroid issues celiacs but there was no symptoms from her whatsoever. I mean, nothing. I tried to look back on it and see if I missed anything. But absolutely nothing she she had been complaining I guess for maybe a day, maybe two days of lower right abdominal pain. So for me doing what I do for a living emergency number one dispatcher I immediately Went to appendicitis. That's what I was thinking. Sure. And you know, I even touched her right there and she like almost came out of her skin. And so I immediately said, Okay, this, this is what we've got. We've got to take her somewhere. I can literally walk across my backyard to a hospital. So we took her to the closest hospital we've got, and we walked in the emergency room, and it was wall to wall with the flu and a stomach virus. And I was like, this is not going to work because she just got off two rounds, steroids because she has asthma. And I was, yep. I don't want her to get whatever they've got. So my husband took her to oversee hospital and Suffolk with third grade hospital. And she got right in because they know me by name because I work for the police department, the fire department down there. And they took her right in. And they did all the lab work. They thought she had appendicitis. They did all the lab work CT scans, and it came back and they said, we're gonna transport you ch Katie, her bloodwork her blood sugar's 480.

Scott Benner 6:08
Well, okay, so first of all, I love you throwing your weight around getting right in. I am completely amused at the idea that you walk into the emergency room saw sick people, and we're like, this is not the place for us.

Unknown Speaker 6:21
Not getting near these sick. Yeah, now.

Julie 6:24
I'm a germaphobe. Really, really hard. I'm bad.

Scott Benner 6:29
I'm delighted by that idea. Like, this is an emergency who not that much of an emergency.

Unknown Speaker 6:36
I saw sick people blow

Unknown Speaker 6:36
their nose. And we're out of here.

Scott Benner 6:38
That's that's, that's very nice. And see. Interesting. So as soon as they see her blood sugar, this hospital you're at? doesn't excuse me that doesn't mess around just moves right over to the next hospital.

Julie 6:53
Yeah, I'd say it was maybe 45 minutes, the time she got their blood work came back how to transport it.

Scott Benner 6:58
Okay. And so you are really the first person it's one of the things that sort of attracted me to the email that you sent me was that I've never heard someone say there was a symptom. But it wasn't one of the classic. I think I might have diabetes symptoms. Did you ever find out what the pain was?

Julie 7:19
Nope. And she had it for months afterwards. Like it was always one of her complaints.

And then never figured it out?

Scott Benner 7:27
Is it possible that the pain had nothing to do with the diabetes and you just got lucky?

Julie 7:34
I guess possible. We had her pediatrician actually put her on a acid reflux medication after the fact thinking maybe that was the cause. And maybe like a month or two later, it went away. So we're thinking maybe it was just something coincidental.

Scott Benner 7:49
That's really interesting. A little Good luck, bad luck. Right? Mix up. I know, people who have gone in for one thing and, you know, left thinking something very different. And it's saved their lives sometimes. You know, and this is this is a really interesting situation because I, it feels to me, like especially 498 or what was her blood blood work like 480. That's not incredibly high. And it's possible that if she would have got that blood work done, three hours later, she might have been lower, like, Did she honeymoon much afterwards?

Julie 8:22
her honeymoon or denial phase? I call it? Yeah. Because she wasn't even today only on insulin. She was only on levemir for a month, and then she was taken completely off insulin for a year.

Scott Benner 8:35
You did find it by mistake too early. Oh, yeah. That's That's interesting. This is mistaken. Diabetes.

Julie 8:43
Denial phase with the husband and everybody. Oh, yeah. It was awful. So I only have that. IBD

Scott Benner 8:49
Yeah. So my denial only lasted about a day. And it happened fairly far into Arden's time with diabetes. And by far, I mean, you know, months. But there was a day where we just got up and she didn't need insulin all day. And it was all day and it was with meals, it didn't matter. Like everything was just back to normal. And so the pediatrician who sat in his underwear and found me a hospital to go to in Virginia, is also the same person I called later, in that afternoon, and I I knew I was being I knew I was being hopeful and ridiculous. So I started my sentence to him. I said, Look, I'm about to say something. I know I'm wrong. Just stop mean, get me off the phone. And he was like, okay, and I said, I don't think Arden has diabetes. She hasn't needed insulin all day. And he's like, yeah, I get off the phone. Scott. She has diabetes, and I was like, Okay, thanks. That was it. But did you have I mean, a year, you told me a year she didn't need insulin,

Julie 9:56
not for full. It was a year in two months, actually to the day.

Scott Benner 10:00
Did she have high blood sugars during that year in two months?

Julie 10:03
Not Not when we checked my blood now.

Scott Benner 10:06
So what? How does when that goes on for days into weeks into months, tell me about, like how that struck you.

Julie 10:15
Um, my denial only lasted until the blood work came back, you know, those tests that they send off for all the antibodies? Because once I did enough research into it to know what those should look like, so once those came back and they were off the charts, I knew, you know, this is exactly the she definitely has it. There's no way. My husband and my mom, they were absolutely in denial. They're like, nope, those tests are wrong. There's no way she's not insulin, there's no way she doesn't have this. They're wrong. Let's get a second opinion. Let's get a third opinion. When you're seeing I mean, the doctor we were seeing in the practice, he was number two in the country. pd, a pediatric endocrinologist. I was like, how do you get better than that? I mean, who's gonna be your second opinion? Right? Right. There we go from here. So yeah, where do you go from here? And we have since but that's a whole nother story. But anyways, um, so but it lasted and it was a big fight in the house. I was like, I need everybody on board. This is not helping. This is not helping her. This is not helping me. I need everybody on board. But then you go to Disney, we went to Disney for seven days, she ate whatever she wanted, it didn't matter. And she still had phenomenal blood sugar's but something in the background was going off. Because when we every three months, she would go back to the endocrinologist, her Awan see was still, you know, at eight. Yeah, there was still something we weren't saying.

Scott Benner 11:41
And you weren't testing that frequently, I'm imagining.

Julie 11:44
Now, if they still only want us testing three times a day,

Scott Benner 11:46
right? So if you test that they're correct three times every day, you're not going to see elevated blood sugar, if our pancreas is intermittently working, or right, we're working at, you know, at a half power situation or something like that. I'm very interested, I don't want to get you into more of a I mean, I know it's been two years, I don't I don't want this podcast to lead to you and your husband. Having to call you at 911. So, but, but um, gosh, I guess you can't really get into a fight like that. When you're nine one off, you're like, Look, you can call you want, they're not gonna believe you. But, but but so. So how does that manifest in real life? Like when somebody is on one side saying, Look, I don't care, you know, took a test. And sure the test said one thing, but what we're seeing is clearly opposite of that. And you're saying no, don't is Abigail hearing that too? Is she part of that conversation? You you have diabetes, you don't have diabetes?

Julie 12:41
Um, you know, Tim and I have been together for 16 years, married for 16 years, and together for 18 years. So we learned a long time ago, we don't fight in front of the kids. We don't argue in front of the kids. So no, we tried to maintain a united front together. But she kind of believed that Hey, Mom, if I'm not insolent Do I really have this? And I tried to explain to her the honeymoon phase. I was like, look, I think we're just having a really good honeymoon phase. Which to me, I don't know if I'd rather have this one or the other one.

Scott Benner 13:14
Yeah, it's like, I know people who are who go through honeymoons that are you know, drastic, where they need insulin, then all of a sudden, they don't, then they need it again. And then they don't. And it's tiring. Because you're always about to put insulin and thinking like, is this the time? I won't need it? Or the time? I do need it? That's Yeah, it's difficult. I want to sort of keep going for a second with with Abigail, thinking one way I understand the way she was hoping I would have, you know, certainly hope the same way I understand the way your husband thought of it. I understand the way you thought of it, you know, like everybody, you're trying to be pragmatic. He's trying to be hopeful. But did. And she trended to that to sort of his his side? Which opinion Do you present to her? Because it's funny, as you're talking about this, it strikes me like, two parents with two, like, really differing ideas about religion, for instance, like, you know, let's say you're let's say you're Catholic, and he's agnostic. Which one do we say to the kids? Right, right, you know, or do we say both, but and you didn't say, but you didn't say, you know, I think there's a God and he doesn't or vice versa. You said, What did you say? How did you present it to her together?

Julie 14:25
Basically, it was a let's let's live in the now Hey, this is what we're this. I'm not gonna tell you don't have it. Because I know I know that you do. And I was very upset and very honored to there from the beginning, which my husband tells me the fault you tell them too much truth, Julie. But it's, but look, this is what you have. However, right now, you get to be how you were before we don't we don't have to worry about it right now. So let's just enjoy it while we can. You know, we know at some point the other shoe is gonna drop so to speak. But let's just enjoy it while we can. I mean, we got it. Disney, we got in a trip to the beach, we got in the full cruise without ever having to worry about it. And she got to have the best year and a half ever, without having to worry about it.

Scott Benner 15:09
She just embarked on a pancreas goodbye tour.

Julie 15:12
And absolutely, like when an athlete

Scott Benner 15:14
retires, they stop at every stadium and they're like, go ahead, clap for me one more time. And I'm leaving. And yeah, you said your daughter's pancreas is sort of like, I don't know, LeBron James in the last year he'll play

Julie 15:25
Absolutely.

Scott Benner 15:28
So I like that idea. I think because there's no perfect way to handle a situation that says you're about to feel the effects of a lifelong incurable disease, but it's not here today. But it's definitely coming. I don't I mean, it must have been maddening for you. I really, did you find I'm imagining how you've described it. You found relief when her pancreas probably like gave up? How did your husband handle it though?

Julie 15:57
I think it was like a funeral. It was like a death.

Scott Benner 16:01
Yeah, because I mean, it was he really sincerely hoping right?

Julie 16:06
Oh, yeah. Yeah, I don't think he ever had that grief period. Like I had, there was a whole lot of tears and everything in the beginning for me. Because I remember thinking I did something I remember as I broke down to the doctor and ask them, What did I do to make this happen? Because I knew nothing about type one, nothing. But him. He never went through that grief. He didn't go through that mourning period, because he had that phenomenal honeymoon period. And so when it finally happened, now, this statistic turn,

Scott Benner 16:35
Julie, I just realized it's possible. You and I have cried in the same room at a hospital in Virginia.

Julie 16:41
Probably

Scott Benner 16:44
just thinking, huh, I think I grabbed that room too. So yeah, I got you. I really do. I'm just I, you know, I'm gonna move on. But I that's just a fascinating conundrum to be in, you know, I get that I get him wanting to be hopeful. And then I started thinking, gosh, he got to be hopeful for 14 months. When it actually happened. It had to be it just had to be crushing. Get You know, sorry, feel for I feel for you guys. That's that's really something. So when it happens, and you know, for 14 months after your daughter's diagnosed and she gets diabetes, because she had a pain in their side. I do wonder like, when would you have actually found out? Like, like without that pain in her side? Would you have been diagnosed 14 months later? I know. You'll never know. But that's just really interesting.

Julie 17:31
Yeah, so now like my other daughter, I'm like, everything freaks me out. Like, are you okay? Why did you pee seven times today? Like what's going on? Yeah, yeah.

Scott Benner 17:41
Did you ever test Do you ever test her blood sugar when she's not looking? Like when she's asleep?

Julie 17:45
It was she loves me. And we've done trialnet on her too. Okay. Yeah.

Scott Benner 17:49
And you? Did she have any other markers, or do you not talk about?

Julie 17:52
Gosh, she has one. She's one of them.

Scott Benner 17:55
How about you guys? Did you guys do with it

Unknown Speaker 17:57
as well? Your? We did? Yeah, we're negative.

Scott Benner 18:00
Interesting. Who's got the thyroid issue? Is it in your immediate family?

Julie 18:05
Yeah, my mom. My dad had thyroid cancer my grandmother.

Scott Benner 18:11
So so just a you. Abigail wasn't dodging this one. This was this was coming in here. It did it. Did it all skip you.

Julie 18:19
It all skipped me so far.

Scott Benner 18:21
so far? Yeah. Yeah. You don't want the thyroid thing. It's a small thing. And it's manageable. But it's also not always manageable. 100% and it's sort of sucks. So I know Arden since she's been diagnosed as hypothyroid Geez, just she can never quite even though her medication is we think really well measured. She can never ever feel completely rested. Like she just doesn't can't accomplish that. And to be perfectly honest, my wife has it too. And she always has that. She always looks tired. To some degree. I think she's learned to live with it. But she's always tired to some degree. It's, it really sucks. It's such a small little thing, but it has a big impact on you. Okay, so too interesting. You've had so you count yourself as having diabetes for two years from the day you went to the hospital. But in reality, you've been living with insulin for about 10 months. Is that right?

Julie 19:21
In reality, I've really only been living with the two types of influence and June of last year.

Scott Benner 19:29
Okay. All right. Yeah. Gotcha. So how does it start? They You know, it finally kind of kicks in. Do you just have this moment where you're like this? Is it her blood sugar's not coming back down anymore?

Julie 19:41
Yeah, it's kind of gradual. In April of last year, she started going back up slightly, so they put her back on 1111 mere half a unit. That's all we were taken, which is incredibly difficult to get my syringe. As you as you know, I've heard with Arden when she was little Yeah, I think credibly difficult. But, and then we did that from April to June, she was only on a half a unit 11 year, did beautifully. And she never went back up. We didn't have to do a unit. We never had to go to full units on it. And then we'll It was like, over a course of two days, she gradually went back up, you know, she was at 150 and 160 and 180. And it was Friday. In June, it was a Friday. And she started she went back up to 300. And I was like, okay, I've never seen this number, like on a like I've never seen it. So I called it I forgot they closed half a day, the doctor's office. And I was get ready to go to work. I work nights, I work 60 to six day. And I called the doctor on call and I said, Look, I don't know what to do. Because we weren't trained on anything in the hospital, except the long lasting, we weren't trained to do carbs. We weren't trained to do any type of rapid acting insulin, nothing. We were only trained on the left mirror. And I didn't have any at home. So I didn't know how to bring her down. So our doctor was on call another doctor was on call. He said, Well, you got two options. I can give you a crash course on how to do this. And I can call you an insolent or you can bring her in and they can get her in the emergency room and they can bring her down. And I said oh, I said let's do the Crash Course Tell me. I said I can do it.

Scott Benner 21:24
Yeah. Especially if it's sniffle season. You're not going back in that emergency room. I know that for sure.

Julie 21:28
Yeah, absolutely not.

Scott Benner 21:31
So he called me in in one and we got the crash course. And I'm I mean, I did it. And I she didn't get in to be seen probably I think it was almost six days. So we we handled it for six days. Yeah, you basically just had a like a little stick and you beat the blood sugar back with the with your needles and your new insulin and your lack of any kind of real knowledge. And they worked out. I mean, it's Yeah, that's excellent. Good for you. Well, by then, you must have been pretty ramped up for it. You must have. I mean, I can't imagine what even back in the beginning when you say to yourself, look, this is diabetes, she just doesn't need insulin yet. I can't imagine you thought it was gonna go 14 months, there had to have been a time where you forgot about it.

Julie 22:10
Like I knew it was coming.

Scott Benner 22:12
Yeah. But prior to that when the blood sugar started creeping up, was there ever moments where you just didn't think about it? Or was it always sort of in the back of your head?

Julie 22:21
Not for me, I'm a realist. Like, I'm one of those that I hope for the best. But I prepare for the worst. So I knew.

Scott Benner 22:28
Yeah, no, I understand. I also would imagine being a 911 operator doesn't leave you a ton of latitude to believe things go? Well. I mean, it's a well, it's a weird situation, isn't it? Because I know I, I mean, I'm incredibly close with a police officer and who's been, you know, a police officer for decades. I think the one harsh reality of his life is that everyone he comes in contact with while he's working is either breaking a law or had something horrible done to them. And that starts to become your expectation for the world, you know, that? I just had happen to you with your job.

Julie 23:06
I mean, yeah, I mean, there's there's certain things I guess we we all deal with there. You know, everything like I'll go into a restaurant, my back doesn't face the door. There's just there's certain things that because of what we've dealt with, I mean, I know I don't see the front lines. I don't see it in person, but I've heard things on the phone that just completely freaked me out. And so I don't I don't take it for granted at home.

Scott Benner 23:29
Yeah, that's interesting. Just just isn't it something to because you do it every day. And maybe I'm assuming you're saying, you know, what, if there's a an invasion at the, at the restaurant, the place gets robbed or something like that happens, like I want to see what's happening. And maybe you've heard maybe you've heard that, uh, I don't know making up a number. Maybe you've heard that a dozen times in your life, but it's enough to think, you know, it's going to happen because it does happen. So you You are a pragmatic person then because of that.

Julie 23:59
Yep. Yeah, absolutely. Makes a lot of sense.

Scott Benner 24:03
You did not I'm going to skip in a second skip forward, but you did not ever drag your husband into a room and look at him in the face and go I told you no, you never Did you or did you not do that? Did you did you in my

Julie 24:14
head? I wanted to I wanted to but I did it in my head.

Scott Benner 24:18
It's like the one thing in the world you don't want to be right about. You're like, oh, like nailed this one. I was so right about this. So today, you know, 11 years old does she use a pump or glucose monitor or anything like that? Are you still doing injections? Well, with any luck your brain is not as broken as mine. And during this episode, every time you realize that Julie works for 911 a voice in your head doesn't yell. Somebody call 911 shorty fire burning on the dance floor a whoo as my brain does. Anyway dexcom.com forward slash juice box there you're gonna find out about the Dexcom g six continuous glucose monitor. Now what are you gonna find out when you get there? Let me save you a little bit of reading. The dexcom g six is FDA approved for no finger sticks means you can make dosing decisions based on the information coming back from the G six, that's a big deal, save you some finger sticks. Here's the next thing, share and follow. That means someone with type one diabetes can have the dexcom on them, share their information up into the magic of the cloud, and it will come back down. Like magic on your phone, or a loved one's phone, or a school nurse or whoever you choose. up to 10 followers can see that information. Huge, right? that's available for Android and iPhone. By the way, you can wear a dexcom sensor for 10 days. That's pretty cool, right? put a new one on every 10 days get a long wear time. It's discreet and small. And it's magical. The decisions that we make every day to keep my daughter's blood sugar where it is, or a one c stable, her variability comfortably smooth. That all comes from the dexcom g six. And that could be that way for you as well. dexcom.com forward slash juice box. Check it out. Because when you get that information back, you'll be able to just switch right over to your on the pod tubeless insulin pump and make insulin decisions that are reflective of what's really happening. Not a wild gas, or a hope or a prayer. But seeing the direction and speed that your blood sugar is moving in then you just pick up your Omni pod Okay, blood sugar's 84. And little man we're gonna have 35 carbs up on the pod says it's this much insulin, push the button, little beep. And the insulins on its way of having pizza want to stretch out your insulin with an extended bolus, no problem. This is 70 carbs. But I'd like 50% of those carbs to go in now when I push the button and the other 50% can be stretched out over the next two hours. Want to do that? No problem on the pod does that. Now all the pumps do that I'm not gonna lie to you. But those other pumps, you can't get into the swimming pool with no no you can't. Those other pumps have big piece of tubing off of them. And then there's a controller on the end that you have to clip to your belt or your pants. You imagine a little four year old you know with a something hanging from their pants just pulled pants right down and probably by pulls down pants my four year old. That's not right. What if you're a nice lady and you were in a cooler? Is that clothing? You have to stick your pump in your bra then? Not good. That's busting up your head. You know what I mean? What did they say that the the lines right of the clothing you don't want that either. Here's the coolest thing about on the pod on the pod lets you try the pound. absolutely free with no obligation. You go to my on the pod.com forward slash juicebox. There's links in the show notes right here in your podcast player or available Juicebox podcast.com. If you can't find your way through your podcast player, it's no big deal. When you go to that link on the pod send you an absolutely free, no obligation pump that you can try on and wear and decide for yourself. You don't even have to believe me, all you have to do is get the demo and see for yourself. So whether you want the Omni pod the Dexcom or both. But on my on the pod.com forward slash juice box dexcom.com forward slash juice box. You can hit those links at Juicebox Podcast com right there in the show notes of your podcast player. I've made it as easy as I possibly can to support the podcast and to get great gear to help you with your type one.

Julie 28:37
She was on the MDI from June until October. She got a T swim in October. I loved it when she originally got it. And then it hit summertime. And you know what? I don't like being plugged in. I don't want to have to unplug and so we just paid out of pocket for the Omni pod. So we have posts and she has the deck comm to size

Scott Benner 28:59
the file. So not to I'm not making this into an ad at all. But it was the being connected that she didn't like about the tea sign. Just the tubing.

Julie 29:09
Yeah. Yeah, it's hard to argue with.

Scott Benner 29:13
And it's funny so when she was around the house and a little more sedentary it wasn't such a big deal. But you're saying that once she got up tried to run around outside do that kind of stuff. It felt in the way towards that point.

Julie 29:24
Yeah. And that the infusion sets honestly for me. The T slim she had so much anxiety with the infusions that it took us an hour to get them infusion sets on her. I don't have that with the Omni pod. She doesn't. I mean, I've posted on Instagram like she's so adventurous with these Omni pod. She puts them on her forearm. She puts them on their calf that has no issues. Try them anywhere. I just trade.

Scott Benner 29:49
It's I was about to say it's early in the morning. It's 1030 but it's summertime so my kids asleep. It's early

Julie 29:57
for me.

Scott Benner 29:58
Yeah, it's early for you. My children are Sleep. I believe last night at something like three in the morning I remember texting my son just saying like, would you please give up and just go to bed. And I you know, Arden was up late talking to friends and cleaning her room. She likes to clean a room at like 130 in the morning. It's a thing for her. But her pump is you and I were getting you know, the hour before I was getting set up before we were going to start recording. I'm watching her on the pod slowly dwindle down. It's out it's running out of insulin. And I'm like, oh, it'll make it till I'm done with Julie. It will it will and then about 45 minutes before I got on with you. I was like I don't think it's gonna make it. So I I went downstairs, I got insulin, I filled the pod. I walked up into a room. I put the pod down next to boom, I push the button it primed. I I whispered in her ear are not going to change your pump. I took off her old pod cleaned her site, dried it, put the new pot on insert it put the blanket back over top of her and left the room.

Julie 30:59
Yeah, that's it.

Scott Benner 31:00
She's done. She never woke up. It didn't take more than a few minutes. You know, it didn't throw I didn't have to call you and say Julia it's gonna be a you know, I'm gonna be late because we have to switch a pump. It just it just took a couple of minutes. And it's it's fantastic. And I'm looking at her blood sugar right now. And everything's good to go. So her blood sugar's at eight at the moment. Anyway, I mean, 86 Yeah, we're doing good. Seriously, same hospital, same blood sugar we're doing You and I are we're simpatico here. Right. Does Abigail play any sports? Or what kind of activities does she do?

Julie 31:34
She did gymnastics for a while. I'm hoping to get her back into it when she was on the teeth limb is a little bit embarrassed. Still, I think I think it's because it's so new. So she didn't like that and asking questions. Like they would ask about the G five and they would they would touch and she didn't like it. I was like, You know what? Just explain it to them. Tell them what it is. We're punch one of them. Or that? Yeah, I'm all for that. Like, the one that you? Yeah,

Scott Benner 31:58
kidding. We can't hit people. I'm just saying though, in a big place. If you really just lay one person out, the rest of them probably will leave you alone. Okay, let's not hit people. I think we all know I'm not saying that. But now I hear what you're saying. So she did not like the attention. And now was it? Like, was it Okay the first time but not the 50th time? Or did she just not like it at all. She doesn't

Julie 32:18
like it at all.

So, but she loves to skateboard. So she does that quite often likes to ride her bike. So we've been taking her to the skate park quite often. Except now they're flocking to her. They see the devices. And they're like, Oh, that's that's, you know, pretty awesome. They use different words there. But anyway, I won't use them on your show, because I know it's clean. So, but they see those and they flocked to her and there wouldn't help her. Because they're older kids. And they're like, hey, let me show you how to do this. And so we're trying to see how long that's gonna last before she doesn't like it either. Yeah,

Scott Benner 32:54
that's, that's interesting. You know, Arden, he has played softball her entire life, but she hurt her shoulder. Gosh, nine months ago or so. And the rehabbing of the shoulder took forever and she's having some like tight like muscle tightness and her shoulder still, it's just can't really, she can't really throw. And so she hasn't played softball in a really long time. And it's at, I think, a pivotal, a pivotal moment in her life, where she went off and found other things to do. And I think there's a sincere possibility that one day when she can throw a softball again, the way she's used to that she just might not want to. And we're actually looking right now because you know, sometimes when you let go of activity, you got to replay You know, it doesn't just get replaced with other activity. So I think she's considering yoga. I think that's actually one of the things we're going to do later today is look for a place for her to like, kind of get some yoga lessons and see if she can she's just looking for a way to stay, you know, limber and active and strong. That maybe doesn't involve running around in a pile of dirt for the entire weekend. She's fine. I if people were listening are probably Oh, Scott's probably so disappointed. I'm genuinely not I just you know, I told her I was like, you should just do whatever you think will make you happy. I'm not up for to be honest. Like not playing softball for the last nine months has made a ton of time in my life. So I sort of happy about it to be honest. It's it's very nice not to you know, get up at six o'clock in the morning and drive an hour and a half to some dirty hot place and stand in the weeds. swatting, you know, mosquitoes away from your leg. I'm pretty good with that. Plus, I thought my son to watch so I'm okay. Yeah, but But yeah, so it but her her her conflict is more around people's attention. Now. Would you say that outside of diabetes? Does she struggle with that as well? Does she not like attention?

Julie 34:56
Yeah, she doesn't like it at all. Yeah.

Scott Benner 34:59
Yeah. I think See that? We don't know if we've really talked about it here. My wife has a fairly like introverted personality. But she can, you know, she can deal in the real world. Really well, you wouldn't know you wouldn't meet my wife. I think I've just met an introvert. But if you got to see her, the hour after she got home from a large gathering, you'd see an exhausted person from, like, creating that, that energy, you need to be around people, you know, like, I'm, it just works for me. I get around people, and I'm like, ooh, I'll stay stuff and we'll all laugh and it's fun. And you know, like I can that is energizing to me, like, I, I feel pumped up by that even just talking to you. Like, you know, sometimes I think you can probably hear on the podcast, like, I get carried away when I'm talking. I love talking what is happening. My wife, not so much the exact opposite. And if Abigail does not want to be, you know, intersecting with people to begin with, it's got to be incredibly difficult when they start saying what's this and then touching her and she's so new to it still. And that just it sucks that people feel comfortable reaching out and touching people, you know, like, like that, instead of just stepping back? Is it mostly kids? It's not is it adults, too?

Julie 36:15
Um, the older kids. Okay, it's um, you know, 1617 because that's usually who hangs out at the skate

Scott Benner 36:23
park a park. Yeah. And they're not it's not a judgmental thing. You don't think it's just it's intro

Julie 36:28
now? Yeah, it's interest and and they liked it. She skateboarding? I don't think they've ever seen somebody her age. Like a girl especially. Yeah.

Scott Benner 36:38
And you're not having any luck talking her into being like, Look, they like you. This is fun. And she's like, No, tell them not to touch me.

Julie 36:46
And I'm like, Abby, I'm like, I just explained like, she went to water country. And apparently, she put it on Instagram Live the other day. She's like, has anybody ever had people stare at their devices? And I'm like, Eddie, if they're staring. Look at me be like, hey, if you want to look, ask me questions. That's the type of mom I am. I'm like, Dude, don't don't let people bully you. You know, look at them and be like, okay, what's your problem? Right? are you staring at?

Scott Benner 37:10
Yeah, it's, it's, it's and it is so personal, though, too. Because, you know, I'm just lucky on the other end of this because Arden doesn't care. Right? She'll, if you ask her, she'll show you her friends joke around about it all the time. There's the newest thing that they're doing now is when we get in the car somewhere. So I didn't recognize this was happening. So this happened about a half a dozen times before. I was like, why is this happening? But we'd get together with some of her friends for a movie, or they go shopping or something. And I'm always there, because I'm basically a lady. And, you know, I'm with the kids all the time. And, and we're driving somewhere. And I'd be like, hey, Arden, can you you know, you know, I need you to do some insulin. And she'll sometimes she'll say how much or I'll just blurt out a number or something like that. And I and the kids are all like, 783. And I'm like, Wait, what? And so I'm not paying attention. The first couple times. I'm like, Why are these children randomly saying numbers? But I think it's part of whatever they're doing, right? So the other day, we're on our way to Spider Man far from home, me and the girls. And we're all driving in a car. And I said, Hey, Arden, let's you know, let's get ready. Like what are you thinking about? You know, what are you thinking about eating at the movie? Are you thinking of getting anything? And she's like, yeah, I really want one of those icees. And I was like, oh, great sugar and water will. That'll work. And so I was like, okay, that's let's get some insulin going now then. And her friend goes three, and then I hear six. I went, Oh my god, they're guessing the Bolus, like I finally hit me like what they were doing, you know? And I turned around, I was like, you guys are trying to guess how much insulin we're gonna use? And she's like, Oh my god, Mr. Benner, we've been doing that for so long. It's so much fun. We're never right. And I look back, like in the mirror and they're all laughing and smiling. And that's sort of the level of comfort Arden has with it. Yeah, you know, if her, you know, if if she gets low and doesn't do something about it. I can, you can, like hear her friends like art and Come on, don't die. We got to go. Like let's say you're trying to go out like just drink a juice. So we can leave like that. Everyone's very loose about it. But maybe that's just because she was diagnosed at such a young age. She doesn't know any different and your daughter does, like nines are real, like a real person age. You know what I mean? Like she had a life that she understood before she was diagnosed.

Julie 39:30
Yeah, I think I think so. I think it was that awkwardness. And she was already going into that awkward age anyways. So I hope she'll get there at some point. Yeah, um, can we try to help her as much as we can? Of course.

Scott Benner 39:43
How involved is your like, what's the division of labor like on diabetes in your house? Is it because you have a weird schedule is your husband I would imagine just as involved as you are?

Julie 39:53
Absolutely. Yeah. Now, numbers wise, no. But he has involved, like he, he could change the pump, he can change his XCOM. But it's funny because when I listen to your podcast, and I'm only on episode 101, by the way, I'm just letting you know that right off the bat. I started at the beginning. But we, it's funny when you talk about how you when you look at stuff, you're like, Oh, that's going to be about three units. That's how I am. Yeah. So, like, he went to go get them a Slurpee the other day. And he sends me they have a, like a sugar free Slurpee, although it's not really sugar free. I don't know if you've seen it. Sounds. Yeah, it's based off of Powerade. Okay, if you read the fine print under it, it tells you like, it's, it's like six grams of carbs per eight ounces. And so he sent me a picture of what it looks like. And he's like, so it's sugar free. So she doesn't give anything, right. And I'm like, I'm on a zoom in on the phone, you know, really tight. And I'm like eating. I'm like, No, I'm like, so that's like 48 grams. And for eight ounces. And like, Okay, I'm gonna need you to give her 66 per 60 grams of carbs. And he's like, but it's only 48. I'm like, do it for 60. He's like, how did you come up with that? I'm like, just do it. Because I know, because it's liquid and it's gonna hit way different.

Scott Benner 41:17
Right? And so quickly, so you need to be a little a little stronger up front to catch that that initial slam. And then Oh, yeah. Did you have to adjust out of it later, did that number end up working for you?

Julie 41:29
I'm still learning a lot. So it that one hit really good. I'm still learning how to eat out. Things like a pancreas has helped me a lot with that. Actually. That book, we actually had like a we went out to Applebee's and had like a is almost 100 grams of carbs. And we went out to eat which is rare for us. We don't usually have that many grams of carbs. But she never went over 100 but that meal.

Scott Benner 41:51
That's excellent. Fantastic. Yeah, and that's fantastic. And some of those chain restaurants especially are are hard getting any meal like they really are hard on on you know, you can't it's it's difficult to just guess it's not the same as it would be in your house I guess is what I'm saying is you know that you look at a cheeseburger like oh, that's probably like this, but I don't know they have like magic elixir. They put on food in those restaurants so that it tastes extra foodie. You know, it's hard. It's funny. You said think like a pancreas, which is a terrific book. The author of think like a pancreas is the owner of integrated diabetes where Jenny Smith works. So Oh, I didn't know that. Yeah. So when you add because you're listening in order, which by the way, also, Julie, I'd like to say to everyone listening, when you find the podcast and you love it, you should absolutely start at the beginning, I listen to every episode, because it makes it much easier for me to you know, have those contract conversations with the advertisers later when you guys really download all the episodes. So thank you very much joy. But, but But yeah, Gary, Gary is the owner and the operator of integrated diabetes. And when you'll hear Jenny Smith come on and do the pro tip series, as you're listening through, and Jenny works for Gary at his company. So it was very interesting that you just said that it's a great book.

Julie 43:13
Yeah, it is. It is. And it helped a lot discussion during that meal. I did I think his book he said, you know, for high fat meals, you know, do a extended our Temp Basal for like 50% for like six hours and then wait to Bolus after the meal. And I was like, Dude, this is not gonna work. It worked beautifully.

Scott Benner 43:31
It's great. Yeah, it's really something I I've said before, but I had lunch with a person doing like a very low carb diet. And they had a lot of there was a fair amount of meat and you know, fat in this thing that they ate. And they didn't like Bolus for I think like 45 minutes after they ate. It was really but they put in insulin. I was like, this is fascinating. Yeah, it's it's, it's all really but what you just said honestly, is the right amount of insulin at the right time. Like just have to get it in the where it belongs. You know, where when, when there's a need, you need to meet it with insulin, that's all. Yeah, very cool. Okay, so how are things going overall? Are you feeling good? Are you feeling lost? Is it a slow progression? You know, what would you tell people? You know, if I said to you just Hey, how's this diabetes thing going?

Julie 44:24
Um, you know, once you got on the pump, we learned a lot with the Dexcom has been fantastic. I learned how everything works, how food works for her. We learned the doctor we were originally with, he wanted her to have anywhere between 50 and 60. And he wanted to have 60 plus grams of carbs every meal. Unfortunately for Abby, that didn't work for her, that would shoot her straight up and drop crashed her it didn't matter what kind of carbs they were, how we Pre-Bolus how we extended anything. We learned real quick that did work. So at home, we very low carb, very low. I just don't bring it in the house. We splurge when we go out. And so that's worked beautifully, you know, at this point? Well, I don't know about right now because we have to go back in July. But you know, right now we have her down to right about a 681. c. And it's, you know, it's been great. She averages right about 110, hundred and 20. At night, I keep her around 85 to 100. We're doing amazing. I had to get comfortable. And I think I put my email to you that now my husband knows I'm not insane. Because I'm not I'm aggressive with insulin, and I'm not scared of it. He was scared of it. I'm not.

Scott Benner 45:47
Totally let's say that he thinks you're insane about one less thing. Like, let's not get crazy and say that he thinks it's true.

Julie 45:52
Yeah.

I am insane. And it's cool. So am

Scott Benner 45:57
I but I'm just saying that if my wife decided oh my god Scott's actually right about that one thing. She would not make a blanket statement out loud that everything I've ever said about him wasn't right.

Julie 46:09
That's probably true. I'm crazy. In a good way, though. I think,

Unknown Speaker 46:13
Oh, I believe it too.

Julie 46:14
And I think that's because of the scare tactics that they give you in the hospital, which is probably rightfully so that, you know, hey, here's this kid, they have this insulin can save them. However, insulin can also kill them. Yeah. So he was definitely afraid of it. Where I wasn't because I read what 180 and 200 blood sugars can do to them in the long run. And that was an acceptable to me.

Scott Benner 46:37
You guys just chose a different thing to be scared of. That's all like you picked one thing he picked the other thing he picked, actually his brain picked now over later, your brain picked later over now. And and not necessarily over. You know, you didn't say, I don't want this to happen one day. So I'm going to be dangerous about it. Now, you just said, I think this needs more attention right now. So that later doesn't happen. I listen, is in most married situations, there's someone who you would look to for an illness, you know, just a regular illness. And there's someone who, you know, sometimes does the other stuff. It just happens that way. Sometimes, those things inform no differently than you're having a job as a 911 operator, those things inform how you feel about things. And the guy who's not in the room during the flow, might think, Oh, this will pass or it won't be that bad. And you were a mom, so you have that extra gear. You know, I believe there's a, you know, an extra an extra gear in every every mother, that that just is protective in a way that's difficult to you know, put into words. And you didn't just see now you saw the entirety of it, you know, and that's excellent. I think we all need to see that to be perfectly honest.

Julie 47:57
Yeah. Oh, I just I don't know. So hopefully that you know, that would be I think that would be my only advice is to just definitely not have out of continuous glucose monitor though. I don't think I would have done it. I don't think I would. Yeah, yeah. If I couldn't have seen what it would have done to her. You know, at night, they wanted her before the CGM. They want her around 180 I still didn't keep her there. We would put her to bed around 120. And she would wake up around 120 now what she did in between there, I don't know. But she always woke up. I didn't check her at night. They didn't tell me to Yeah.

Unknown Speaker 48:39
I hear you. Um, so

Scott Benner 48:42
I do agree with you. I sat with a teenager, two nights ago, you know, 20 1920 year old guy. And he is just pins and a meter. and has been for like seven years since he's been diagnosed. And he I was at I was with him at a meal where we were going to talk about, you know, I was basically going to give him a crash course in the podcast because we know them personally. And when he took out his meter and tested his blood, and then made this, you know, injection bolus for his meal. My brain was like, Oh my god, I wonder what's happening now. Like, how does this wasn't enough for too much or? And I got I got transported right back to what that felt like. And I because I hadn't been around that in a really long time. You know, that idea of something's going on right now. It's either right or wrong or indifferent maybe. And we have no idea and I said I was like when will you check again? Next thing is like before bed. I was like, it was like seven o'clock. And I was like, oh my god. No, no, no. And and it's so but he's completely comfortable that it's his life and it's how it works for him. is a one He's not where he wants it. It's not bad and it's not good. And, you know, he came into that restaurant with a blood sugar that was almost 200. And that seemed incredibly normal to him. And I just thought, wow, like this is, this is how people feel, you know, when they they don't know any better. And they don't have this technology. It's it's just it's very, it was just very normal for him. Yeah. I just I guess I have to I guess I'm looking for it from you, because you're so new to this still? Is it? Like, how would you describe the difference between before you could see and now?

Julie 50:40
Night and day? I mean, once she was on the two different insolence, I checked her more regularly, not at night, I still I don't, I guess it comes from the mentality when I had babies. You don't wake a sleeping child. I never woke her at night ever. But during the day, I wasn't one to just check her before a meal. And never check her until the next meal, we would check before we would check you know, roughly 30 minutes after and then we would check her an hour after and probably two hours after I wanted to know what was happening. So her poor little finger tips were brutal until we got the G five.

Scott Benner 51:20
Wait, I want to stop you about the overnight thing for a second. Because that's fascinating to me. Because I I can't it's hard to wrap your head around I and why does it matter what your blood sugar is when you're awake, but not when you're asleep? And I'm not coming down on you. I see a lot of people do that. And it's fascinating like the this simple idea that just stops you from looking like well, she's asleep. So that's it, you know, but but those things you were incredibly worried about during the day you just were you magically not worried about them when she was asleep? Or did you just not think about it that way? Or can you describe that because I've never asked anybody right out and you brought it up. So I'm interested in to kind of dig I don't think

Julie 52:01
it's further that I wasn't worried about it. I think it's that there was always a cut off that I didn't give her insulin. So I knew it wasn't active in her body. I knew it wasn't working. So there wasn't really anything that could cause her to go incredibly low. I knew what I was sending her to bed with. And if say she was 110 I knew I was going to give her some chocolate milk or I was going to give her something to bring her slightly up was less of a chance. I knew I just knew how our body worked. There was less of a chance that she was going to go low. And she never did. I mean, let me even rephrase. I'm not gonna say she never did. Because I didn't know. Right. But she never went to a point that she didn't wake up. And I know that's horrible to say. But I was. I mean, I work. You know, between 60 and 80 hours a week, my husband worked 40 hours a week, I go to school full time. So waking up every hour to two hours. And I know it sounds horrible. I love my kids with everything in me. We just we just can't.

Scott Benner 53:05
Yeah, no, so you just use a little bit of chocolate milk or something like that. And and we're gonna kind of err on the side of caution now. Now that you have gear that was very honest of you. By the way. Thank you so much. When now that you have a CGM, would you let her be 150 all night?

Julie 53:23
Absolutely not that interesting.

Now she stays it's like I said between 85 and 100. And she's pretty steady. Right? It's a very rare occasion. She goes well at night.

Scott Benner 53:34
My point is, is if you see a 150 at two o'clock in the morning, are you getting up and correcting it?

Julie 53:41
Yes, yeah.

Yeah. Usually, usually I'm at work. And I'm waking my husband up, like get up and fix that. You must love that. Yeah,

Scott Benner 53:51
you must love waking up to do that. I my wife looks delighted. Even in her sleep. She's like, Scott, that thing's going on. That CGM is going off? I'm like, oh, I'll get it.

Julie 54:01
Yeah, he doesn't hear it. He sleeps like the dead it can be going off right next to him. And I still have to call to wake him up.

Scott Benner 54:07
Oh, I believe that I I have trouble hearing it sometimes. And it gets different more difficult as you you know, like anything else. I sometimes like in a time when I when I was growing up, I lived on a major roadway, like my parents were broken. You know, our house was like on a four lane street that constantly had traffic. And you could invite somebody over to the house that had never been there before. And you could see the look on their face was they could just hear the traffic going by the entire time and those of us who live there, we didn't even hear it. Like it just became background noise, you know. So it's just what, you know what you just said, but like I said, was incredibly honest about like, Look, I needed to sleep, there's no way around it. So we make our blood sugar a little higher so that everybody can do that. And then the minute you saw what that really meant, like in real terms, like looking at it on a graph. He said, oh god, I can't let this happen. I'm gonna push it Down here and find a way to do this. But you couldn't have done it blindly. Because because it just would have seemed too dangerous. And it very well may have been to put her blood sugar at 80 and hope that it like stayed there all night without being able to check it. It's a very unfair disease. It sucks that we're standing here saying that like without this technology, I've got to err on the side of caution. And what that means is a raise blood sugar and everything that comes with it. It's not fair. It's just it's I feel like I just felt incredibly sad for you as you were saying it and yet I did the same thing years ago. And at the time, I did not feel sad for myself. I just thought I was doing the best I could, you know?

Julie 55:42
Yeah, Dexcom should be standard issue or some type of CGM should be standard issue when you leave a hospital.

Scott Benner 55:48
On this podcast, we don't talk about other CGM. But I hear what you're saying. And I'm just kidding.

Julie 55:54
Yeah, but it's, I mean, they should it should be standard issue. Um, oh,

Scott Benner 55:59
no, I've said it before. Like, if you had a heart issue, they'd put you on a heart monitor, they wouldn't go, let's just hope your heart's Okay. Go ahead home. And we'll just hope, you know, like, it's, now this stuff exists. And you see what it does. And you can also see what happens if someone lives so long without it. And all of a sudden, you give them the information, it can be overwhelming. You don't I mean, so just like diabetes itself, and all the other things that come with it. I say get it early. It's everything's uncomfortable in the beginning Anyway, you get accustomed to it, you'll learn as you grow, and then it just becomes a, you know, a simple part of your life. To me, that's the best way. I mean, obviously, anybody can do whatever they want. If you're listening right now, you're like, I don't want to see gentlemen, I'm doing fine. Like, right on, I don't care. You know what I mean? Like, do what I need to do. I'm my experience. So. But I agree with you. I really do. I just, I don't see, I know for certain that the things we talked about on this podcast management wise become much more difficult and intensive. Without a glucose monitor, then you're testing more frequently, you're probably not being as aggressive as you want to be, which I'm assuming leads to more like misses on insulin and higher blood sugars and things like that. And how do you correct that blood sugar when you don't know? You know, like, like, when you don't have that information? Like how do you make this like, like bold decision to put in a bunch of insulin? To get a head of a Slurpee get on a man? Something like that?

Julie 57:27
Absolutely. Yeah.

Scott Benner 57:29
So when you guys make insulin, you don't when you're not at home? Does he always contact your husband always contact you and say, Hey, this is dinner. What should I do here? Or does he get it? Get it sometimes on his own? Or do you guys talk about it

Julie 57:42
every time? Not always know. He's gotten much better at it. Especially since we've gotten the pump. He's I don't want to talk bad, but he would agree he's bad at math. So when we were on MDI, he doesn't, he doesn't like math at all. But once we've gotten the pump, and it kind of does for him, he's he's fine with it. But if he's eating out, and it's not that standard meal, because I cook every day, like we have a two week menu, I cook meals every day. So he's got the carb counts. He knows what they are. That he's fine with that if he's at taking the girls out to dinner like they're going to Busch Gardens this weekend. I'm sure I'll get phone calls. Yeah, like Hey, hey, we're,

Scott Benner 58:28
yeah, that's activity and heat. And then I'm assuming some weird soft pretzel. It's probably not even flour because it was made six years ago and it's for sale at Busch Gardens. And you know, like all that other stuff. Ya know, there you need a little bit of a I don't know little Zen little ninja little judges, whatever you gonna call it? Right? Yeah, just that kind of feeling where you can just go out. I know what that is. I in this situation. That's very cool. And texting I would imagine is like a huge part of it.

Julie 58:55
Oh, yeah. We're hoping to get that in the school next year. We'll see how that goes.

Scott Benner 59:00
Oh, you're gonna you're trying to manage the way we do like, just with the kind of direct contact? Is she going to the nurse right now?

Julie 59:07
Um, yeah. And that was that was mostly on the it wasn't anything with the school. The schools actually phenomenal. The doctor was the problem. So we've since changed doctors.

Scott Benner 59:19
Gotcha.

Julie 59:20
Oh, yeah. We like our new

Scott Benner 59:22
doctor a lot. A wonderful note from a person last night. That said, that thing we talked about all the time happened to them. They were like, I would just heard you talking about this in an episode yesterday. I it happened to me, I have my great agency and my doctor yelled at me and told me to make it higher. And then the rest of it said so you know i? I have another appointment three months from now, but with a different doctor. I was like, Wow, good for you. Like that was just that person did not take that crap for one second. Like I've been working at this so hard. I randomly bumped into a podcast like you can't take this from me like I'm an adult with diabetes. Like I just got this right and you're gonna come along Don't say no, I'm not doing this with you and didn't even didn't argue with them just was like, Yeah, okay, thanks. Thanks. Thanks. Got their prescriptions left change doctors.

Julie 1:00:10
Yeah, I think that's the only thing I would you know, advise any, is stick up for your kids. But if your kid you know, I think are the doctor we had, he was fantastic. Please don't get me wrong he's a fantastic doctor, but he thinks every kid is the same. And it came down to our fork in the road was during sLl to shear I don't know if you're familiar with sLl in school that standardized testing that Virginia has tried

Scott Benner 1:00:36
to get out of luck. Now I have to put a beep in dammit.

Unknown Speaker 1:00:42
That's what I thought.

Julie 1:00:45
It is kind of what else me but it's standardized testing in Virginia. And it's a massive test that they prepare for all year. And Abby has horrible anxiety with tests. And her blood sugar's go through the roof. It happened last year. And and I tried to get them to manage it in the test, like having have her cell phone with the proctor where I could text and say, Hey, she needs to do this. So she wouldn't have to leave the test because the way it works, they have to stop the test for everybody. She has to leave. And they keep the test stop until she comes back. That's her she was ridiculous. Yeah, that's not right.

Scott Benner 1:01:25
That's what Arden does. Arden has the has the phone in the test. I will say this. It took a meeting. It took me getting a person in the on you know, at the school level on my side for the idea that person had to go to the state and advocate for me the state actually listened. And now in New Jersey, if you live in New Jersey, guys, you can press now for that because we did it now they're okay with it. So you can do it too. But yeah, Arden's phone stays with the proctor and I'll text and be like, you know, just point six, the proctor season walks over to where holds the phone up, and she gives herself insulin and you know, she does the point six or whatever it is, and she's on her way.

Julie 1:02:09
Well, the school had no problem with it. It was it was her medical plan. And so I had to have the medical plan change. And when I called him and asked, I was like, Hey, can we get this change? Because you guys were planning on making her independent next year anyways, that middle school, he was like, I'm not making her independent Middle School, probably not in high school. I'm like, whoa, wait a minute. What? Wait,

Scott Benner 1:02:32
what somebody's gonna end in this situation is gonna be me from you.

Julie 1:02:36
Right? And I was like, I was like, Okay, I was like, well handle that the next deployment when I'm face to face with you. However, at this moment, I was like, she goes up to three and 400. And he's like three and 400 for a 30 minute test isn't a problem. I was like, it's not a 30 minute test. It's a four hour test for the next four days, four times in a month. And he's like, that won't hurt her. I was like, Oh, no, I was like, this is a problem. I was like, this is a serious problem, it will hurt her.

Scott Benner 1:03:05
I don't understand if your doctor doesn't know that. Or if your doctor just is trying to comfort you and thinks there's no way to fix it. But I would just say to anybody, if you if you're not involved with a medical professional, who's willing to sit down and figure something out that fits your life, you're with the wrong person. Like whatever it is, like, forget diabetes for a second, just you need to be able to say, look, I have a specific situation. This is it. Let's all put our heads together for a half a second come up with an idea, especially you who came up with an idea. You're like, Look, this will work. I know for sure. Because there's a guy on the internet that told me it worked. And so you know, I get that part. Maybe you don't tell him that part. Right. But but like I had this great idea. And this is gonna work, all I need to do is like change this sentence here in her medical order that and then the school will go with it. And that's it. And and to tell you that maybe I won't let her be independent, even into high school. Who is he? I don't like that at all. That may I guess, is this doctor over? 50 years old? Yeah, yeah, you need younger, younger, more agile thinkers. Not people who have been doing lacks the same way for decades. You know?

Julie 1:04:14
I think the problem is, is he thinks that he's the only doctor in the area and probably for people that way he is but we live so far. West that I drive an hour and a half because that office is it is so I go an hour and a half the other way I hit Richmond. Gotcha.

Scott Benner 1:04:30
So he doesn't have a monopoly on you. You're already you're already making a day of it. So right. I might as well make a day of it and go talk to somebody else. Boy, that's just that's terrible. I hope that person is listening. And if they are, I don't like what you do. But for everybody else, stick up for yourselves. do what's right. When somebody won't let you do what's right. Find somebody who will there always will be someone out there. And I mean, listen, Joey's driving an hour and a half, which by the way, oh my god. I'm so sorry. I think our endo is like eight minutes from the house as I'm driving all the way over here, you know, so

Julie 1:05:08
you probably have more traffic than I do too, though, so I don't have much traffic.

Scott Benner 1:05:11
Oh, there's something here. Yeah, I hear you. So is that did Abigail make it through the whole hour in that room watching you do this?

Julie 1:05:21
Yeah, she's still there.

Oh, no, no, no, she left the board. She bailed on.

Unknown Speaker 1:05:27
How long did she make it?

Julie 1:05:31
About 40 minutes. She did pretty well. She's on her phone.

Scott Benner 1:05:33
Nice. That's nice. I was gonna try to say goodbye to her if she was still there. But she's gone. We've done a terrific hour together. Thank you very much. Are you still nervous now? Or has it passed?

Julie 1:05:44
No, no, I'm good. I'm good.

Scott Benner 1:05:47
Should we start over? You can really jump into it right now. Trust me, that doesn't go well. I had a technical problem once and we I literally interviewed a person and then had to interview them right away again right afterwards. And it's tiring in the second hour. I'll tell you that much. Joy, just I really appreciate coming on. You were incredibly honest about some difficult things that I think people will be will find a lot of commonality. And I think he helps some people today. So thank you very much for doing this.

Julie 1:06:17
Oh, good. Thanks for having me. Absolutely.

Scott Benner 1:06:21
Huge thanks to Julie for coming on and telling her family story around type one diabetes. She was incredibly honest number of times. And I really think that's why the podcast is, is what it is. It's pretty cool that people are willing to come on and do that. So thank you, Julie. Thank you all so Dexcom and Omni pod for sponsoring this show. I appreciate it greatly. dexcom.com forward slash juice box, my Omni pod comm forward slash juice box. There's also links in your show notes at Juicebox podcast.com. Check out the sponsors. Click the links, please. And thank you. Alright, guys, it's the end of April. I don't know about you. We've now been inside for 123456 weeks, three days, six weeks and three days. Quick. Math tells me six times seven is 4242 plus 345. By the time you hear this, it'll be tomorrow. Let's call it 4646 days in my home 46 days in your home. Hope you're not getting stir crazy. I found myself actually bored the other day, just bored. And I sat down. I was just like, Alright, I'm gonna stop, like, ignore the feeling that I'm always supposed to be doing something. sat down. Kelly sat down. Cole sat down, Arden sat down. We're all sitting around the table doing nothing. We're there for 10 minutes, I swear to you, people are quiet. Some people are looking at videos working on homework, just sitting I was reading something. I'm thinking about getting a new grill, I was reading about a grill and art and goes, Hey, this is really weird. What are we doing? It shouldn't be weird that we were all just sort of sitting together for a couple of minutes. So you know, interesting. Anyway, hopefully we'll all be out and about soon, but not before it's safe and right to do. But definitely before I give in to the odd impulse to buy a drone. Now, keep in mind, I could never fly a drone. I know for 100% certainty that if I had a drone, it would go up in the air and turn upside down and crash right into the ground. I have no spatial awareness around things when they get out of sync with me. Like I can drive and I mean, but that's because I'm looking through the car. The minute you point the car the other way and keep me in control of it. Not going to go well. So I have to fight off the urge to look into buying a drone about every three days during our shut in period. I don't know why it is I think it's something in me that thinks it would be amazing to fly it away and be able to see things which maybe it would be but the the intelligence side of my brain that knows that I would just crash the damn thing in five seconds. Plus, I don't want to buy it. It's very expensive. There is I can tell. Anyway, that is one of the urges I'm fighting off during the during our time of incarceration. I wonder if you're not doing the same if there's not something that every day you're stopping yourself from buying just like I don't want this I don't need this but so bored. But then you know, I realized it would come in a box and then what would I do and have to redo the expert What do you people do do you spray the box with Lysol or wipe it down with wipes or something and then did like a special place open boxes in the house that then gets like completely wiped down in the box gets you know incinerated right away. You'll laid on fire and wash your hands like up to your elbows like you're gonna do surgery. That's that's the get the mail, right? That's the meat the Amazon guy. So anyway, that's how I talked myself out of it. I'm like, I don't wanna have to unbox it. But the truth is, I would crush it tree. Okay, guys, I really appreciate that you're listening. podcasts are down. Some say 17%. during April, do the Coronavirus This podcast is not down nearly that much. I do miss you guys commuting a little bit. There's a couple of shows in there. You're not catching because you're at home. But uh, you know, I respect you. I respect that you're, you've got a different situation right now. We'll get back into the car one day and start listening. I'm good. But I don't have a 17% drop is what I'm saying. And that is in large part due to you I so I really appreciate it. Please continue to share the show if you're enjoying it. And I just really appreciate you all. Please stay safe. Wash your hands.

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Please support the sponsors - Contour Next One

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#328 Ask Scott and Jenny: Facebook LIVE Edition

Answers to Your Diabetes Questions…

Ask Scott and Jenny, Answers to Your Diabetes Questions LIVE on Facebook.

• How do I attack meals that cause spike without crashing later? Is it with a longer pre bolus? More insulin? How to evaluate your bolus strategy.

• Any recommendations for helping with Freestyle Libre accuracy?

• What are the pros and cons of CGMs being used on patients in hospital settings?

• What is the best way to tackle losing weight for a type 1?

• Should I calibrate Dexcom on day one if off and how do you manage that if using an algorithm?

• How do you know if it’s a bad site or another variable?

• What are good tips for managing diabetes when you are trying to get pregnant?

• Is there anything physiologically wrong with a post meal spike if it comes down later without extra insulin? Should we try to master that meal?

• Let’s talk about pod changes and patterns.

• Is it possible to have the opposite of Feet on the floor?

• Let’s talk about female sex hormones.

• How do you manage the inconsistent eating pace of a toddler?

• What is honeymooning?

• Is there a cure on the horizon and near future?

• How do you manage kids and growth hormones? Finding the right amount of insulin.

• Can you explain insulin deficit?

• How do you manage unexpected diabetes variables like unplanned exercise, sudden stress?

• How do you know when to start eating when pre bolusing and looking at the Dexcom arrows?

• What factors affect the hypoglycemic risk value on the Dexcom Clarity app?

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Pandora - Spotify - Amazon Alexa - Google Podcasts - iHeart Radio -  Radio Public or their favorite podcast app.

+ Click for EPISODE TRANSCRIPT

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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 0:01
Hello, everyone, and welcome to Episode 328 of the Juicebox. Podcast. Today's show is the audio from a recent ask Scott and Jenny, Facebook Live. Now the audio is super good. It's clean, clean the way you like it on a podcast. Don't worry, it's not all Facebook. It's not like Jenny's like, I think that we should do this thing with the input doesn't sound like that at all. Sounds crisp and clear. Right? Imagine Wolf Man jack and your house is like, hey, their kids. No one knows who that is. But that's not the point. The point is, it's a good recording for podcasting. And I didn't want you guys to be left out. So I was just trying to do a little live thing on Facebook if people you know, something to do during the day while they're trapped in their house. But then I wanted to get that audio right up here for you guys to listen to, in your ears the way podcasts are supposed to be heard. Anyway, Jenny and I started with one question from my ask Scott Jenny list. And then we let the viewers of the live ask the rest of the questions. I thought it went great. actually had a fun time was nice to hear from everybody. I'm giving you this episode. As a bonus this week. This is the third episode this week. So there won't be any ads on it. But it isn't going to stop me from mentioning the advertisers so that you remember that the good people at Dexcom on the pod Contour Next One blood glucose meter and touched by type one are the reason why I could be messing around yesterday doing a Facebook Live. So I'm gonna put links at the end. And they're going to be in the show notes here. If you'd like to check out any of the sponsors, clicking on the links is very helpful to me. And I appreciate when you do it. Alright, so let's get to it. This is episode one. I say 328. It's a live ask Scott and Jenny from Facebook. And you need to remember while you're listening to it that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please always consult a physician before making any changes to your health care plan. We're becoming bold with insulin. And just like that, you're listening to Scott and Jenny. redirecting to Facebook. Oh, there it is. I'm making a funny face. There we go. We're alive. Oh, that was easy. Okay, so obviously, it's gonna take a couple of minutes for people to get on. Gonna first say that. I'm Scott Benner. This is Jenny Smith. You may know Jenny and I from the diabetes pro tip episodes on the Juicebox Podcast. Jenny also does ask Scott and Jenny and defining diabetes. And today we thought we would do an ask Scott and Jenny live. Now we have a question to get started with that came from one of you. But we're totally willing to see some questions from other people. So first, I need somebody in the chat on Facebook. Tell me if you can hear me and Jenny Say something. See if I can hear you.

Unknown Speaker 2:53
Hello. Okay.

Scott Benner 2:55
Just somebody tell me in the comments if if you can hear us. Oh, hi, Maddie, how are you? Have you never seen Jenny live before?

We already have 18 people? Awesome. 24. We'll start right at three o'clock because you guys are on time. I like prompt.

Jennifer Smith, CDE 3:18
You got a minute or maybe less? I don't know my plaxis 150 or 259.

Scott Benner 3:23
They should definitely be everybody can hear. Cool. All right. They should definitely be rewarded for being on time that people will come later. Gonna have to watch, you know, watch the replay or hear it on the podcast. I can hear both of you. All right, Laura. Thank you. Whoo. All right. So if you guys have questions, throw them in there. And we'll see what we can do. But Jenny and I thought we would start with let's see, I have it here. I have it here. Here it is. Um, oh, you know what, before we start, did you guys know that? I'm Jenny. I'm gonna give your phone a few days here. Jenny Smith is an RD LD CDE T one day. She has a bachelor's degree in human nutrition and biology from the University of Wisconsin. She's a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes a pumps and continuous glucose monitoring systems. Jenny has had Type One Diabetes for how long journey

Jennifer Smith, CDE 4:17
on May 15. It will be 32 years. Okay, so that's a long time.

Scott Benner 4:23
And that is definitely a long time. So any of you who have heard us on the show before? No. This is basically what you know, it looks like for Jenny and I when we record and you guys just don't usually get to hear so we're gonna get started with the first question. Yeah, it's how do I attack meals or times of day that cause a huge spike, but come down eventually. If more insulin is added, I go low later, when I wait longer, like when I Pre-Bolus I go low earlier in the meal. Now by the way, guys, there's a disclaimer here. We're not healthcare professionals. This is not advice in this cause, just us talking and you hanging out so if everybody's okay with that. Cool if you're not jumping, all right, I went, we did not do any problems for you people just get it. You don't like it? Okay. All right. All right, Jenny. So I, you know, I hear this question a lot. I tried to Pre-Bolus. But I got low before I ate or, you know, I tried to shorter Pre-Bolus. And I just got high later, what are some of the reasons that can happen?

Jennifer Smith, CDE 5:23
So to begin with beginning of the question would be your bolusing getting high, and eventually, without correction, it comes down. That initially would be a bolus timing thing, right, where you need to Bolus sooner to stop the rise. It's an indication that there is enough insulin there because ultimately, the Bolus you took does get you down to where you want it to get later after the meal. There's just not enough time between taking the insulin letting it get started, and the food actually impacted blood sugar. But the further part of the question sounds more like if you add more insulin, like upfront thinking there wasn't enough to begin with or you correct, and then you end up going low in either of those scenarios. Clearly, there was too much insulin, right, you didn't need more insulin, you just did it in a different bit of timing for taking it right. The third part of it. So like little segments here. The third part of it really is, if you do take the amount based on your ratio, you end up climbing, or you Pre-Bolus with enough time, and you end up sinking within the time period after you Bolus, but then you still climb up later. That could be especially for those who are using an insulin pump. That could be not only a timing issue, but also a delivery of insulin issue. Okay, right, where you would probably need to use all the pumps have some type of extended bolus feature. Could it be combo bolus extended bolus dual or squarewave. bolus, all the pumps call it something different. But essentially, it allows you to take a certain percentage up front, potentially in this scenario to stop the bump up, gives you let's say you decided to take 50% of the Bolus now and then distribute the other 50% in the back end, what it allows is the 50%, you take now you can Pre-Bolus thus decreasing the amount at the beginning that you get. So you don't have a drop, but you also get the Pre-Bolus benefit of not having that rise up after the meal. And then the later impact is that you still get a finish of that end of insulin, which you knew was enough. You just needed to distribute it a little bit longer to impact, you know, the full content of whatever this meal, I guess, added.

Scott Benner 7:50
Okay. And I like obviously I agree with you. But what I was gonna say is that when when I see that I don't often see a Pre-Bolus It's so like heavy that she crashes before she gets low. And so I think that ends up being a situation where people are like, well, I Pre-Bolus and then I got high anyway. So I'll keep trying longer and longer and longer. But it's not at some point, the length of the Pre-Bolus is just not your issue. You know, and and I hate to I don't want to put a number on it. But you know, if your Pre-Bolus thing, 30 minutes in the future, you're probably coming out of a much higher blood sugar to begin with, and you have issues on the back end that you're not dealing with. I find myself saying a lot that diabetes, using insulin specifically is like time travel, everything you do now is for later, right, right. But everything that's happening to you now is from before. So if you're putting in a healthy Pre-Bolus, like you said on a good site that you can count on, etc. And you're you know, you're still climbing afterwards. I mean, the Pre-Bolus probably at this point isn't the question. And there's little things for CGM users, you can kind of look at the trend, the angle of the trend, right. So if you're, if you're shooting straight up like this, you've either missed, I think, huge with the amount of insulin you're using, or you know, if you just bolus and five minutes later start eating a real sugary thing. You're going to shoot straight up, if you come more on that, that kind of gentle rise that I tried to describe as the it's the minor or no, not the minor, like the the mountain climber on the prices, right? Any guy keeps like rolling back and forth like this, right? Because when you have a Dexcom and you you have that gradual lineup, everyone's done it, they stare at it, they're like it's gonna stop, it's gonna stop, it's gonna stop and then eventually that guy falls off the end and true Carrie says you can't have the money and it's all over right and your blood sugar's 280. And, and then that's sort of the end of it. So like Jenny's saying, there's just 1000 different ways. But in the end, what you're trying to do is manipulate your insulin and put it where it's needed. So you need that nice Pre-Bolus but if an hour later You started having this crazy rise, like she said, an extended bolus, or even coming back and readdressing with more insulin, at some point is the answer you get low later, when you put so much insulin up front, to control that line, that eventually when the impact of the food goes away out here in the future, the insulin still leftover and you crash low. So you've got to, you know, for the lack of a better term, you have to put the insulin where it's needed. I always say when you're about, you know, you have to address your body's need with with the right amount of insulin. So, right, that's cool. That's a really it's a great question. I appreciate that question. And people have left other questions. So dig in here, and see what I can

Unknown Speaker 10:40
love questions, right? Oh, yeah. But I'm

Scott Benner 10:43
on the wrong browser to see I got to get into it. Everybody chill out a second, this is my first time doing this. So a lot of pressure, like running the show, and

Unknown Speaker 10:52
like asking the questions.

Scott Benner 10:54
I was gonna feel under pressure here. Alright, I'm on a different browser. So one browser is sending you guys the Facebook Live? And then I'm going to look on a different one. Where am I looking at? I mean, the wrong I have too many Facebook groups.

Jennifer Smith, CDE 11:16
While you're looking, I'm going to add something extra to that comment. And question from before to it you were talking about, you know, the trend kind of even coming into the meal. And that can definitely determine things, you know, if you were if you were at an excessive insulin coming into a meal, and you are already on this slope headed down, right, and or if that's commonly happening within the same meal time, it could be that your Pre-Bolus thing with a load of extra previous insulin on board. Thus, you're consistently coming down in this time period of the day. And so any Pre-Bolus, it's going to look like that Pre-Bolus is causing you to drop within the first time period of that meal. So you're less likely to Pre-Bolus as much as you need to from previous experience. And thus you're getting this rise up that you wouldn't have if the hours leading into this meal. Again, if it was a consistent problem at this time of day, it sounds like the hours ahead in this setting, could need to be evaluated. Maybe the bazel is too high heading into this meal, okay, or maybe the insulin to carb from a snack three hours ago, is also giving you too much insulin. So you're consistently coasting down into this meal time. So you've got this excess behind the scenes insulin. So are some other things that could be evaluated to cool.

Scott Benner 12:36
Alright. And somebody said I was lower than you. So I just turned my voice up. So if I got if I'm now too loud, somebody told me. All right, Anna asks, I have been having trouble with the accuracy of my freestyle libri. Sometimes there's a big difference. I think I will change Dexcom was I finished? The my inventory I currently have at home. But do you have any recommendations in the meantime? While I'm using these?

Unknown Speaker 12:59
That's a good question.

Unknown Speaker 13:00
Yeah. Is there an answer?

Jennifer Smith, CDE 13:02
Well, is there anything to adjust? There's nothing from our, from our practice, all all of us within our practice. At integrated, we've all used the libri all got our like trial, you know, couple of sensors to try out and I try to as many people often do you make yourself the guinea pig, right, you try a couple products at one time to see what's actually Right, right. So I wore my Dexcom along with the lever a and the three sensors of the libri that I wore, they were all consistently reading lower than my actual sensed Dexcom and fingerstick values were consistently center to center they were all consistently different. And enough that from a blood sugar and a meal bolus and a correction standpoint strategy, it would have been enough of a difference to make adjustments kind of diff difficult to base off of, is there anything that you can do about it? In this setting, what we usually recommend is for the prime times that insulin is going to be dosed based on a glucose value, do a finger stick, get a finger stick and dose off the finger stick don't dose off of your libri what you can know from any sensor system that might be reading a little bit off or different than you know it should be is that while there is a difference in the number, the trend is still a good, it's still a value for you. So you can still tell whenever you're trending up or trending down, and you can use that to your advantage for future planning. Okay, so but you wouldn't necessarily dose off the value.

Scott Benner 14:43
So um, I guess what he's saying is when you find you're not trusting the device, test, but still look for I mean, I guess I've never used the library but arrows and direction and rate of change and stuff like that. And then when you really need to know I guess what we're saying? Is that if it's a pre meal, and it says you're 120, but you think you might be 150. That's important to know when you're making your Bolus, right. Okay. But Hmm, it's still important. I don't want to minimize the idea that a big a big difference is a problem, but at least you can be safe. When you're when you're putting in like more when you're

Jennifer Smith, CDE 15:19
putting in insulin. Yeah,

Unknown Speaker 15:21
yeah. Cool. So,

Jennifer Smith, CDE 15:23
to let her know that that's not uncommon. Gotcha. A lot of people find the variants,

Scott Benner 15:27
it's gonna be hard to keep. See, I want to, we only have an hour, so I need to keep Jenny movie but Jenny will talk and like, get all her knowledge out. And then we're gonna answer one of your questions if we do that. So Maddie, how do you Jenny see CGM being used in patient hospital settings now that we're seeing COVID-19 error How is going to help diabetics? And Maddie, what I'll say to you is, did you hear the episode of the podcast that went up today? Because Dr. Dan disalvo came on and talked about how decks coms are being used in hospitals right now. But so I have something to add, but you go first.

Jennifer Smith, CDE 16:00
That's pretty awesome. Because I have I've not obviously listened. I've been working with people all day. So I'm, so I have I both pro and con feelings to it. Okay, so from the standpoint that great, there's a lot more information, there's a lot more data, it can be beneficial. On the con side, however, there's a lot of data, and healthcare workers in hospital who we already know, have have little experience with type one, consistent glucose information management, they are used to doing finger sticks every several hours, to base decisions on right, whether it's dosing or whatever adjustments in doses. With all of this extra information, the trends, the alarms, the things that are going to be visible to them. Yeah. There's no, there's no quick education that can be done within 10 minutes to the thousands of health care, nurses, doctors, whoever that's looking at this information to help the person wearing it. Yeah. I feel like there's a lot of information, they're not going to know what to do with it. So that's what I feel like I feel like it's good. But it's also, I don't know,

Scott Benner 17:20
let me share with you what Dan said. Dr. salvo told me that what it was really helpful with in the moment was, it was preserving PP for nurses because they were, you know, they do finger sticks on patients a lot. And now you're asking them to go in and out and change their gear every time. So now they're, I guess, Dexcom. If I, if I heard him, right, gave the patients like Android phones. And so there's a cloud service. And now the nurses are able to look at the patients through the share and follow, right? And then they're like, okay, you know, they come down the line. And here's Mary and Mary's blood sugar's this, it seems pretty reasonable. I don't need to go in there. So that was the idea. What I heard while he was talking was a great opportunity nationwide for health care professionals to see how glucose monitoring works, right. And maybe, maybe in the future, things will go better. I told him a story of when Arden had a surgery. And you know, the nurse didn't know anything about it. I just kept talking to nurses till I found wonders like I have a friend who has diabetes, I go, you're my friend. Now come over here and explain to all these people why we need to leave the CGM honor during this procedure. But anyway, that's what I thought of it, Matty, I thought it was I think it's, um, it's great for that saving of the PP. And on the other side, I think it's a good first step in bringing the technology out to people. So

Jennifer Smith, CDE 18:35
yes, yeah. I also think, you know, in that scenario, as if they're using it based on the protocol that they would have used finger sticks, and they're only checking at certain points to see what the values are or responding to alarms. Yeah, it's absolutely valuable. I just hope that I would expect somebody has schooled them in what to pay attention to what not my, my

Scott Benner 18:57
thought was that it was, it was going to be used in a really, I don't know, like a limited way in the beginning. Just to keep you know, from being with people. I saw Donnie ask about managing weight with type one. So and he said, Thank you for being here. So thank you very much, Danny for being here as well. Yeah. Best way to tackle losing weight for type one. Why do why can people with diabetes who are using insulin have trouble with weight loss?

Jennifer Smith, CDE 19:24
The first thing is definitely insulin management. That's that's a huge piece of it. Because insulin is a storage hormone. It's meant to move food glucose out of the system into the cells, either it gets used by your muscles or it gets packed away into fat, right? So from a physiology standpoint, even if you look at a body that doesn't have diabetes, if you out eat what you really need, then overall your body can only pack away that extra calorie, right? Okay, and it does it with insulin. Right to manage the normal blood sugars that should be there. Same thing is happening though. And so person, even without diabetes can gain weight, that that's how they gain weight. Essentially, their body should packing away more than what they needed because their body is managing blood sugar the right way. In a body with diabetes, though, because insulin management is something that we control, body's no longer doing it for us. It's something that we have to, we have to adjust more precisely than people are often given tools to manage. Right. So overall, one, make sure that your baseline dose that bazel is right to begin with, it's in the right place, then the next thing to tackle is the food management, strategizing around meals timings, you're not using more insulin to cover then you actually need to, you're not covering with extra food when drops happen, because you used too much insulin that you didn't really need to have there. And then the other piece, of course, beyond that is, are you eating what your body needs to eat? You know, because if even in this case, if you've got great looking blood sugars, but you're constantly like popping food in and covering it with insulin, you could have wonderful looking blood sugar values, you could still be out eating what you need.

Scott Benner 21:17
Right? So I usually it's funny, I saw john pop in and he said, Don't feed your insulin, which is this is what I was gonna say. I think I think that when people who listen to the podcast have, there's two trains of thought, when you're learning how to use the insulin in the beginning, I will say be more aggressive, you can always have juice later. I don't mean that for the rest of time In Memoriam. I mean, while you're figuring it out, like if you continue to bolus and get low, fix the bolus, don't keep fit, you know, don't keep drinking juice. But it's a great point. Because people with type one can start to think of diabetes first. And instead of health, right, so all of a sudden, an Oreo cookie is not a bad thing, because I need it because I'm getting low, except your real issue is you need to stop yourself from getting low. So you don't have to eat an unscheduled Oreo. And by the way, don't eat Oreos, they're, they're poison. But But you know, like, I really I don't think there's any food in them whatsoever. But my point is, is that don't feed the insulin, but learn the steps so that you can do that. And Jenny, this is a wonderful place to say that diabetes pro tip calm is now open and available to find all the diabetes pro tips with Jenny and I all in one place in case you guys have had trouble finding them in the podcast player.

Jennifer Smith, CDE 22:34
Yes. And we've also gone over that weight piece in there. It's a great episode at least one if not a couple mentions.

Scott Benner 22:42
Yeah. All right. I have. I have one for you. And one for here's a quick one. Yeah, Jenny, you are g six. And so does Arden. Do you ever calibrate on day one? If it's off? No, you don't you let it go?

Unknown Speaker 22:57
Let it go.

Scott Benner 22:58
And how do you manage that with your algorithm that you're using?

Jennifer Smith, CDE 23:02
I manage it by doing finger sticks. Because I have had, as we talked about right away. I've had diabetes long enough that finger sticks have always been a norm. Even once things got approved for not having to do that anymore. I still do that. So that's my thing. And with the algorithm that I use for my insulin management, I can I can populate in my finger stick value for my algorithm to use that value rather than the CGM value. And then I get proper dose adjustment.

Scott Benner 23:41
And you have an apple iphone, right?

Unknown Speaker 23:43
I do. So you go Apple Health,

Scott Benner 23:45
you go into the health kit, and you tell it, you add your blood sugar there, and then that program you're using, yes, the loop app will see it and then it knows what your posture is. Correct. And so my my way of dealing with it is if it's close eye roll, you know to me like if and I test to their their advertisers on the show, but we use the Contour Next One meter, I find it to be incredibly accurate. And so in those first number of hours while the sensor wire still you know, baking in, I will test but I'm going to tell you that if it says she's 70 and she's really you know, and she's really 90, I might let it go a little longer to see what happens. But there are times I do calibrate to get it together. It's not a frequent thing. I probably only calibrate on day one when I calibrate but having said that we don't do it very often law we leave the finger sticks though

Jennifer Smith, CDE 24:42
and there are a There's your so many that trains of thought in terms of that that I've run into in working with people, some people who've got this like system, it works really well for them. Awesome, great, even if it's not what's recommended if it's working for you. I'm not going to tell you this Stop doing that. Right. But from the standpoint of education, you know, we recommend following the recommendations of Dexcom. Don't calibrate in the first 24 hours,

Scott Benner 25:13
you would never do anything like that. Somebody asked for links, I just put them in the comments. And honestly, Jenny and I are not used to being seen we, you know, I mean, for those of you who are new, I have a podcast called the Juicebox Podcast, and Jenny is a frequent contributor to it. And she's not on every episode. So if you really like her, and you hate me, you're gonna be pissed when you like tune in today, and she's not there. But anyway, calibration day one. Actually, that's sort of covered. The next question I had for you. If there's a person who is excited about algo, their algorithm pumping in the in the future, right, but is worried that because they don't always see their CGM rock, you know, rock solid, and they're afraid of what's gonna happen next, what I would say to that is, you know, Arden has definitely done both ways. And it's never been an issue. Like, I've never ran around the house going, like, Oh, my God, everyone's gonna die. Because you know, Dexcom was off and we're using an algorithm, it just, it's a it's a reasonable worry if you've never done it, but once you do it, I don't think it's something you'll think about again, does that strike you like that?

Jennifer Smith, CDE 26:19
No, it does. And it's actually a question that I've gotten more than a number of times from people that I work with, especially parents of kids, you know, wondering, Well, what about those? compression lows? Right? What happens if an algorithm is using that? And now it's not really low? What will have happened? Well, you know what, because the system if you're using one of these hybrid types of systems, whether it's, you know, on the market, or yet to be on the market, um, if you're using one of them, it's going to adjust based on that change in blood sugar, that's being seen, right. But most often, especially in this example, of a compression low, that writes itself pretty quickly. In fact, you can tell it's a compression low, because it looks like your blood sugar is literally like nosedived off of a cliff. Yeah. And then it comes back up very quickly. I mean, you could you can tell it's wrong. Well, yes, the system will have reacted to that drop in blood sugar, it may have taken away insulin where it was supposed to, but within the quick timeframe of it writing itself, that algorithms also going to write what it took away behind that, right. So I've personally, I've had sensors that have been off, thankfully, not very many, my Dexcom, thankfully, has been very accurate for me. In all the years, I've used it. But I have had compression lows. And since I've been using, you know, this algorithm, I haven't noticed that that's honestly been an issue. I've never had any problems of excessive high blood sugars or no problems with like, strange, odd low blood sugars that shouldn't have been there because of this sensor. You know, okay, she being off.

Scott Benner 28:00
Yeah. I hear you. I'm, I'm down. I think it's, it works. I mean, I've I'm not gonna tell you I haven't gone Norton's room been like, She's like, the first thing I do if she's laying on her side, because she wears hers on her, like her body, her hips. So I'll touch her hip that she's not laying on. And if it's not there, I'm like rollover. Just kind of like shutter and, and then you'll wait a minute, it comes back. interesting side note about a compression low with a CGM. The number it's reading is actually correct still, although not indicative of what your blood sugar is. So it's reading your interstitial fluid, which is you know, freely running through your body. But when you press down, it disperses it. So it's dispersing some of the glucose that it's reading. So it might tell you your blood sugar's 60, all of a sudden, the truth is, the interstitial fluid around the wire, the glucose value is 60, your whole body might be 110. But that's why when you roll off of it after it gets to the algorithm gets to think a couple more times, it'll come back and tell you Oh, no, you're one time. And that's it. How does that engineer makes a great point, if that happens, the worst thing that's gonna happen is the algorithms gonna take insulin away, you might get hot, but you know, you might get a little higher, but you're not going to be in a dangerous situation. And that's a great trade off, I think, yeah, you know, Jenny, I'm gonna ask you, somebody jumped on and said that I recently said on the podcast that I don't abide a bad pump site that I get, I get away from a by a pump site pretty quickly. But she wants to know, how to, you know, it's not just your period, or, you know, and so I'll you know, because you and I deal the same way about that we don't stick around for like,

Jennifer Smith, CDE 29:39
I don't stick around. And and I guess, you know, from a female perspective, if you're like, well, gosh, is this my period? Or is it you know, a bad sight or whatever? I mean, most women, most not all, but most women have a pretty consistent timing rhythm to their cycles. Yeah, right. So if it's You know that it's probably coming into that time, or you know that it's that time and your high blood sugars are usually associated with that. You wouldn't necessarily think that this is unless you, you haven't changed your, let's say, your settings or your insulin doses as you needed to for this time period. And if you forgot to do that, obviously the high could likely be associated with that. The best way to tell though I mean, because even in your period, you could certainly have a bad sight. Like two things hitting you at one time. That's not fun, either. It's

Unknown Speaker 30:31
okay, hit from both ends. Right? That's not

Jennifer Smith, CDE 30:33
that's not joyful at all. So, you know, if that's the case, I think, regardless, for anybody, whether you're male or female, if you've got an odd looking high blood sugar,

Unknown Speaker 30:45
yeah, that

Jennifer Smith, CDE 30:46
shouldn't be there. Right? You know, you've done everything you would normally have done. And this is just a weird, all of a sudden, you're like, double arrow up and you're to something. You take a correction, right? In my case, and what I recommend, if it's not coming down within the next 30 to 60 minutes, that's it's done. Yeah, it is done. I don't play with it, even if I pull it off. And I'm like, well, it doesn't look like I don't know, whatever the problem was, that the candle is not bent. It's not bloody, it doesn't look weird. Sometimes it might look a little bit wet, or mediawiki. So maybe for some reason, the site was like leaking up along the canula. And you didn't really get as much insulin as you should have. Yeah, um, but yeah, I don't, I don't play with like numbers that aren't where they want to be. Right. And

Scott Benner 31:32
there's a couple of ways that the way I taught myself so the answer to a lot of these questions ends up being repetition, you do something over and over again. And one day, it just makes sense to you, right? And you don't you lose that checklist in your head, like, well, I said, this is it, this, like you stopped doing that. You just see it, you recognize it, and you go, so before I could recognize it, I would inject with a needle. So if the pump didn't act the way I expected it to, I'd come back with a syringe. Now if there was no reaction after that, then I was pretty sure that my site was over also, last day of a sight, you know, or you just put it on and it just never ends up working. Because I know some people switch their pumps and they, they they'll experience a little bit of a high when they put it on. There's a lot of you know, talk about why that is I part of me thinks in children that it's anxiety. It's the you know, it's the that whole thing kind of gets you jacked up a little bit. That could be it. That's what it used to be for Arden. She's obviously much more relaxed around it now. But we've changed upon this morning, it went on and we did a more aggressive bazel rate for the next hour to try to her blood sugar was good at like 110 but to try to mitigate any kind of arise you know, same thing on the other side, if you think it's not working anymore, once you get it back on, you have to really think about for a second How long has this like not been working? And now I'm just going to slap on a new site and go oh, everything's fine now because the insulin deliveries back it's not because everything for now is for later and everything that's happening to you now is from before I get insolence always from before, go back to the beginning if you're falling late, but that's really it. Now the next one is more for you. Although people are asking follow up questions, so hold on. This is great info inside. Oh, great. Okay. Oh. By the way, there are people in the comments helping each other somebody was like, what's the compression level before we could explain it they jumped in You guys are awesome. Jenny, I drew a picture of a lady with a big belly to remind me that someone asked about good tips for thinking about getting

Unknown Speaker 33:41
everywhere just didn't write down pregnant. But anyway, I'm not showing anybody it's not a good drawing but

Jennifer Smith, CDE 33:47
good tips for getting pregnant. So preconception time. Um, we we kind of define preconception time, the three to six months, potentially even a year up to when you want to start trying to conceive. And the goal there is to aim to get glucose values into the pregnancy target. If you think about and or don't know what the targets are for pregnancy. The goal is to be under 7%. And then in pregnancy and even see more around 6%. Within the fives if lows aren't the big reason for being in the fives. But typically, most practices will say under 6.5%. through pregnancy more around six is the preferred just from the standpoint of health of you and the developing baby. For the preconception time then it's really focusing in quite a lot on what are the variables that you can learn and manage better in your life. And if some of the variables like every Friday night you eat the whole box of chocolate, you know ice cream bonbons And you can't manage around that. You know what, for nine months, you can manage not eating your bonbons on Friday night? Yeah, I mean, that's, you know, those are the things those are the strategies that you sort of learn in that preconception time. I mean, the beginning tips really are, look at what preconception or look at what pregnancy targets for blood sugar should be. Because aiming to get those as close preconception will make it so much easier. Once you're pregnant, as you don't have to shift this whole mental. Oh my gosh, now my blood sugar has to be 90, and it's been riding at 150.

Scott Benner 35:36
Just count on, I'm going to get knocked up, and then I'll do this better. Right, right, just and that probably wasn't the right way to say that. But you know what I mean, thoughtfully and through love, make a baby and then trying to get better at your blood sugar, get better first, prove it to yourself that you can do it over and over again, Jenny, if you had to say to somebody, how a way they could get better at this, what would you tell them to do?

Unknown Speaker 35:57
What would I tell them to do? Like a web address? Yes, well, they can call me

Scott Benner 36:03
just put Jenny's email address in the comments.

Jennifer Smith, CDE 36:05
They could. They could also i we've got, I wrote a book with a good friend of mine, Ginger Vieira, who's written a couple of her own books. It's, it's pregnancy management for type one diabetes. You can find it on Amazon. And we actually have a big preconception, month to month guide for pregnancy management, postpartum lactation, we've got all of the information in the books, I would

Scott Benner 36:31
also bet that sometime later this year, there might be a pro tip episode about being pregnant with somebody too, because that just sounds like a good idea. And I typed it into our running list of ideas for the podcast. Awesome. Yeah. Okay, that's a great answer. I wanted to just say that.

Unknown Speaker 36:48
I think

Scott Benner 36:50
I think that once you figure this all out, you get pregnant, you keep your blood sugar, super stable, and you're a onesies nice and low forever. It's gonna be difficult, but try not to lose track of it after the baby comes. Like, just you can do it. If you did it, then you could do it forever. You know what I mean? Like, you know, it's interesting, as I interview more and more people over the years, to see that some people who have trouble managing their diabetes, for themselves, don't have trouble managing it for someone else, you have no idea how many people have come on and said, I met somebody and I fell in love. And I got married, and I wanted to be healthier, so that our relationship or I had a baby, and I realized I wanted to do more. That's not specific to diabetes, by that it's a very human idea. But yeah, keep putting yourself at the top of your list of things to worry and be concerned and

Jennifer Smith, CDE 37:38
he can take care of you. You can take care of other people.

Scott Benner 37:40
100% I think and Wait, do you see having a baby? It's It's wonderful. Nothing like having a kid my wife and I were just sitting on the other night going, we think having these babies was really, really good idea. No, we were choking, because they were both being annoying at the same time. People are thanking us, which is very lovely. Thank you very much. We really appreciate that. You guys listen. evany asks a question back about bolusing. That I feel like I have something to say he said, Is there anything physiologically wrong with a post meal spike? If it comes down later, without extra insulin? Would you try to master that meal? I think you probably can. I mean, unless it was, like you said, Well, you know, I can't even say unless it's cereal, because I can get cereal, right? Sometimes, too. So yeah, I have an In my opinion, if you're going up, hanging up, coming back and leveling out again, and never getting low, there is a way to get more insulin up front. And you know that and we talked about it earlier that really Evan should go back to the beginning of the live, right.

Jennifer Smith, CDE 38:44
Yeah. And I also think, you know, from the standpoint of that kind of management, what it also leads into longer term, if you consider, for the most part, you're looking at your day, let's say you're using a CGM, and you can see how much of the time you're in range and where you want to be. And you're only, let's call them problematic times are these spikes above where you really would want to be after a meal. Yeah, but the end result is that you're back in target. And that looks awesome to you. Right then, one managing the timing, again, it's all about timing the insulin right, but to that peak is still leading into your overall a one C, okay, it's still leading into time out of range. And those post meal spikes also lead towards things like some of those many things people don't want to talk about, but the complications, more of those microvascular complications with these peaks that come into play, the more you can minimize and have more gentle roles, the better long term, so right.

Scott Benner 39:57
To do your best and keep messing around little sooner, a little later. Little more or a little less in there somewhere is the answer. It sounds like he's got the amount right and the timings off. Listen, even if you don't listen to podcasts, I maintain that most of managing insulin is timing and amount, it's just about getting the right amount in the right place where the need comes in. If you can get more up front to stop that initial spike, it might not have to be that much more, you'd be surprised it could end up being a couple more minutes of a Pre-Bolus or another half a unit of insulin or something random like that. That's still because that momentum from the food is so great. At that moment, it'll eat up that insulin, it won't leave you extra on the back end that will make you low. Right, hopefully. Julia asked, What do you consider a gentle roll? Did you just use the words gentle roll? Okay. Do you mean like one of those little Pillsbury things with the?

Unknown Speaker 40:47
Oh, no, no, no.

Scott Benner 40:48
Julia, I can I can talk Jenny as a matter of fact of Jenny's husband ever leaves her we're perfect for each other. what she means is not like, not like sharp, sharp down. She means like, it's cool if you go like this a little bit. By the way, this. So much of what we do is, is easier when people can see our hands moving Jenny and my hands move a lot while we're talking.

Jennifer Smith, CDE 41:11
And the funny thing is, nobody can ever see like our expressions or anything because it's just all voice. There are times when Jenny goes, I wish

Scott Benner 41:17
people could see what we're doing right. And I'm like, Yeah, they can't so Oh, Rachel, it is the best podcast ever. Thank you for saying though. I asked if the group earlier forgot. I would ask here. I had been pumping on the pod for six months. And I've just noticed the pattern. Day one runs high. Day two, good day three low. Any ideas how to combat this? More or less insulin? She's heard of the opposite problem. Brittany has a day three being a little higher. I would say that's if I see anything. It's day three higher Ardennes pumps either work, right out to 80 hours, or right around

Unknown Speaker 41:55
two and a half days.

Scott Benner 41:56
Yeah. 70. I was gonna say right at 70 hours ish, then I have to start paying attention more.

Jennifer Smith, CDE 42:01
I've actually personally noticed that when it does, it's not a time factor. It's more of a when my pod gets to about the 20 unit mark, I can almost guaranteed if I continue to use it after that for boluses or anything. Yeah, I will ride higher. Even though the pump tells me I've delivered the insulin. And it's the same way it's the same factors ratio is everything that I've used. It's it's a, it's a dose amount from what I and I've used Omnipod since 2006. So I got a lot of experience of yours.

Unknown Speaker 42:35
Yeah.

Scott Benner 42:37
I was telling Jenny the other day Arden's been using it since 2006. And it's, it's amazing. Like, I have nothing bad to say, uh, you know, a number of people asked, they said, they have the opposite of the feet on the floor up, they have a feed on they wake up in the morning and their blood sugar drops pretty drastically. Have you heard about that? from anybody?

Unknown Speaker 42:57
I've actually not.

Scott Benner 42:58
So so then would we consider maybe that the bazel leading up to their wakeup time is too strong?

Jennifer Smith, CDE 43:05
The question would be first, which is always my question to people are is your wakeup time the same? Please, it is the same. And you're noticing that drop, as soon as you get out of bed in the morning, okay, then the next thing to do would be try to sleep in and see if the drop happens. Because my guess would be the drop is there. Because you're getting up at the same time you think it's because you're getting out of bed. But it's because as you just said, the bazel in the hours preceding that are probably too high, and the drop was going to happen anyway. Um, so If, however, you find that when you wake up in the morning, and or sleep in completely different, let's say the sleep in stays totally stable. And when you wake up and get out, that's when the drop happens. Yeah, that's it. I mean, it's the complete opposite of what a good majority of people see. I'm not saying that it's not your personal experience. I've got friends who have a drop in their blood sugar with adrenaline rather than the typical peak in blood sugar because of adrenaline. So it could be the case, it, I would say that it's going to be a little bit, it'll be a little bit harder to maybe manage a drop. Because if it's related to when you get out of bed and not really wanting to like eat glucose tablets, or drink some juice just to stop the drop, though only a couple of options would be, well, if you can get up at about the same time, you could technically decrease the bazel leading into that time. So the drop doesn't happen. The only thing there is if you if you get up later, then you're not really going to need that

Scott Benner 44:48
decrease higher than listen because of this whole Corona thing Arden has been she shifted her life drastically. She's staying up way later and getting up way, way late. Yeah. And so I know if by 6am, I don't take away the power of her bazel by half, she's going to be low by eight o'clock. Like, because her daytime numbers are, you know, the insulin we use during the day is just different than what we use at night at night. She needs far less. I don't know, I hope that was helpful. Let's say I know I have a drop because I'm not waking up at the same time. Every day when I had a normal work schedule. There was no drop when I wake up. So then Laura, look is did you do you have a stronger basal rate in the time you're supposed to be awake? Because if so then that's it. Your bazel is just building up and building up and you have nothing going on inside of your body that needs resistance from extra insulin, then, at that point, a bazel. could act like a bolus eventually. Yeah, right. Okay, cool. I like the way I said that. Well, Melinda, thank you for loving the podcast. Thank you. This morning, I was 111. Justin says when I woke up later in bed and read the news got up 45 minutes later and went to 72. Hmm. And that's not Justin, it's tough. I can't have a conversation. But was that not bazel related. Somebody here said they have a new bazel program that's called pandemic. So that's a good point, too. Don't just change your settings, you can make a new program so that when this is all over, you can switch back to the way it was. I've had to you know what, I have a question for you, Jenny. This happens sometimes when we do the podcast. Let's do it now. And then I'm going to get to a question about kids and growth hormone. I was interviewing someone today who talked about when they got pregnant, they suddenly needed much less insulin. And I was saying to them, it's interesting, because for three days before Arden's period, she almost needs no insulin to and I'm wondering what hormone we're going to figure this out, I know this isn't going to something you're going to know now. But we're gonna figure this out and talk about later in the podcast, there must be some hormone that's released. For oscillation. That must also exist while you're pregnant. And maybe I'm wrong. But I'm going to find out if that's true. Because those two things like a bell went off my head as Ooh, maybe this is it. Because Arden Will you know, Jenny and I've talked about it privately, Arden will use like almost no insulin for a number of days before some of her periods. Not all of them, you know, just to keep things interesting. But do you think? Did I just say something you've never thought of before?

Jennifer Smith, CDE 47:25
No, it's well, and typically, oops, some reason went off my screen. There you are. Hi, hi, sorry. Um, I was gonna see the horrible and that's present in the lead up to your cycle, as well as the horrible and that's present very heavily prevalent in the first part of your pregnancy in that first trimester up to about like, six weeks is progesterone. Your body is having this ramp up, almost up a hill climb. And when you get your period, because your body's like, hey, you're not pregnant. So then the progesterone kind of like falls off the cliff, right? You come back down to this normal level. So most women, not Arden, but most women have a right up in blood sugar in the days before their cycle starts. And then it calms down. Same thing in those early weeks of pregnancy. Typically, women will actually see a heightened need for insulin in the first about six to seven ish weeks. And then around eight weeks of pregnancy, there is a bit of a dip off for a couple of reasons. Um, you know, hormonal II and what the body is doing, why there would be a dipped in blood sugar prior to the first day of a cycle, or maybe in the first part of pregnancy, when normally most women are experiencing a rise, the hormone, hormone drive there, I can't say that it's different. I would have to research let me give

Scott Benner 48:56
you a number another variable for this story. And I guess this is me ruining an upcoming episode. But what if the pregnancy didn't last much longer than eight weeks? Maybe there was something else going on? Sure. Yeah.

Jennifer Smith, CDE 49:09
In fact, that is if you've had a normal increase in insulin in early pregnancy, and if prior to that eight to 10 ish week point where usually your insulin needs at least stabilize and or dip down a little bit. If that dip happens sooner. Oftentimes, it can potentially be an indication of like miscarriage only because the hormones are not staying steadily, you know, there's not a steady climb. There's also you know, an early pregnancy. If you've ever had miscarriage before and or you're just worried. You can always get this the HCG hormone tested, which is the early pregnancy hormone that's released that actually gives you that positive result in your pregnancy home pregnancy test. So that hormone should add Actually, mostly double, sometimes triple in those early weeks of pregnancy, which is, it tells you is that your pregnancy is progressing the way that it's supposed to. Okay. Um, so those hormones, you know, that might have some indicative factor too. But that would be something I'd had, that's a great way to look into

Scott Benner 50:20
a little more research sound like there's more in there for to understand, hey, I want to go back to Justin for a second talking about getting up and getting low. Justin, I just had a thought maybe you should do a bazel test day, maybe you're eating enough to feed a basal rate that's too strong. And that way you sat in bed, you looked at the news and everything, maybe that is what's happening, maybe it's not, but if you bazel test and find out you're always low, maybe, you know, like, when I talk about, like, you know, manipulating bazel rates, sometimes when you manipulate them too much, Justin, you're in some belong somewhere else. So you can you might be I could be wrong. But you could be in a situation that a lot of MDI people find themselves in where when they switch to a pump, and they realize that their basals way wrong. But you know, people are like, Oh, I switched to a pump, my blood sugar started going up. Well, it's possible, your bazel, you know, before was too strong or too weak, you know, one way or the other. And so, I guess the way I like to talk about it is, so then what's happening? You can't draw a parallel to the things you think they're attached to. So I don't know, Justin, that's maybe worth a shot. Somebody here said I've been diabetic for 31 years, Melanie. Hi. And you guys have changed my life. That's lovely. Isn't that nice? Thanks, Jenny. I feel nice.

Jennifer Smith, CDE 51:33
And they can see a smile.

Scott Benner 51:35
Yeah, because we really do smile. Yeah, cuz I read those two jenine. And you probably think we're just all like, just jaded and like a doesn't matter. But no, it makes everybody really happy. It does. Sabo. Can Type One Diabetes go into remission, I can answer that one. No. That it definitely can't. Oh, what's the proper way to bazel? test? Caroline? In my opinion, that's a long conversation. It's not an easy conversation to have. But Jenny and I have had it in the pro tip episodes. So find the link, go to diabetes pro tip comm and look for the Basal testing episode. I listened to all of them If I was you, but at least to get to that one. Justin says, like, maybe we're onto something. All right. You're good to go for a little longer. Yeah, Caitlin. My toddler has decided to wait, we're gonna go somebody else said something about Caitlyn disappeared, my toddlers decided to pace himself differently during meals resulting in dipping down into the 60s mid meal. I'm concerned about our low percentage has hiked to 6%. and wondering if we should make changes.

Jennifer Smith, CDE 52:43
So if your toddler is now decided to like, pick it things like he'd rather he or she graze like over the next one and a half hours instead of like slamming it all down within 15 minutes. That was the case. You know, kids are different. I've got a three year old, they sort of roll and change without telling you they're going to Gee, sounds like the dose is probably not wrong. It would be again, the timing of the insulin distribution. So if the picking of the food he he or she ends up eating everything, but it's in a slower timeframe. If you're on a pole and extended bolus,

Scott Benner 53:27
yeah, so extended bolus you could do two different boluses if you wanted if that's get that idea scared you. Kenny says try to get them to eat the carbs first or the shorter to help it there's a you can manipulate the food. You know now you're going to get me into my my coma when I'm on stage and I start talking. Too often with diabetes, we think of just one thing, how does the insulin impact the number, but you should be wondering about how the food impacts the insulin, how the food impacts the number, how the insulin impacts the food, like there's all different sort of perspectives you can use to think about it and one of them in there is the answer. And Marcel makes a good point. Maybe the person who asked if diabetes could go into remission maybe they were asking about honeymooning and, and so, so back to that some people really can. Maybe we should go over honeymooning real quick, but honeymooning is a spot where you have Type One Diabetes you have this insulin need. And then sometimes for a day, three days, three months I've spoken to people it's gone on for years for suddenly it feels like their pancreas is shouldering the burden a little more again, and then they call that a honeymoon. Well, I think that's a fairly good explanation of what honeymooning is so it does eventually for most people go away.

Jennifer Smith, CDE 54:45
Right and you're eventually you will return to using insulin completely

Scott Benner 54:50
right for right. If I go away, I mean, your pancreas is gonna, it's gonna give up finally poop out go down like Bugs Bunny eventually. And then for those

Jennifer Smith, CDE 54:57
who are diagnosed as adults or What we call often call ladder. Some adults, it can actually have a very long honeymoon Yeah, where they may very well be able to control even without insulin for months at a time after they're initially diagnosed with just lifestyle changes before they actually start to need to use a basal insulin and eventually a bolus insulin, etc. So

Scott Benner 55:27
let me address this one question. Then there's another one here. I like that I want to go to back to Sabah because he's asking, Is there a cure on the horizon and near future? I don't know that there's any cure on the in the near future. I have a very simple concept around this. I live with a lot of hope for advancements, but I make decisions day to day like they're never coming. Because far too many people I see ignored thinking, Oh, this will be over soon. I can my body can take bad management for a little while. I that's how I feel about it. I act like it's not gonna happen. I hope I'm hopeful. But, you know, somewhere in the middle there i think is the answer. And Jenny, do you know of any cures on the horizon?

Jennifer Smith, CDE 56:08
I don't there's, as there have been long term, there's a lot of research, there's a lot of animal based studies that show some warrants some benefit. But you know, 32 years with diabetes, I explicitly remember my doctor telling my parents not to worry that within seven years, it was seven years when I was diagnosed within seven years, right? You won't have to worry about this anymore. And, you know, even into my teen years, then my team brain even started to tell me, this is like lifelong, right? Just the hope has always continued to be there that maybe there will be some grand discovery, and it'll get through and everybody will benefit from it. You know, I am, I'm hopeful more in technology, and where the technology piece is going for helping management. But I am hopeful, but I don't see it.

Scott Benner 57:06
I agree. I hate saying that. I know it sucks to say it, but I'm on the same page with you. And not for any nefarious reason, just that if you really if you go look, I think as a species, we've cured like eight things. And a few of them are just inoculations. They're not even really cure. So I'd live like, I'd live like it's not gonna happen with my actions around diabetes, but I'm always hopeful. I and here's another thing not to make light of it, though. But somebody said on the podcast recently, no one's going to cure diabetes, and you're not going to know about it. It'll be on the news. You know, you'll figure it out or turn yourself into a mouse because it seems super easy to cure them from type one diabetes. Maybe that's what we should be doing. Looking how to turn people into mice. Hmm, now we're getting somewhere. Yeah, I'm sorry. I feel bad about that. But all right, Mallory says, No, wait, Mallory. I'm sorry. That's not the one I was gonna read. And I'm like, Damn, they almost got the mind. A Kelly said nearly every night after my son falls asleep, he shoots the 300. I've increased bazel by as much as 95%. But once he's there, I can't bring him down. When he wakes up, can I answer first?

Unknown Speaker 58:13
Sure.

Scott Benner 58:16
Hold your thought, I'm just gonna put something on that you can come through with Trust me. Just because your kids bazel rate is I'm going to make up a number here, a half unit an hour and 95% puts into a unit an hour doesn't mean that's how much insulin he needs in that time. So you may have to extend on your pump, the amount of bazel you're allowed to use to get to the point where you can keep him down because there is an amount of insulin that will stop that kid's blood sugar from going up and hold him steady. What were you gonna say?

Unknown Speaker 58:46
What I said, You're so funny. So

Jennifer Smith, CDE 58:48
pretty much along that line? Yeah. One is, you've got data that shows you that this is happening every night, right? You're not like, Oh, this is only two days. And now it's not happening anymore. This is it sounds like it's every night. So one, you know, insulin needs to change to right along with what you said. It's in very low level bazel rates, especially in many kids. If you're turning Bayes a lot by 95% at a bazel. That's point one. You're not hitting the mark, by any means.

Scott Benner 59:21
Remember, you're not going to

Jennifer Smith, CDE 59:23
write it. That's that's not hitting them. You can even look at it a little further if you take into consideration. What what's the climb in blood sugar. Let's say the child is starting at a blood sugar of 91 at bedtime and climbing up to 303. Right? That's a huge increase in blood sugar. You can also take a look at Well, what is your correction factor? Most little kids have correction factor somewhere around like one unit changes their blood sugar by 150 points or by 200 points. If your kid is climbing 200 points, that little notch up 2.2 When your kid really needs a whole unit to correct a 200 blood sugar climb, right? That's how much you need to change the base and why

Scott Benner 1:00:08
Yeah, here's the thing, you'll hear me say this a lot. If you listen to the podcast, you need more insulin. That's it. If you have more insulin, it wouldn't happen. And by the way, for the person who asked about the group, and by the way, too, for a little kid, that could be growth overnight. Right? And for the person who jumped in and said, their kids in the teens and going through growth, and they can't keep their blood sugar down. Here's my answer to that to use more insulin. Because there is an amount that will stop it. Trust me, there's an amount like, now the question is, how do you get to that amount in a way that doesn't feel frightening? Especially for somebody who's now talking about Look, it's supposed to be point five, I made it one, how am I possibly going to go higher than that? That feels frightening. I've told the story in the pious, long time, so I'm not going to waste it here. But there's an amount you can do just find yourself being more aggressive cover with a fast acting is used if you've gotten too much, but the truth is Peters bazel up a little too high. He's not going to go from 300 to negative 10. Out of nowhere, you know, and keep in mind too, that if you see arise at midnight, that doesn't mean change the bazel at midnight, it could mean change the Basal at 11 o'clock even or it could be a little earlier a little sooner, depending on how his body or her body reacts to the increase of bazel. Just like you putting in a bolus doesn't start working right away. Putting in a bazel doesn't start working right away. There are more thank yous in here. Those are nice. Thank you. Jen, do you have to go at the top of the hour?

Unknown Speaker 1:01:34
Oh, no. I've got about 15 minutes.

Scott Benner 1:01:37
Jenny's giving you her personal time. That's lovely. The takeaways more instant mirror it always is. Kara? I'm glad you think this is awesome. Okay, so she got correction factors thinking about it so that way. Jeff is saying protein and fat that are hitting around dinnertime. Okay, Scott. Jamie said, Scott, I've heard you say things about being an insulin deficit. From overnight, I'm pretty sure I understand what you mean, I suspect it's a reason why some people go higher than expected in the morning. It was a lightbulb moment for me. So I'm sure others may find it helpful. Anyways, I love you guys to explain what you meant here. I'll let Jenny explain what I meant. So I can drink something.

Unknown Speaker 1:02:27
Yeah,

Scott Benner 1:02:28
I see what I mean, afterwards, just you go first, relax.

Jennifer Smith, CDE 1:02:32
So if you're at a bazel deficit, essentially, you're coming in to a time period when first thing in the morning most people are trying to put food in right away, right. And if you're coming in at a deficit of insulin behind the scenes, then the impact of that food even with potentially a Pre-Bolus, it, you're still going to rise because there wasn't enough behind it in the hours leading up to that meal time. If you're at a deficit of insulin as well, you're likely seeing that you're writing in at a blood sugar that's higher than you want to be or it's higher than the target, you've had your your pump set to keep you at. And that's a telltale sign right there. And that's only then going to lead into that real time, also causing more of a rise up than you want. Because you're already starting higher than you wanted to begin with.

Scott Benner 1:03:26
I would and I think of it, if you want a different way to think about it, it's like eating a meal without a Pre-Bolus. Right, because there's just you, if you don't Pre-Bolus a meal, you start eating that foods gonna win way before the before the insulin starts working. Same idea, like Jenny said, people jump out of bed and they eat. And you know, we just explained to the last person that you turn, you put a basal rate on at, you know, not at midnight for a jump up at midnight. So if you're getting up at seven in the morning and beginning to eat right away, your blood sugar's jumping up, it's possible your basal needs to be stronger, starting at 6am. And you still have to Pre-Bolus it's not all the base, or you're gonna have to Pre-Bolus and you're gonna have to have the base. All right, it's all just the timing and amount. Everything you see with Type One Diabetes, in my opinion, is about the balance of insulin and using it when it's needed. And you have to be able to step back sometimes to see the bigger picture. People get hyper focused on what's happening in the moment. I get up in the morning and my blood sugar gets high. That's it then they stop there. It's not about that. It's about before I've now this is going to be the third time I send everything. Everything you do now with insulin is for later, but remember now is always some other times later. Ah, that's how Arnold Schwarzenegger tried to kill those people in that movie. Right. Time travel time travel.

Unknown Speaker 1:04:47
Okay. Yeah, that's all. I think

Jennifer Smith, CDE 1:04:50
the other part of it too is that there is a very there's a very emotional level to managing your diabetes. Managing somebody that you love. Diabetes, yeah, right. And so, as hard as it can be, sometimes you have to step outside of yourself. And you have to kind of say, especially for the person who's managing their own diabetes, you kind of have to step back, take the emotion out and say, Okay, um, hi. I love being high, but I'm high. Let's, let's look at the information and see what I can do to fix it. Right? Um, sometimes taking that emotional piece out of it also makes you think a lot clearer about what you want to do. I mean, that's, that's the big reason for baseball maker.

Scott Benner 1:05:40
I maintain, I maintain that I'm as good at this as I am, because it's not happening to me. If I had type one diabetes, I wouldn't have this podcast, I'd be a mess. I'd be on the floor with my 10 a one See, God, I gotta know what's happening. You know, but it was for my daughter, right? Like, no, I don't know, like I you know, it's for her. So that I'm able to, I'm able to be more aggressive because I have a bigger fear of letting her down than I would have letting myself down. I think. So a lot of the things you'll hear about on the podcast, which by the way, you can listen to on any podcast app, absolutely. For free, just search for Juicebox Podcast, there's over 325 episodes, the podcast has been up for almost six years. You know, if you don't have a podcast app, they should be free. If you can't find one, go to Juicebox podcast.com. Scroll to the bottom there are links to all your different phones to get you on. And someone just asked a question here, how to manage unexpected activity, but a bunch of people just jumped in and said have a snack. decrease your bazel Yeah, that's it. Now listen, something somebody said was amazing. I'm gonna assume it was me and we'll just move on.

Unknown Speaker 1:06:50
I don't really know what she's talking about.

Scott Benner 1:06:53
Yet, so they're talking about that they're talking about activity around all this. Also, I want to bring up around you know, a lot of people stress, anxiety, or all of a sudden sedentary lifestyle because you're not going to work anymore. All those ideas somebody in here asked about they said their blood sugar's jumping up at night, not always, since the pandemic has started. And I wonder if when your brain slows down after your days over, do not find yourself thinking or worrying about Coronavirus because stress, anxiety, pain, there are a lot of things that can make your blood sugar go up. So I would I would look into that a little bit.

Jennifer Smith, CDE 1:07:30
In fact, there's it's really funny that you bring that up because, uh, somebody that I work with, she actually just emailed me. It has nothing to do with diabetes, but my brain was right away, like bringing diabetes into the picture reading it, it's all about dreams, since Coronavirus became the thing that it is, yeah. And the fact that dreams are, they are the way that our our mental self kind of manages through things. And we can learn some things, you know, if your dreams are kind of scary, or if they're really scary, or if they're just sort of like hinting at weird things. You know, I mean, it's the way that your body manages to sort of work through some of the thoughts that it didn't have in the daytime, right? Or that were sort of in the background. And with diabetes in the picture. Some of those can be very stress inducing in the overnight time period. So you know, if you're looking at, you know, many of your overnight values and you're thinking Whoa, why is this weird? This night was really weird. I had this strange rise and I woke up high and that's usually not happening for you. Maybe you had a horrible dream about

Unknown Speaker 1:08:37
something that you know, and it's not about never hugging another person again.

Jennifer Smith, CDE 1:08:44
Could be I had a I had after all this started I had a horrible dream about zombies. Did you? Horrible like I woke up in like a panic. And I usually I don't remember many of my dreams. I usually see sleep pretty soundly. Yes. Dream had me like, I was like all levels.

Scott Benner 1:09:03
When Natalie just jumped in and said playing video games makes her teenage son's levels go up. That's adrenaline, I would imagine. And Natalie I bet you they come back down again. Right? And because that's that's another thing. So stress, anxiety, those sorts of things are always going to well always have the ability to impact I'm sure there's some people get stressed out in their blood sugar's don't go up. But it does happen to a number of people enough that it's worth paying attention to.

Unknown Speaker 1:09:27
Yeah, and

Jennifer Smith, CDE 1:09:28
sometimes you can address the rise. If you know that it's not going to come down sometimes sometimes you have to correct for it. Many times adrenaline rises, though. We often don't have to touch oftentimes once that stress factor or the adrenaline like surge sort of passes. You'll see things come back down.

Scott Benner 1:09:46
You know it's funny somebody jumped in as you were making this and said a bedroom could make your blood sugar go up at night, mira said and there people my daughter's goes up with Xbox so if you know, listen, it's not the easiest thing to to Guess schedule. But if you know, Xbox time is going to be in a certain place, you probably could do with Temp Basal increase. Right. And that would

Jennifer Smith, CDE 1:10:08
that would definitely kind of like weightlifters if you know, you've watched enough to know how much blood sugar typically rises during Xbox use, you could technically take an amount of insulin as a bolus to offset the typical rise that you see based on what your correction factor is.

Scott Benner 1:10:23
Let's see if we can get one more thing in, because we have to go so somebody asked about their Dexcom user, and they're talking about Pre-Bolus. And when do you know when to start eating. So for my daughter, in a perfect situation, I like to see a diagnose Down Arrow before she starts eating. And you also have to get right in your head what's high and what's low, too, you know, for me, I don't want my daughter, I try very hard for our not to go under 70. That's my goal. And I try for not to go over 120 do we always do that we do not always do that a number of times a day, she ends up higher, it just happens sometimes. Okay, all the things that you just heard about happened to us to my daughter's a one C has been between five two and six, two for almost six years. But she got out of bed didn't have enough insulin going because she slept in try to eat something with a lot of carbs and her blood sugar's 200 right now. And it's and we're going to get it back down as fast as we can without it getting well it's not you're not shooting for perfection. You're just shooting for as much time and range you can get in there. But back to the initial question, I like to see a diagonal down arrow. But now I know how fast the food is going to hit or just you just have to practice right like, started 100 put in the blood sugar when you get to 91. Diagonal down, eat, see what happens? Did you go up to 150? But then level back out? Cool. Maybe you could have waited till 85 diagonal down. Maybe that would have taken you do 130 c? It's just trial and error. You have to go over and over again.

Jennifer Smith, CDE 1:11:53
Experience teaches you? Yeah, a fair amount.

Scott Benner 1:11:57
JOHN, I don't know that. Jenny knows this answer. But I'll ask before she goes john wants to know if you know what factor? What factors affect the hypest hypoglycemic risk value on the dexcom clarity app, you know what it takes into account to come up with that? I don't,

Jennifer Smith, CDE 1:12:13
it I don't, but my assumption is that it calculates the percentage of time that you've been low, within the timeframe that you're looking at, to classify what your risk is, you know, if you're, you know, 1% of the time low, I guarantee that your risk factor for most is not high. Whereas if you're pretty consistently at 10%, low, even if it's not really red low, it's just that pink low, right? Because there's a different designation. There's a 55, red low, right? But I mean, if you're really low, pretty consistently, that risk factor obviously goes up. I don't know exactly what parameters they're using to establish that percentage value for you. Um, but

Scott Benner 1:13:09
Alright, so let's roll through these last three, Jamie brought up that if she waits for a diagonal Down Arrow for her credit goes lower, so it's gonna be different for everybody. Yeah. Lisa is saying hello to us from Sweden and said, we've both been very helpful in her first six months of being a type one mom. Hi, Sweden. That's cool. And Sue asks, do we recommend the in pen which I think we both though?

Unknown Speaker 1:13:29
Yes,

Scott Benner 1:13:30
yeah. If you can't pump, you can get a lot of the knowledge that a pump has from in pen pairing with their in pen app and your your glucose monitor and even a meter. Not as much luck and Jenny's holding one right there.

Jennifer Smith, CDE 1:13:42
I've got the pink. You can get them in different colors.

Scott Benner 1:13:44
Yeah, I've got blue in here somewhere. But it's a demo. So. Yeah. Okay, so listen, Jenny was only supposed to be here for an hour. It's 409. She got to go back to her life. I want to say that at one point. This was up to 120 people and it never got below 80 even 15 minutes after it was supposed to be over. So awesome. Really appreciate all you guys. Thank you so much for listening to the podcast. If you enjoy the podcast, please share it with somebody else. It's the only way it can grow. I do not have money to to do any kind of meaningful. You know, advertising for the show in the last comment here again is Jenny's email address. You can hire Jenny. She works at integrated diabetes services. You can have one on one calls just like this with her. Check it out. See if your insurance has covered it or if you want to pay cash, whatever you want to do. Jenny is very cool. She is 100% my diabetes spirit animal. I've never heard her say one thing that I was like that's wrong. But as I've mentioned on the podcast before, that might just be my narcissism because she agrees with me. I think she's terrific. But who knows exactly, you know, this will be available on the podcast soon. And it will be running on Juicebox podcast.com as well. And it stays here on Facebook. So thank you everybody very much and Hope you guys have a great day. And Jenny, I really appreciate you doing this. Thank you.

Jennifer Smith, CDE 1:15:02
Yeah, no, this was great. Thanks to everybody who commented back and forth to each other as we were answering. It's a great way to help each other. Yeah.

Scott Benner 1:15:10
Very cool. All right, guys. Wash your hands. Stay safe.

Unknown Speaker 1:15:15
I why.

Scott Benner 1:15:19
Don't forget even though this episode was not sponsored, the podcast does have sponsors like Dexcom. The Contour Next One blood glucose meter, touched by type one and Omni pod. There are links to those sponsors in the show notes of this episode, and at Juicebox podcast.com. If you're not looking for those types of things, go into your podcast app and leave a glowing review of the podcast. It would make my day and Jenny would smile about it too. Alright, let's turn off the music and we'll dance our way out of this

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This is a bonus episode and was not sponsored. That said, these are the show sponsors.

Please support the sponsors - Contour Next One

About Jenny Smith

Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com

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The Juicebox Podcast is a free show, but if you'd like to support the podcast directly, you can make a gift here. Recent donations were used to pay for podcast hosting fees. Thank you to all who have sent 5, 10 and 20 dollars!

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