#1148 Grand Rounds: Diabetes Management

March 8, 2024Scott Benner

Scott and Jenny discuss proper type 1 diabetes management concepts.

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

Scott Benner 0:00
Hello friends, and welcome to episode 1148 of the Juicebox Podcast.

Jenny's back for another grand rounds episode and today she and I are going to talk about how doctors should be thinking about diabetes management, how to talk to you about using insulin, and so much more. While you're listening, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan, or becoming bold with insulin. If you'd like to help with type one diabetes research right from the comfort of your home, it's easy to do go to T one D exchange.org/juicebox. and complete the survey. That's it, it takes like 10 minutes. We're looking for US residents who have type one diabetes, or are the caregivers of someone with type one of specific and special note. men and men of color were boys or boys of color. Difficult to get that data. The T one D exchange thinks they could really help people if they had it. If you fit any of these categories, I'm talking about men, boys, girls, ladies have type one, you're the parent of somebody filling out that survey is a great way to help. And it's a great way to help the podcast, it also might end up helping you t one D exchange.org/juicebox. Today's episode of The Juicebox Podcast is sponsored by the contour next gen blood glucose meter. This is the meter that my daughter has on her person right now. It is incredibly accurate and waiting for you at contour next one.com/juice box. This show is sponsored today by the glucagon that my daughter carries G voc hypo pen, find out more at G voc glucagon.com. Forward slash juice box. So today for the Grand Rounds series, we're going to talk about management. That's our that's our our header. And Rod topic. Well, and there's a lot here. So indeed, it is a lot of feedback from people, a lot of feedback from people a lot of notes that you and I made on this document back home, we're talking about doing this. A couple of things. Why don't we just start with a little bit of feedback, and we'll work our way into it. Well, I wish my doctor would have told me that staying high for long periods is just as dangerous as a low. Yeah. So that's education. Right? Like, that's, that's understanding big picture. And whether doctors know it or not, this don't. I was about to say don't have a seizure idea, which is something I really don't want anybody to do. Right? I didn't want to sound like I was minimizing it. But this this better high than low idea. I understand why they might say it initially. But you have to tell people, the rest of that story. And why high and low is bad, why stability is what they're looking for how to get through stability, because just telling them better high than low, I think leads them down the wrong path that that that's difficult to get back from mainly

Jennifer Smith, CDE 3:27
because there's not enough there's not follow up to it is what that really leads to, they are given a directive of better high than low initially. And you know what? Maybe Okay, right now, but define that, give them a week from now once we're seeing how your insulin is working, once we see where numbers really are, once we see how you're reacting to the current doses and we make some other adjustments. We will talk further about this, right? Because initially, you may actually, I mean it is there's a math equation to figuring out initial starting doses for any age and person. But it's still just a starting place. And it's still not as precise as it eventually will get. So sure, a little higher right now, let's see how things go. We're going to touch base in a week or in a couple of days. We're going to look at this and we're going to say okay, now we can nudge that high. We don't want to stay high, long term down the road. Right now. We're just going to keep things from here to here. Maybe the target range is wide right now. Narrow it when you have follow up and also put that into you know your your notes about what was discussed. We defined blood sugar target range here to here so that whoever is the follow up physician or clinician knows what you've talked about. They can easily see it in the medical record and then that doctor or caregiver can clean that up. Yeah, can help to define that further for you. But when you give a blanket statement that sticks

Scott Benner 5:09
Yeah, it also makes the next physician, not just the patient, but the next physician leery about changing what's happening right now. Right? Right. Right. They think this is this was for a reason somebody told you to keep your blood sugar at 180 all the time. And you can explain to them no, that's not the case. Because somebody didn't tell you. No, that's not the case. So, right. A lot of this series, I think is about, it's about not just saying the first thing that you that you think to say, but giving it real context and an explanation. This is what we're going to do. This is about the timeframe we're going to do it in, this is why it's important. You just can't forget about it and say, Oh, he said better high than low. And then you go on, you know, from their emergency situation, to you know, a GP, then the GP finally gets you to an endo. And then the endo gets there. And this, oh, everybody's got this person's target set at 180. They might think that's on purpose, because you can't handle it. Or maybe you had lows before they'll make assumptions. And you know, these assumptions are what killed everybody. Right? Yeah. But this is how it comes out. I wish my doctor would have told me that saying hi, for long periods is just as dangerous as a low

Jennifer Smith, CDE 6:23
end for this person, it might have been that there wasn't enough follow up then. Or maybe they didn't follow up with somebody who could have helped them put the targets a little tighter together, right? Maybe they also didn't know enough to ask, Hey, I was told initially, the higher targets are okay that I shouldn't necessarily live there. But if I touch to 50, after every meal, and four hours later, it comes back down. That must be okay. Right, because that's what I was told it. It takes I think, you know, diabetes, especially is it's an evolving sort of trend of discussion, where this is where I am, this is the scenario, this is the really important stuff to focus on now. Okay, a month from now, a week from now, whatever, you're very likely going to be in a different place, you're ready to get more information, you're ready to ask more questions. And the doctor should also sort of move down that path with you, if you're not bringing up that they should be bringing it up and saying, Well, you're here. And everything looks safe, right? It looks good. But you could be here, right? Let's try this. This is why and that explanation to the why is really important. It's

Scott Benner 7:37
the nuance of the conversation. Like you can tell somebody, it's not wrong to say to somebody, Hey, if your blood sugar shot to 250 and came back down and leveled out again, that's fine. Not every time, you know, but not every meal. Because if you want now you tell me that's okay. And what you're probably trying to do is, is give a little bit of comfort. You don't I mean, like, Hey, don't don't kill yourself if stress about Yeah, if it jumps up one time it jumps back down, let you you know, that's okay, let it go. But not, once you tell them it's okay. Then breakfast jumps up lunch jumps up, dinner jumps up, a snack jumps up, they get high overnight, but it comes back down three hours later. And before you know it, that's an eight a one C? Yeah, you know, and they in their head, they're like, Well, the doctor said, It's okay, if it goes up and it comes back down again, they don't understand the big picture. Listen, right. Most people don't understand the big picture of health. I was just talking to a nurse on another recording recently. It's not out yet. And she said one of the most shocking things about becoming a nurse was learning how little people knew about their own body. Like she called it. Jenny's making the face. Yeah, like shocking how bad it is. And it led me to say, I saw somebody eating nachos with a bowl full of queso the other day and I saw the bowl, like the size of a softball full of liquid cheese. And I thought you're not supposed to consume that in a year. Right? Yes, yeah, you know, like, and here you are, you know, in one sitting, and then metabolic issues come up, which you don't see right away and are hard to diagnose. And they end up looking like I get headaches all the time, or my knees always hurt or why does my stomach hurt? Or how come I don't poop? Right? Like it's because it's and then you're off to the races. And before you know it your blood sugars are hard to deal with, you have all kinds of other underlying issues. And they don't come to the surface until they come to the surface in a very aggressive way with like some specific problem. And when we're talking about people with diabetes, we're talking about renal and cardiac and your eyes and absolutely big stuff, you know, not just go on a diet for six months and this will all work itself out. You know, what

Jennifer Smith, CDE 9:44
you said initially is 100% the case unless you have any type of biology avenue of education, you really are left in the dark about what your body is supposed to be able to do. How does it function when I do this, this is what my body does with this, right? And I, one of like my best examples of that was years ago working just as a dietitian in education specifically in diet in gestational diabetes. A woman had come in to me, and we're talking about kind of her eating and how that impacted blood sugar. And I said, Well, you know what, I don't see like, a lot of fresh stuff. And I said, I don't see any fruit at all. And she's like, No, no, I eat fruit every day for breakfast. And I was like, Oh, we didn't mention that. You know, she's like, Yeah, I did ice. It's right here. I eat Froot Loops. i She was not kidding. She was not joking, which means that as an adult age where she was long term, she never knew that Froot Loops don't count as a fruit. Like

Scott Benner 10:50
me, I out myself for a second. I once said to my wife, I was half joking but contour next one.com/juice box, that's the link you'll use. To find out more about the contour next gen blood glucose meter. When you get there, there's a little bit at the top, you can click right on blood glucose monitoring, I'll do it with you go to meters, click on any of the meters. I'll click on the Next Gen and you're gonna get more information. It's easy to use and highly accurate smartlight provides a simple understanding of your blood glucose levels. And of course with Second Chance sampling technology, you can save money with fewer wasted test strips, as if all that wasn't enough the contour next gen also has a compatible app for an easy way to share and see your blood glucose results contour next one.com/juicebox And if you scroll down at that link, you're gonna see things like a Buy Now button. You could register your meter after you purchase it or what is this download a coupon? Oh, receive a free Contour Next One blood glucose meter. Do tell contour next one.com/juicebox head over there now get the same accurate and reliable meter that we use. If you take insulin or sulfonylureas you are at risk for your blood sugar going too low. You need a safety net when it matters most. Be ready with G voc hypo pen. My daughter carries G voc hypo pen everywhere she goes because it's a ready to use rescue pen for treating very low blood sugar and people with diabetes ages two and above that I trust. Low blood sugar emergencies can happen unexpectedly and they demand quick action. Luckily, G voc hypo pen can be administered in two simple steps even by yourself in certain situations. Show those around you where you storage evoke hypo pen and how to use it. They need to know how to use Tchibo Capo pen before an emergency situation happens. Learn more about why G voc hypo pen is in Ardens diabetes toolkit at G voc glucagon.com/juicebox. G voc shouldn't be used if you have a tumor in the gland on the top of your kidneys called a pheochromocytoma. Or if you have a tumor in your pancreas called an insulinoma. Visit G voc glucagon.com/risk For safety information. But I don't think I was completely joking. She's like you don't get enough vegetables. I ate veggie sticks the other day and she goes Scott, those are potato chips. There's carrots in them.

Jennifer Smith, CDE 13:28
Yeah. I mean, and there are a little bit of like a humorous component to that. But I was just like I came home and I said to my husband, he's like, No, he's like she was joke. I was like, no, no,

Scott Benner 13:39
I told you before when my mom looked pre diabetic, a handful years ago, and a doctor told her to change her diet. She put together a diet that was worse than the one she was eating. Yeah. And she was trying trying to eat something that would follow along with what he was saying. Didn't people just don't know. So it's not your fault. But the doctor needs to know that that's the situation. Yeah, you know. So this next person says there are ways to have a lower more healthy a one see there being kind here about the podcast, such as being bold with insulin, let us know that this is possible and help us to achieve better agencies. Please don't shame us for falling short, but do encourage us to do better. I see this a lot, right. Like nobody wants to tell somebody they're not doing right. Well, right. became a social thing for a while. You know what I mean? Like nobody wants nobody wants to tell you the truth. Sometimes

Jennifer Smith, CDE 14:34
I feel people are worried. On the end of professional people are worried about creating like a shame type of explanation. When really that's, that's your job is to tell somebody when they're not healthy. That's that's your job, right? You didn't go into health care, to tell people to keep eating what they're eating or to keep, you know, not doing what they're not doing. You're

Scott Benner 14:57
not there to make friends and know that Yeah, you're and I get that I would listen, I would bet the argument back would be, if I push these people, they're not going to come back again. And to that, I might say, least you told them the truth. Right? You know, like, now it's on them, at least, you know, but keeping it from them or pretending they're going to do the right thing. That's not helping anybody. That's just mean, that's, that's you're lying, and they're lying. And we all know each other's lying. And none of us are saying anything about it. It's weird, right? You know, I

Jennifer Smith, CDE 15:26
see, I see questions often still, in this sort of day that we're in with technology, I still see questions about why people are. And it goes right along with this management and even like, target range for blood sugar and whatever. Why are we explaining blood sugar targets that are outside of the realm of what somebody without diabetes? Right? Why? Why are we saying that? A 200, blood sugar, a 250, that's safe. That's okay. You can come up here, you can kind of settle back down, etcetera. You know, the human body does not do that without diabetes. So why are we constantly telling people that it's okay for you to be in this really wide range, and then down the road, their expectation comes to be? Well, I stuck within these targets. And now I have problems with my eyes, or now I can't feel my feet. And I did what I was told. I was told this is okay.

Scott Benner 16:27
Yeah, no, I think it's got something to do with the physicians either not understanding it themselves, the mechanics of getting to those other blood sugars, or they've seen so many people fail at it that they think it's not possible. So why am I going to give them a target, they can't reach at least I'll give them one that they can, they can get but, but that's where this this person here says learn how to communicate diabetes, those things, suggestions. So often, we're told to do something, but not given a reason why? And then you and I made a note after that, that said, that says don't just give us a fish. Teach us how to fish. And right. Yeah, right. Yeah,

Jennifer Smith, CDE 17:03
absolutely. I think you had a thought. Let me bring it back into my brain. Like right there on the tip of my tongue. It'll come back to me.

Scott Benner 17:12
It's okay. Well, I think we got thrown off when your cat's whiskers came into the camera first.

Jennifer Smith, CDE 17:16
Yes, I sorry. I was gonna comment. And I was like, No, it's okay. I know she was

Scott Benner 17:21
you were like you I say something about that or let it go? Yes. Sorry. On the fault, though, I stepped over you. You had a look on your face. Like you were gonna say something. And I said that it's okay. Don't worry about it. I wish it diagnosis. They told us that what we learned at the beginning is foundational. And there are many things to learn. Moving forward for best management like Pre-Bolus and glycemic impact load bolusing for fat and protein, being aggressive when aggressive isn't necessary. Also, I wish they would have emphasized emphasize that ratios and basil will change and what numbers we get aren't set in stone. Okay, so this becomes another big problem. You know, you you set somebody's this happened to me. I remember the doctor was saying what's Arden's insulin to carb ratio. And when I pulled it up, it was like one unit that like, I don't know, like some insanely large number 300 carbs or something like that, because she was diagnosed when she was so little. But we were like, years later, and no one had ever changed it. Oh, and I didn't know anything about it back then. So I'm like, Oh, she's having all these high blood sugars all the time. And I'm like, I'm having a lot of trouble with meals, and I can't figure it out, back then I wasn't the guy who was like, Oh, just do this. I went back to the doctor, and I was like, I don't know what to do. And they pulled that setting out. They're like, Oh, and it was like it was off by like, I think she was one to 100. And it was set at one to three, she was using two thirds, too little insulin at every for every carb. So, you know,

Jennifer Smith, CDE 18:46
that actually, it kind of made me think of what I was going to. What I was gonna say is that, I think that in, at least initially, and maybe even for somebody who has had diabetes a long time, and now is really coming in with a set of questions. What it boils down to is explaining that this initial information is just that it's a baseline to start with, and navigating diabetes. I wish people would just be honest, and say it's not easy. It can get along the way of learning, you experience a hoz Oh, well, that totally makes sense, right? Or, gosh, this definitely can be built in now. So they're, they're stepping stones, if you will, to management. But as you just said, There's not just a start here, dose this there is again, kind of evolving changes. And that growth has to happen in your understanding, but how you understand it needs to be what comes from the clinical team that's helping you so they should explain to you that this isn't simply just put the insulin in and eat the food, right? That's not how simple this is.

Scott Benner 19:57
Yeah, I remember a doctor once saying when our was younger Wait, oh, she gets hormones like, oh wait, do you see the female hormones? Oh, and I was like, what she was like, wait a minute, UAH context? Is there any context? You know, oh, hormones make it harder. And I'm like, and, and you don't you mean like, though I figured it out between that and, and when it actually happened for myself, but nobody ever likes in that time no one ever stepped up and said, Are you bolusing? differently? Do you notice any strategies that help or hurt? Or, you know, are there times of the month that are different than others? That conversation never happened? Just oh my gosh, you should see Wait, do you see what happens? And I spent years going like, oh, like,

Jennifer Smith, CDE 20:41
like, I'm worried I wonder what's gonna happen? Yeah. And as if she didn't have hormones. age that she was,

Scott Benner 20:48
she was growing, I'm sure she had growth hormones. So at the very end others, this person says, this is kind of funny. bolusing for fat and protein impacts is a type one diabetic should not be considered an advanced topic. And I thought, but that's really true. It's very, very true. You cannot, you can gather up 100 People with type one diabetes and ask them, you know, what is your endocrinologist taught you about dosing for the impacts of fat or protein? They're not gonna, I mean, two people are gonna say somebody had mentioned that to them, you know? Correct. And yet it throws off every meal, almost every meal of every day and someone's management for 24 hours, that turns into a week that turns into a month. And it's it can be at the core of the whole thing the other day, Arden. She's weighed school. And she said, I did get a text from her. Hey, I had to stop at a drive thru on the way back. I'm, you know, I had to grab some DT amount of time. I said, What do you get? She said, I got Chick fil A. And I said, Okay, 45 minutes from now your blood sugar is gonna go up. And I was like, Don't forget. So you know. And by the way, you know what she did? She forgot. And but I was, she was probably driving. Well, she was now at another place doing this homework. And then she had to get into a class and stuff like that. And I said to her, I'm like, I'm like, okay, look, just look at your algorithm. Is it suggesting any insulin? And she said, Yes, I was like, I think you should put it in. You know, because the algorithm was trying to fight. It was trying to fight the fight, but it wasn't going to because it wasn't compensating for the she didn't put fat into the she didn't it didn't know what it was trying to fight. Didn't know what I was doing. Just like this morning, by the way. She thought she lost her ID. Oh, so like, I get this call. I'm like, why did that happen? This is gonna happen a couple of times, I'm pretty sure. Yeah. But while she's searching for the ID and doing the math in her head that she doesn't leave five minutes from now she's gonna be late. And if she's late, and she misses a class, and she only gets the missed so many. And she says I'm watching her blood sugar, it is just going up. It just went from 100 to 120 to 130 to 140 that he got an arrow straight up from trying to find her ideal stress. Yeah, from the stress of it. Oh, Doctor, I gotta tell you that. They're gonna say something like, oh, the mornings, huh? Yeah. Oh, no mornings. They're hard. Thanks a lot. Right. And

Jennifer Smith, CDE 23:13
that will be as we talked about before, that'll be one of the fingerpointing on the records. We'll see what happened here. Yeah. No, it was probably in school one

Scott Benner 23:25
month from now if you ask garden, what happened there, she's not going to say I lost my ID thought I was going to be late and got upset. Like she's gonna I don't know what this is, you know, so. But all this goes back to Tools. Like give me this person says, give me the correct tools give me parameters and instructions. Let me know I could probably do this, if I had these these things in place, right. And to what your point is, I always say, it's experiences. Like you have to have them over and over and over again before they just start becoming not just like second nature, but they make sense to you. Like out of nowhere, something happens you I know what to do? Yes. As soon as she drove away, like, you know, she had her ID this morning, and she left. I thought she needs a temporary Basal increase. Like I don't care if she's on an algorithm or not like right now she needs a Temp Basal increase this algorithm is not it doesn't know there's an impact here. It's it's changed rising as if she ate food. And it has not been told there's any food there. So we did that. And it came back down pretty quickly. Yeah.

Jennifer Smith, CDE 24:25
Good example I have of like those lived experiences. You can provide all the information possible. And then when you get into like, from my angle of providing education, and give you scenarios, things that might happen, but until they really happen, you have nothing to apply that to and you may need to dig deep and think about it right? A good example is somebody I work with, who had emailed me about a scenario and emailed me just to say, You know what, everything that I've learned, I knew how to work around I found it. And I think I did the right thing. Yeah. And 100%, this person had done the right thing, right? blood sugars that were doing something that shouldn't have been happening based on everything else that had led up to that point. And what did the person do? They change their site, they changed their, their insulin, and it all navigated back down. But without some lived experience and some information pointing to Hey, If this, then this, right, right, they're gonna throw their hands up and be like, I don't know what it was not

Scott Benner 25:31
make that change. I also, you know, that's true. Because oftentimes, you'll see people changing out sites, when it's not the problem, right? When their settings are bad, and they're constantly the pump doesn't work, the pump doesn't work. They over and over, and I, sometimes I online, I'm like, stop there, like, I've changed the pump three times, like, Stop changing the pump. Just stop. It's not your site, right? Like, your settings are bad. Like, we're your settings are great, but something's happening right now. And your settings aren't up for the challenge of what's happening today. You know, like, it's, again, lived experiences. That's how you'll figure this all out. I like this, this feedback here, give me all of the options, not just the ones that you think are best or better or efficient. I would like to make my own decisions, and then craft my own ecosystem of how I deal with this. I think that's a great point. You know, there's more than one way to do this. And everybody's brain doesn't click with the way you say it one time, right? That just you have to give people the autonomy to autonomy is such a big part of this. Because if they don't have that, they don't have all the ideas, and they can pick and choose from it make their own tool belt. That's a problem. But if they don't feel like they can make changes on their own, that's also a problem. Like, that's a big, big problem for people with type one diabetes, the ones that don't feel comfortable, or don't feel like it's their job to make changes to settings. They're the ones I see struggle, the most long term is adults. Do you agree?

Jennifer Smith, CDE 27:05
Yes, absolutely. Because they from an early on diagnosis, whether it was childhood, and that's how their parents navigated, because that's what they were taught how to do. And then they move into adulthood, managing that way, really only following up with the doctor every six months. And that's when something gets shifted and changed and not not really knowing that they're in the driver's seat. 24/7, between that 1520 minute visit with the endo every six months, right, you are the Navigator. But unfortunately, if you don't tell somebody, it's almost like giving the Okay, many people with this type of a, you know, a use of something that supplies like insulin, right? You really have to be directive and say, You know what, I'm going to give you these starting places. And here are some pointers for adjusting. I'm happy if you adjust. In fact, give me feedback when you try and adjustments so I can help you behind the scenes if there's you know, communication with an electronic record or something like that. But you do you have to almost give the okay to people. Otherwise, they may also come back to the office and not provide feedback that they've been tweaking things on their own, because they may feel like they're gonna get their hand slapped. Yeah.

Scott Benner 28:20
Oh, that's definitely happening. Right? Yeah, people are definitely lying. They're always like, I can't I can't let my doctor catch me doing this. And when people say that, to me, I'm like, What are you talking about? Like, oh, I want to make an adjustment to the basil, but I'm afraid I'm gonna get in trouble in trouble, like, so. Ironically, you're not in trouble, quote, unquote, for the seven and a half a one C, but you wouldn't be in trouble for putting the Basal up point three an hour and making it a sentence? fascinate, right. Yeah,

Jennifer Smith, CDE 28:45
absolutely. And insulin, interestingly, is, I think it's, I can't think of any other medications on the market, that people self adjust, right? Like you don't go to your cardiologist and they give you blood pressure medication, you're like, today, I think I'm going to take two of these tablets with you. It's gonna happen, right? Like insulin is one of those. It's I think it's the only thing that really, it does require you to look at your own information and make adjustments based on what you're seeing and where you want to end up. What is the target you're aiming for? What are you trying to get to, things aren't working?

Scott Benner 29:23
It's also interesting where the line gets drawn, and I had a, I had a root canal go bad. It was like 11 years old. So I was pretty happy. It lasted that long. So I'd have changed out right. And when he got in there, he's like, Hey, there's like a little bit of an infection there. You know, this is really going to hurt tomorrow. Let me give you a prescription for a pain medication. He said, The one I'm going to write for you is highly addictive. He said, so you have to be careful. And I was like, I'm gonna go with Advil if you don't mind, right? And he goes, No, no, you should probably take this script because this is gonna be a problem, blah, blah. And I was like, I'm good. I don't I don't need your script. All right. By the way, I didn't even take an Advil when it was over the guy said, great dentist and did a great job. But he was so willing to be like here, would you like a week's worth of narcotics? Because I dug around in your gum for an hour. And I was like, and I'm like, Wow, look how easily he would have given that to me. Yeah, but then you go ask an endocrinologist. Hey, you know, wouldn't it be cool if that lady could change your basil and they can't handle that? Right? Again, and all that, but you can give them oxy. I was like, right. All right. Can we make sense once in a while? No. All right. This person says, Can you give me your medical opinion, please don't parrot what you're reading, ah, in this example, as their kid was doing a six for a lot of years. And then it rose up. And the doctor went, That's okay. It's still within target. And they're basically just telling them like what the ADA said, like ADA says sevens fine. This is fine. And like, so then that takes the onus away to do better again, it's again, it's just like, oh, whatever, you're fine. It's like, what's your blood pressure supposed to be? I don't know these things. 120 over something. It's

Jennifer Smith, CDE 31:06
well under 140. And it's like, what let's call it like, 130? Over 80. Okay, right. But in anything kind of, you know, within that sort of the range, but just your blood

Scott Benner 31:20
pressure was 150 over 90 all the time. What a doctor guts. Alright, it's cool. Not bad. No, no,

Jennifer Smith, CDE 31:25
they shouldn't.

Scott Benner 31:29
But you I saw you getting upset earlier talking about those column? 250s. Okay. You know what I mean? Like, that's the same thing. But you don't but that doesn't get seen that way. A cardiologist would never say that to you. an endocrinologist would say that to you all day long. Oh, just 250 it comes back down. You're fine. What? How am I gonna be in 20 years? Right? Yeah, yeah. What do you do you own a LASIK center or something like that. And you're thinking of getting into diabetes surgery to like, what are you trying to have happened to me here? And what and oh, sorry, I got upset. Now you can talk? No,

Jennifer Smith, CDE 32:04
I was gonna say and for the person who is a little bit more concerned about the lower blood sugars because of whatever fear that was instilled eons ago or whatever. Those numbers that are higher that they've been told are okay, even for lingering or you know, non lingering time periods, like a blip up and then it kind of comes back down. Eventually, they may get to feeling that they're safer. They're okay at those numbers, because in their mind 250 becomes okay, then all the time. Yes, not just the up and it comes back into what you define as the as the healthy brain to be re

Scott Benner 32:47
in range. Yeah, yeah. Especially with the thing that you don't feel. Listen, if your blood sugar's if you're a one sees rise slowly enough, you won't feel the impacts the physical impacts, your body is going to do a pretty good job of trying not to die and like what it was it this opens up blood vessels that like does all kinds of stuff, right? Like to try to like Yeah, yeah, yeah. To, to do that kind of stuff. So. So when you say it's okay, this person is slowly not becoming themselves anymore, they're altered mentally even, you don't even realize how foggy they are, they get used to that their body gets used to trying to exist like this no different than, you know, how you end up with an enlarged heart from smoking. Right? Right. Same idea. And, and yet, it's like, it's okay. It's okay. It's not okay. Like, it wouldn't be okay for you. If if you were that if the doctor, his blood sugar was 250 all the time. They'd be going like, we gotta fix this, you know, so I don't, I don't know why that that tired. It's just tired. It's lazy. Well,

Jennifer Smith, CDE 33:50
and again, with today's technology, and everything that we have, that it's got such tight ability to have alerts and alarms to keep people safe. And yes, technology can be a little weird and whatever. Yeah. But the majority of the time, what we have today with the alarms and the alerts, there's no reason to say that you can skirt up to this value as long as you're not under here. And as long as you're not hanging out in the low zone. And again, that's not even often very well defined. Yeah, what's too low? Where do you want to hit? What how long? Can I sit at what you're not telling me about a low number? What do I do it? Again, it's very like Flim

Scott Benner 34:32
Flam. It's nebulous. It really is. And by the way, even now with a within a non aggressive algorithm, like the eyelet, for example, that thing's still targeting probably under like 180 or 170. And you and I would be like, I mean, listen, it's a great tool, and I think it's going to help a lot of people but I wouldn't rely on my daughter and like, and that's 70 points better than telling somebody to 50s Okay, so I just need to understand speaking Understanding even though we had management under control and a consistent a onesie in the fives, my Endo, my son's endo said that we need to do less work, we need to do less work and let his numbers get higher. So as a one sees more like in the mid sixes or sevens, that whole you're trying too hard thing. I don't get that, like I really don't, because I know they don't want people to go crazy taking care of themselves. Right. But at some point, it does become second nature. Like you don't you mean you? It's a lot of hard work upfront for a lot of benefit long, long term. And

Jennifer Smith, CDE 35:39
I think in a visit where you the clinician, you're looking at that, let's call it a one C, which again, is not

Scott Benner 35:46
that shallow, I'm enraged and everything just

Jennifer Smith, CDE 35:48
not right. Are you asking more in depth about how much work it is taking? Because again, once you've been there for a while, as you said, it becomes more most of it becomes more second nature and you you're able to just navigate and keep that yeah, because you're doing what is pretty typical. And until or unless something changes with a growing child or a teen or something in adult life. For the most part, you're doing a good enough job. And that's when you have to define or ask the person. Gosh, how much are you checking? Yeah, right. If you can see that, you know, even in a visit somebody's like every two seconds, they're like looking at their numbers. There might be something more like on the mental angle to logical

Scott Benner 36:34
issue. Yeah, they might be under a lot of stress and pressure. But yeah, just assuming, you know, it really does it piggybacks on to this point that you added to here, you told me please bring it up, that seeing a good low a one C and assuming it's from like low blood sugars is a dangerous way to think as a doctor. This is Oh Jenny, this happens constantly the amount of people who listen to this podcast, then head off back to the doctor super excited, oh my god, I got my one seat down. It's nice. It's not that hard. Even I figured it out. Like turns out my settings were wrong. And the doctor yells at them, because they as soon as they see a number that's lower on that agency, they assume you've had multiple, you know, elongated lows to create that agency because they don't even know how to do it. It's such a unknown quantity to them, that they just assume that you've cheated the a one C test by having a lot of lows. Right? Yeah. And some of them won't listen, when people try to explain it to them, or the people are put their head down and you know, don't stick up for themselves. Right? It's a dangerous assumption to make. That's just because somebody has an A one C and the sixes are the five that must mean they're low all the time. My kids never low. Like, like, once in a great while. And even that means a drifting to 55 not like, you know, oh my god, what you know, Bob a lot most of the time her blood sugar's I don't know, it's not it's never usually under 70. Right, you know, honestly. So we have some bullet points that go through here at the end. So we'd like 10 minutes left. Yes, some of them are repetitive, so we might have to pick through them. And I'll skip over the ones I wished my doctor knew that tightly managing my son's blood sugar is far less stressful than living on the roller coaster. That's the thing you wouldn't know unless you lived with it. Correct? Like actually trying and working towards it is not as hard on you as the unknown aspect of it. You know, I think it's the difference between being told you're about to walk through a haunted house and not being told, you know, when stuffs just jumping out from around the corner all the time. You're always like, I don't know what's gonna happen next. Right. But yeah, working hard. I find this to be true for me. I don't know that everybody would find this to be true. I assume you do. Right? Like the work you do is, is worth what you get out of it? Absolutely.

Jennifer Smith, CDE 38:49
Yeah. 100%. Because I have, I have things that are known. And it makes the majority of my management, more like brushing my teeth. I don't think about the like, brush my teeth, whatever, right? It's not a thought. I have the time it's like out of my brain that you're putting the toothbrush on the brush and brushing and whatever. That's how I think about the majority of my management, unless something is really shifting stress or whatever, or I'm ill. But even that I've got enough enough years of experience to have a go to. Yeah, right. It's a starting point of oh, I can try to do this. And definitely it helps, right?

Scott Benner 39:32
So I always describe it as walking through a door. I don't like consciously think reach out, grab the knob, turn it pull. I just I just end up outside the door. And that's how diabetes works for you after a while and it is it becomes a muscle like I bet you Mike Tyson hasn't fought in a while but I bet you if you walked up to him and tried to slap him, I bet you his head would move pretty quick and he'd pop you right in the mouth. And so like and that's kind of how diabetes ends up working out. You don't know what to do. happening. But now you have all this experience and you know, blah, blah. This person says, Please tell people that they could actually go into decay with a normal blood sugar number. Yeah.

Jennifer Smith, CDE 40:11
That's so important. And where do you usually go? If you have ketones, and you're not feeling well, and you can't keep something down? Where are you going back to

Scott Benner 40:25
the hospital? That doesn't seem to know anything about helping me with my diabetes. And

Jennifer Smith, CDE 40:28
in that scenario, we actually, unfortunately had a really sort of a bad situation with one of our clinicians who her fiance had to advocate for her. And she's actually kind of corresponding with the hospital system, because of how they navigated it for she knew she was there for five hours, trying to get them to just give her fluids, her blood sugar was normal. They kept telling her she wasn't in detrimental need,

Scott Benner 40:59
right? Yeah, yeah. But she, I

Jennifer Smith, CDE 41:01
mean, and that's it. She knew she knew what she needed. I mean, sure, if you can stick your own IV. Oh,

Scott Benner 41:08
great. Imagine knowing so much about it that you know, you're in this trouble. This is the next need you have you need, you need IV fluids, then you take yourself to the right place, tell the people who are supposed to know and they're the ones who are going to be the impediment between you and not maybe dying. And that's by that happens quick. By the way. I forgot how nursing, how do they put it like it's not compatible with life, the acidity, right? That happens, right? The

Jennifer Smith, CDE 41:36
changes in all of your electrolytes and all of the things that should be being measured in the body. And ketones are one marker. And obviously, with diabetes, blood sugar would be technically another thing that they look at. But you know, when we talk about you, glycemic DKA, that's unfortunately, a level well above what most emergency departments even understand how to navigate Yeah. So

Scott Benner 42:01
I'll run through the rest of these here. Somebody said, Please, you should talk about the benefits of like mini glucagon injections for some people, especially with little kids who have trouble with lows. Please tell people about Pre-Bolus thing this woman says how we said this already today, protein and fat and how it impacts blood sugars and spikes. An explanation of insulin resistance would have been nice, when it happens, why it happens and how to manage it. So that's a person saying even if your settings work, when something else happens, I should know, like what to do next. Right? I wish my doctor knew that a one C wasn't everything. As soon as my doctor hears that my a one C is 6.8. I hear from them. You're doing great, don't worry. Meanwhile, I'm on a roller coaster all day long. I've at 50 blood sugars and 400 blood sugars on most days. And I have no idea where to begin. But they saw the 6.8 and said hey, you're doing great, right? Yeah, that's it. I wish they knew that there was no good reason to delay a person from getting a continuous glucose monitor. Within the hospital or as soon as after diagnosis as possible. I still want people to learn how to prick their fingers. But uh, CGM is such a, it's a next level, I think people deserve it. Who have type one diabetes. I think anybody using insulin deserves one. I agree. Same thing with pumps, please tell us about pumps sooner. This person says you should tell people about the podcast that's very nice. Whoever put that in here.

Jennifer Smith, CDE 43:31
I would say along with the pumps that I think it's gotten better crack. Most practices now have more knowledge about the multiple options that are on the market. But I still see practices that are more prone to offering or suggesting heavily one particular pump versus another. And what that often comes from his just their knowledge about that one particular system and they feel so strongly that it is the right one. Again, this is where individualization needs to come into the picture. So you need to know about everything to help the person pick the right one at the right time.

Scott Benner 44:10
I think in a world where you know, especially while we're making this episode, these episodes in a world where people are so under educated in the things that you're talking to other people about. I understand where this comes from, like, you know, I figured out how to use this one pump at least I can talk to them over the phone about where the settings at and stuff like that, but you are eliminating choice from people and not just their personal choice but choice that might allow them to find something that actually fits in their lifestyle better. Right. You know, I use I saw a little girl the other day online. So happy holding her tandem. Her ex too. Yeah, she's so thrilled, you know, and someone said, How come you didn't get her an omni pod? There wouldn't have been any tubes. And she said this just works better for her. And like, like for her personality. She said, good. Like, that's great. Yeah, but You shouldn't get like, because the, you know, I mean, because think of how that happens. Why are you? Why do you know one pump better than the other one? Right? I don't know, because the salesperson got there first. You know what I mean? Like, what the heck? Because back in the day before all the laws, they sent the doctors on better vacations. Yeah. Why we're doing this one. Jenny's laughing because that is what they used to do. That's not legal anymore. I'm sure that doesn't happen. Good lunches. That's it. They used to have like meetings, but they'd have them in Hawaii.

Jennifer Smith, CDE 45:31
Yeah. Or take you out for you know, good, like dinners where it was like a lunch and learn type of experience. Right?

Scott Benner 45:37
So yes, yeah, a bottle of bourbon and a steak. And all of a sudden, we're getting a pump.

Jennifer Smith, CDE 45:41
I remember when that all changed. Yeah.

Scott Benner 45:43
Yeah. Was that was actually a good law. I don't I don't have anything else for this one. So I'm just want to ask you, you know, for your kind of closing thoughts on how doctors should be talking about actual management to people? Yeah,

Jennifer Smith, CDE 45:55
I think we, I think we discussed the majority of what was I really do, especially along with all of the comments that people offered just in consideration. I think, you know, all of this communication and management and everything that we've talked about so far, it just it It boils down to individualizing. And really knowing starting place and where to move from there with somebody, because that starting place again, is just that you're going to have to move that person along and or help them move along because of the questions that they're bringing you. Maybe they're further along in understanding than you think they would be right so you have to meet them where their need is. Yeah,

Scott Benner 46:40
I know it sounds I always felt I always feel stupid saying cliche things but meet people where they are big deal. You know, you understanding what you're talking about. Big deal. You being able to communicate what you're talking about big deal and giving people a complete story. And not just snippets is is very, very important. Anyway, thank you for doing this with me. Thank you of course.

A huge thanks to the contour next gen blood glucose meter for sponsoring this episode of The Juicebox Podcast. Learn more and get started today at contour next one.com/juice box. A huge thank you to one of today's sponsors, G voc glucagon, find out more about Chivo Capo pen at G Vogue glucagon.com Ford slash juicebox you spell that GVOKEGLUC AG o n.com. Forward slash juice box

if you are a loved one has been diagnosed with type one diabetes. The bold beginnings series from the Juicebox Podcast is a terrific place to begin listening. In this series, Jenny Smith and I will go over the questions most often asked at the beginning of type one. Jenny is a certified diabetes care and education specialist who is also a registered and licensed dietitian and Jenny has had type one diabetes for 35 years. My name is Scott Benner and I am the father of a child who has type one diabetes. Our daughter Arden was diagnosed in 2006 at the age of two. I believe that at the core of diabetes management, understanding how insulin works, and how food and other variables impact your system is of the utmost importance. The bold beginning series will lead you down the path of understanding. The series is made up of 24 episodes, and it begins at episode 698. In your podcast, or audio player. I'll list those episodes at the end of this to listen, you can go to juicebox podcast.com. Go up to the menu at the top and choose bold beginnings. Or go into any audio app like Apple podcasts, or Spotify. And then find the episodes that correspond with the series. Those lists again are at Juicebox Podcast up in the menu or if you're in the private Facebook group. In the featured tab. The private Facebook group has over 40,000 members. There are conversations happening right now and 24 hours a day that you'd be incredibly interested in. So don't wait. So don't wait. Check out the bold beginning series today and get started on your journey. Episode 698 defines the bowl beginning series 702, honeymooning 706 adult diagnosis 711 and 712 go over diabetes terminologies hit Episode Seven pick team we talked about fear of insulin in 719 the 1515 rule, Episode 723 long acting insulin 727 target range 731 food choices 735 Pre-Bolus 739 carbs 743 stacking 747 flexibility. In episode 751 We discussed school in Episode 755 Exercise 759 guilt, fears, hope and expectations. In episode 763 of the bowl beginning series, we talk about community 772 journaling, 776 technology and medical supplies. Episode Seven at treating low blood glucose, Episode 784. Dealing with insurance 788 talking to your family and episode 805 illness and ketone management. Check it out it will change your life when you support the Juicebox Podcast by clicking on the advertisers links you are helping to keep the show free and plentiful. I am certainly not asking you to buy something that you don't want. But if you're going to buy something, or use the device from one of the advertisers, getting your purchases set up through my links is incredibly helpful. So if you have the desire or the need, please consider using Juicebox Podcast links to make your purchases. Thank you so much for listening. I'll be back soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com