#80 Think Like a Pancreas Chapter 8: Meeting the Challenges of Daily Living with Valerie

Who's ready to think like a pancreas?! This is the eight episode in our 10 week, Think Like a Pancreas Book Club Series and today I am covering chapter EIGHT called, Meeting the Challenges of Daily Living. My guest for this one is a sweet and strong T1D mama named Valerie. This chapter is probably my favorite because it covers all those factors that affect blood sugars that they DON'T tell you about at diagnosis. Take a listen and, as always, let me know what you think!

Listen, if you have type 1 diabetes or your kid has type 1 diabetes or someone you love has diabetes or perhaps you have type 2 diabetes and are taking insulin, I can confidently say you need to own a copy of this book and actually read it. I call it my diabetes bible and refer back to it often! It will teach you how to manage your insulin better and empower you to make all those hundreds of daily diabetes decisions faster and with more confidence. I sure do hope you will follow along with us. See links below to get your copy from Amazon or get your signed copy from the author, Gary Scheiner, on his company's website,  integrateddiabetes.com. Enjoy!

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OTHER INFO MENTIONED IN THE SHOW

Episode on alcohol and Type 1 Diabetes!
https://www.sugarmamaspodcast.com/60-teen-series-part-8-drinking-and-diabetes-with-rachel-halverson-rn-cdces/

Episode on Insulin Needs in Teens (the menstrual cycle):
https://www.sugarmamaspodcast.com/54-teen-series-part-2-insulin-needs-in-teens-with-rachel-halverson-cdces/

Transcript

Katie: 0:00

Hey everybody. It's Katie. and this is episode 80 of the sugar mama's podcast today. My guest is another awesome T one D mama named Valerie and Valerie and I are going to be going over chapter eight of think like a pancreas by Gary Scheiner. Chapter eight is called meeting the challenges of daily living. I think chapter six, the chapter on basal insulin dosing was maybe the most important, but I think this chapter is probably my favorite and you'll find out why don't forget to take a look in the show notes for a link to buy your very own copy of the book. Think like a pancreas so you can follow along with us. All right. Without further ado, let's get started. You're listening to the sugar mamas podcast, a show designed for moms and caregivers of type one diabetics here. You'll find a community of like-minded people who are striving daily to keep their kids safe, happy, and healthy in the ever-changing world of type one. I'm your host and fellow T one D mom, Katie Roseboro. Before we get started. I need you to know that nothing you hear on the sugar mamas podcast should be considered medical advice. Please be safe, be smart, and always consult your physician before making changes to the way you manage type one diabetes. Thanks. Hey everybody. I am here with Valerie Harris today and Valerie and I are gonna be talking about chapter eight of think like a pancreas, which is called meeting the challenges of daily living. So Valerie, before we jump in introduce yourself and tell us your connection to type one diabetes.

Valerie: 1:47

Hi, my name is Valerie and my 10 year old son Cohen has type one. He was diagnosed in January of 2021.

Katie: 1:55

Okay. So not that long ago, a little over a year.

Valerie: 1:58

Yeah.

Katie: 1:59

Would you just give us a little, a brief story about his uh, diagnosis?

Valerie: 2:02

So I have three other kids besides him and they all had a little bug and he just didn't get better. And in the middle of the night he woke up and he was throwing up and I thought, that's weird. He's not getting better, but I didn't really. Think anything of it. And then in the morning we woke up, he was really sick. And my father-in-law is a type one. He was diagnosed because of medical issues later in life. And so by the time we got to the hospital, we knew we had tested his blood sugar here, but he was in DKA and his breathing was really rapid and shallow wouldn't it was terrible. So we were uh, life flighted to a ho hospital that is two hours away. That's where the peds hospital is. So,

Katie: 2:45

Wow. So it was like, it was pretty serious. I mean, life flight, they're not messing around with that.

Valerie: 2:50

yeah.

Katie: 2:51

Goodness gracious. I mean, was he like conscious on the life flight or

Valerie: 2:55

Um, he was, but it our drive to the hospital was like the longest drive ever. And it's two minutes, but I was like, hold hand, squeeze my hand. And Because of COVID we weren't able to go through the hospital because he'd been throwing up and he was having difficulty breathing and all these symptoms, they said, we know it's not COVID, but we can't take you through the hospital to the ER. So I had to go around to the ambulance entrance and it's not far, but I had to carry him. He couldn't walk. Like he was so weak. It was, it was bad. Um,

Katie: 3:25

gosh. That's terrifying.

Valerie: 3:27

We spent only one day in the ICU which seemed like reading some people's stories. Doesn't seem like a lot. And then we spent a few days in the peds unit just to get training.

Katie: 3:35

Wow. That that's a crazy story. Hmm. I'm glad that's over. Goodness gracious. I mean, Oh, my okay. Well, I mean, this is kind of a horrible segue into my next question, but I do like to I do like to ask people just a little bit about themselves because you know, it's all diabetes all the time and I would love to know just what are some like fun, interesting facts about you and your family outside of diabetes.

Valerie: 3:58

right. Um, Like I said, so we have my husband and I have four kids. We've been married for 17 years. And it's been fun. As the kids get older or oldest is 15 finding things that we like to do together. So last summer we started golfing together, which was really fun and we're not great. but it's a fun way to spend an entire afternoon together.

Katie: 4:19

Yeah. Okay. So when you say golfing, you mean like you're on a course? You're not like at put putt.

Valerie: 4:23

no, we're like on a golf course. Yeah.

Katie: 4:25

Okay. I love it. I love that. You're like, not really that great, but you're still getting out there and doing it.

Valerie: 4:30

Yeah. Cohen, who's our type one. He is pretty athletic like skilled wise. So I don't really wanna go play with him again cuz I'm pretty sure he is gonna beat me.

Katie: 4:38

yeah, that is one sport that I'm like, I just have no interest whatsoever in playing and we actually live in a neighborhood that has a golf course. And so my husband will just like take the kids up to the driving range every now and then. And we're, we're not members of like our golf course here, so we don't, we can't really just like, go play golf whenever we want, but there's a college nearby that has like a, I think right now it's just a four hole golf course. And he'll, he'll take them like one at a time to do that, but he's like, you, you should come with us. And I'm like, I just don't know. I'm like, let's go to the beach. Let's get in the pool. It's gonna bike ride, but golfing, I don't know. That just seems extra hot in Florida.

Valerie: 5:15

Yeah, yeah, that would be hot. We don't play in August here. It's hot in August.

Katie: 5:21

Yeah. Yeah. But I'm glad you guys enjoy it. I mean, we see neighbors out all the time golfing and it looks like they're having a blast. I just feel like this. Maybe not for me. well, have you ever read, think like a pancreas or is this your first time reading it through

Valerie: 5:36

So this is my first time reading it through. I started it and got super overwhelmed. You recommended it to me right at the beginning of our diagnosis. And I, there was so much other information coming in that I was like, I, I can't. So I started it and put it down. And so I've been reading it through now, which is great to have little bits of time to be able to go through it.

Katie: 5:56

I think it's definitely just for anybody listening. Like I know it's a big book and it's a lot to get through, but like, if you are able to get through it one time, you really should go back and like, reread it again. Maybe like six months later or a year later, because it just all makes so much more sense. And you, I mean, I've read it three times now. The second time was kind of like more of a skimming, but and I just feel like I learned something new every time, or I see something that like, I don't remember reading this before, so it's a good, it's a good book to own. And just it's, you know, I call it my type one Bible. Like I feel like when I need to reference something, I'll, I'll go back and look it up and think like a pancreas. So, so that's a good plug for check out the show notes because I will leave a link in the show notes to where you can buy your own copy. I think people would definitely wanna copy. There's just so much in the book that I can't possibly explain with words. So,

Valerie: 6:44

no, my it's all highlighted and written in.

Katie: 6:48

Yeah. Yeah. I've been making outlines as Valerie knows. Cause I center the, the outline for this chapter and I'll start and I'm like, okay, this is gonna be a pretty quick chapter. And then I get started and I'm like, okay, this is taking me forever. Cuz every, you, you know, you wanna pick out just what's important, but it's like, everything's important. So it's hard to pick and choose. All right. So what do you think in your opinion, in your own words, what do you think the goal of this chapter was?

Valerie: 7:13

I feel like the goal of it, it kind of covers all the things that make diabetes, diabetes. like the things that you just, it might happen this time and not this time. And you never know, and you're always juggling and going, is it this? Could it be that? And it kind of covers all those things.

Katie: 7:30

Yeah. Yeah, I agree. I feel like so chapter three which if people are like listening to these episodes in sequence, they've already listened to that one, but chapter three was called beyond the basics and it covered like the five major factors that affect blood sugar. And those were insulin, duh other injectable and oral medications, physical activity, food specifically carbohydrates, and then the livers secretion of glucose. So I feel like that is the chapter that people that when you're diagnosed, they kind of tell you about like sort of not, not even all of that really. But this chapter is like all of the things that you have to learn on your own when you leave the hospital and then you start to live life and you're like, wait a minute. There's like a million other things that can affect your blood sugar. So this chapter kind of dives into all of these secondary factors. So personally it was, I think it's my favorite chapter. All right. Well, we're gonna, we're gonna jump in. All right. So we're gonna start with the secondary factors that tend to raise your blood sugar. The first one on the list should come as no surprise. It is anxiety and stress. And I feel like this is definitely like when people say your diabetes may vary, this is what they're talking about, because you know, it's different for everybody. What might stress you or your kid out might not be stressful at all for, for somebody else. So it's important for you to be a student of your child with T one D and just learn their patterns. And the author says several times throughout this book, which I think it's a great mantra. If you can predict it, you can prevent it. So if you know, you're getting ready to enter into a situation that normally causes you or your kid stress and anxiety. And you've seen a pattern of their blood sugars being elevated during that time or creeping up during that time. Then that's something that you can predict and therefore prevent. So the adjustments that the author suggests are, if you're on MDI, if you're on injections, he says, consider giving yourself a bolus of rapid acting insulin an hour before the event starts. So maybe it's a dentist appointment at 10 o'clock in the morning. Your kids hates the dentist. So nine o'clock give him a little extra rapid acting insulin. If you're on an insulin pump, set a temp basal increase of 60 to 80% for three hours starting one to two hours before the event starts. I love temp basals because if it's too much, you can just cancel it. Right. Like if you've already given a bolus, you can't take that back. But I, I do love I love tent basils for that reason. Cuz you can just cancel it up. And then of course, make sure to check blood glucose levels. Often the first few times you try this because you know, it's, it can be a little intimidating at first to just make increases to insulin even before you start to see that rise. So that can be tricky. So what are some circumstances Valerie that have caused stress and anxiety for your, for your son and how have you guys adjusted the insulin?

Valerie: 10:21

New situations. he is shy and before his diagnosis he didn't like knew anything. He wouldn't even like, go hang out at our best friend's house without me. Like, he's very homebody comfortable. Now his diagnosis has caused him to have to grow in a lot of ways. um, Which has been really good for him. But if he's in a new situation, especially he's, there's a high level of stress or in a situation where he thinks that people are looking at him like where he's the center of attention, even if he's like at our church, he runs cameras for our live stream and sometimes he'll go hi. Like he, he starts to worry about people looking at him and if we acknowledge that they see him, or if he is acknowledged from upfront, I can see him start to get anxious because he is like, don't look, don't talk about me. Like, I'm just doing what I'm supposed to. And so he goes high in that situation.

Katie: 11:13

Hmm. So he does, does not like to be the center of attention. Yeah. Yeah. Sarah's the same, same way. She does not like people looking at her. In fact, today she went to field day at her school and they were allowed to wear like, you know, shorts that they might not normally wear. So she wore these like biker shorts that have pockets on the side, so she could keep her phone in some low treats on, on the sides. And she like, the pockets are a little bit mesh, so you can kind of a little bit see through the pocket, not the shorts, but the pocket. And And she was like, mommy, I, I, but people can see it. Mommy. They're gonna see my phone and they're gonna, they're gonna say something about it. I'm like, sweetheart, it's that? No, they're not. First of all, they're probably really not. And also like, just to say, it's my, it's my phone. I monitor my blood sugars with it, or it's a medical device or, you know, like, I mean, she, I, I don't like to point this out to her often, but it's like, everybody knows you have type one diabetes, sweetheart. You know, it's, they know that you have to have things on you that other kids wouldn't, but just the thought of it just, she hates it for us. The main thing that we've noticed is testing. Sarah gets, and I think it's a combination of, she's not moving. She's just sitting, still taking a test for hours, like standardized testing. And she just gets some test anxiety. So on those days I usually do anywhere from like a 30 to 50% basal increase on those days. And sometimes she needs it and sometimes she doesn't and if she doesn't, we can just cancel it and she can treat the low, but. But, yeah, let's see, moving on to the next section. All right. The next secondary factor is caffeine, which probably most of our kids aren't drinking a whole lot of caffeine, at least not in coffee. Although my oldest 11 year old son does drink coffee every morning, which, whatever man but coffee is a natural stimulant. It can raise your blood sugar levels 30 to 60 minutes after you. Promotes the breakdown of fat rather than sugar to use as energy. And it also stimulates the liver's breakdown of glycogen into glucose. So the liver's spitting out more glucose into the bloodstream when you drink caffeine or, or eat foods with caffeine in it. So the author's recommendations for this to make adjustments are take again a little bit of extra rapid acting insulin. If you know, you're gonna like with the food or the beverage that you're consuming, that's high in caffeine. He makes it a point to say, you know, it's lots of trial and error to kind of figure out how much you need. But for the first few times just bolus for the carbs that are in the food or the drink, and then. See how much of a rise you see after that to kind of know like how much extra insulin you need to give. So like if your insulin sensitivity factor, which we talked about in chapter seven, so the previous episode is like 50 and you notice after a big coffee drink, your blood sugar goes up an extra 100 points. Then 100 divided by 50 is two. So he would, you know, suggest you would need to take two extra units of insulin to cover that caffeine rise. The next secondary factor is disease progression. So this would be people exiting the honeymoon phase. Interestingly enough honeymoon phase can last for months, two years. That's crazy to me. And the first thing you may notice is that morning sugar levels tend to be higher perhaps for the first time ever. And the author suggests that if you experience blood glucose values that are above target for three days in a row, bolus insulin may need to be increased at meals and or basal insulin may need to be increased. Especially if the elevated numbers are seen first thing in the morning. So did you guys experience a honeymoon phase at all? And if so, like how long did it, did it last.

Valerie: 14:40

Not in like the, we don't need insulin way, but in the like it's middle of the night and you're low for no reason way But that lasted, oh man, probably about six months. And I'm still like, I go, well, maybe like, I feel like his ratio is small. Like it's not big, small

Katie: 14:56

Yeah, Yeah, no, I know what you mean. Like it's like one to 20 instead of like one to five. Yeah.

Valerie: 15:02

Right. Exactly. And so I'm like, but right. It, doesn't not, everybody's the same. So I'm like in this, I don't think we're in the honeymoon, but I don't know. But I do know that when he gets sick after that sickness, it seems like our needs change again. And we like before it's like this slow progression, it's been weird, but it didn't happen last time. He was six. So maybe we're like normal now.

Katie: 15:23

Yeah, maybe you're normalizing. Interesting. I have always claimed that. I don't think Sarah went through a honeymoon phase. I thought she was at first because we saw the same thing at night. Like she kept, you know, she'd start out at like one 50 or somewhere between one 50 and 200. And then by, you know, two o'clock in the morning, she was like 60. So I thought that was it. But after we kind of adjusted some things and tweaked around with it, we I'm pretty confident now that it was just that her basal insulin was too high. And so we needed to take that down, but but yeah, I just feel like her insulin needs have always just been pretty high right from the get, go. Not as high as some people though. My goodness. I've heard some stories

Valerie: 16:01

Yeah. I'm terrified about puberty

Katie: 16:03

yep, yep, yep, yep, yep, yep. Yeah. it's OK. You still have like what a couple years, year or a year, at least maybe. Oh, yes. All the insulin. That's my advice for that. I mean, not that I've even been through it, but that's what everybody tells me. You just need all the insulin. All right. The next secondary factor is protein in the absence of carbs. We already, we've already talked about this several times throughout this series, but I will mention it again here, cuz it's important, but protein in food will raise blood sugars. If the meal that you're in, if the meal that you're eating contains little to no carbohydrates in it. So when you consume protein with carbs, then your body uses that protein for things like growing healing and creating other hormones and enzymes. But if you are eating a meal without any other carbohydrates, so it's just mostly protein, then that protein becomes a source of glucose for fueling and you know, nourishing the body's cells. So. If there is no other carbohydrates in the meal, about 50% of the protein eaten can be converted to glucose. Like your body will convert that to glucose. So keep that in mind. The author suggests that if there are no or very little carbs in a meal to calculate the grams of protein that, that you or your kid are gonna eat and then cut it in half and bolus for it as if it were carbs. So if you're not having carbs and you're eating 20 grams of protein, cut it in half. So that would be 10 grams of protein. And then bolus for that, like, just like, it was like 10 grams of carbs. And then he does say like, if you, if your kid or you, or whatever, is just having a snack, that's like pretty small, like a couple pepperoni slices or a cheese stick, like that's really gonna have a pretty negligible effect on blood sugar. So you don't really need to worry about that. Are you guys low carb?

Valerie: 17:49

No,

Katie: 17:50

Yeah,

Valerie: 17:51

We eat all the carbs Cohen. He is really picky. he's a lot of carbs.

Katie: 17:55

yeah, yeah, no, we do too. No, none judgment. If you would've said yes, I would've been like, that's great. Tell me all about it, but I, when you open our pantry, it's really laughable. Like how, like that a, a diabetic actually lives in this house. And I don't say that to like brag or anything. It's just, we just eat a lot of carbs and that's how it was before diabetes. And we just didn't made the decision not to, to change it. So I feel like this is not really an issue for us, cuz we pretty much always have carbs during our meals. I remember one breakfast, Sarah was just all she wanted was bacon and eggs. Like I didn't try to push the carbs or anything. I said, okay. And she did, I, she actually, her blood sugar went up pretty significantly just with the bacon and eggs. It was like, I, it was a while ago, but I think it was like at least a hundred points. Maybe even a little bit more than that. Yeah. Yeah. And it was, there was a delay that was like an hour or so after she ate. But so it is true what they say it will bring your blood sugar up. And then of course those things are really fatty. So the next secondary factor we're gonna talk about is fatty foods. Again, something we've touched on a few times throughout the series already, but fat slows down digestion. So there's a delay in the breakdown of carbs. Okay. So it also raises the level of triglycerides In your bloodstream, which makes the liver more insulin resistant. And then apparently when the, in, when the liver is more insulin resistant, it secretes more glucose into your bloodstream. So not only are you seeing this delayed rise from the carbohydrates that are being digested hours later, but now the liver is more insulin resistant and it's dumping more glucose into the bloodstream. So you see more of a rise. The author says that everybody's different. So you can't really, you know, like for some people, fatty meals might not make as big of a cha as big of a difference. In some people versus others, but he does say that if there's more than 20 grams of fat in a meal, it does increase the likelihood that you'll see that delayed you know, sugar rise. But again, your diabetes may vary. So page 2 28 provides a list of foods that are typically very high in fats. So you can take a look at that. Again, his mantra, if you can predict it, you can prevent it. So here are his suggestions for making adjustments for fatty meals. He says, you can take a small dose of NPH, which not, I don't know any kid that's on NPH, but it is interesting to me. So I'm gonna mention it. But if you are taking NPH, you can take a small dose of that. After consuming a high fat meal. If you're on a pump, you can try a 50 to 60% temp basal increase that lasts approximately eight hours. And you would start that one hour after you finish the meal. When we have a really heavy meal like pizza, like, like restaurant pizza or restaurant. Alfredo fettuccini Alfredo. I noticed that Sarah's blood sugar is usually elevated. I would say at least for eight hours after the meal. And I mean that doesn't start right away. That's I usually start to see that about three hours after she eats the meal, but once it goes up it lasts for a long time, like at least eight hours, maybe even sometimes a little longer. And then of course he says, check blood glucose frequently after trying this to see if it was too much or maybe not enough. We had this experience the other night, Sarah went to Bono's barbecue and had ribs and macaroni and cheese. And I thought I gave her all the insulin, but it was not enough. I had to go in probably three different times during the night and give her another bolus of insulin. Well, and then the thing is, you know, now they're insulin resistant, right? Because they're numbers up, there's fat in the system. And so. It's just so much harder to get'em down with those fatty meals. but never give up. We'll try again. We'll try again. I, I, I always, I'm very stubborn. So when foods defeat me, I'm like, oh no, no, we will try it again. And I will win next time.

Valerie: 21:42

I'm the same way.

Katie: 21:44

yeah. Okay, good. So what fatty foods do you, do you guys like? What gives you guys the most trouble?

Valerie: 21:48

So pizza, I feel like we sort of have a handle on pizza and I'm gonna fail miserably next time, because I said

Katie: 21:56

Yeah. Diabetes is listening to you, Valerie. It's like, oh, you think you have a handle on pizza?

Valerie: 22:00

but what I did is we eat at usually the same pizza restaurant and he eats the same pizza because he eats the same thing all the time anyway. And so I started taking notes, whereas blood sugar was when we started and what happened and cuz I was like, I'm gonna win So I took all these notes and so I kind of had it down to like, okay, this was a major fail. Don't do that, try this. And so I kind of have like a, a running list of how to handle pizza now, ice cream on the other hand beats me every time. So depending on the ice cream like drums. I'm like, let's get those all summer long because I can handle that. But like we get the vanilla ice cream that we get, whatever kind it is. I don't know. My husband gets it. I don't know. It's delicious. It just, it holds on and all, like, I can give him a two hour, so he's on the tandem. So we have a two hour that we can give an extended and it will still just hours later, just keep going up. I don't, I don't know what it is, but it beats me every time.

Katie: 22:59

yeah, that's interesting. I. We are on DIY loop right now, we're using the OmniPod's and we're using the, you know, the DIY system that you have to build yourself and it's all different. It's like, there's no extended bolus. First of all, it uses like absorption time. So like for a meal, like pizza, you would choose a much longer absorption time cuz you know, it's gonna take your body a long time to digest it and absorb it. But I feel like I've gotten really good on loop or much better, I should say on loop with all meals except for the really fatty meals. Those are. Those are really giving me a hard time. And I know it's just that I need to mess around with the settings more. But I, I really miss extended bolus, like, can we have loop and bring back extended Bo like, I don't know. I just felt like I had such a handle on that. And now I've, I it's just a matter of figuring it out because you know, I'm in the FA I'm in the Facebook groups for looped and, you know, plenty of people have figured it out. I just need to, I, I have found that I give the bolus and then I'm still having to give multiple bolus afterwards, which maybe that'll just be what ends up working for us. But I feel like there's gotta be a way to configure it to where I'm only just giving the one bolus and it'll figure itself out after that. I don't know. I dunno. I do. I miss. And then Omnipod five, doesn't have ex extended bolus either. Cuz we're gonna give that a try eventually too.

Valerie: 24:22

Yeah. I wish we could give longer extended bonuses instead of just two hours. That would be nice to be able to extend it three or four. I think we would be okay.

Katie: 24:31

yeah. Ice cream. I love ice cream. We're anyway, that was, it's like my vice, if I have it in the house, it's not a good situation. all right. The next secondary factor is growth and weight gain. So back in, I think chapter three, we were talking about insulin resistance and the number one cause of insulin resistance is weight gain. And it is just more fat increases, insulin resistance. And then of course, if your child is growing and gaining weight, they've got all the growth hormones going through their system. And that can cause the liver again, to secrete more glucose into the bloodstream. The author suggests that with every 10% change in body mass, which is not very much, but with every 10% change adjustments will need to be made to probably increase basal bolus and your ISF. So. It's interesting, like ISF is like if you, in your pump, if you have ISF at like a hundred, then your pump thinks that for every unit of insulin, it's gonna bring your blood sugar down by a hundred. And then like, you know, so, so a, a stronger ISF would actually be a smaller number, right? Because it, it thinks it has to give you more insulin because if, if it was 50, then only one unit would only bring it down 50 points. So anyway, ISF is very important for the DIY loop. So I'm a little bit obsessed with it at the moment. So he also says that when you're growing, if you're constantly above target, just start by increasing things by 10%, kind of across the board and see if that makes a. The next factor is illness and infection. And we, well, we can talk about it in a minute, but we haven't really experienced like a major illness since diagnosis, which I'm very grateful for, but I'm like, I'm I'm mentally preparing for that. So build keytones are a big thing when you're sick, they can build up in the face of illness because of the increased insulin resistance. So you definitely wanna check keytones more often when your kid is sick. Extra glucose in the bloodstream can also lead to infections because it provides fuel and nourishment for those yucky bacterias. And that just allows it to continue to grow and multiply infection fighting white blood cells do not work well when elevated blood glucose. When you see elevated blood glucose levels. And you wanna make sure you are at least taking your basal insulin when you're sick to prevent DKA. Even if you aren't able to tolerate much food, you still wanna make sure you're getting your basal insulin. And then you may find that your basal needs actually are going to increase during times of sickness. So the author has a couple suggestions. He says, if BGS are up and you do not have keytones consider increasing basal. By 25 to 50%. But if you have keytones and then it's different, if you have keytones, you actually might need to incre increase things by 50% to a hundred percent, which that's a, that's a lot. a lot. Yeah. that's a lot. The basal increases are in addition to your normal bolus doses for food and correction doses for highs. So you still need to be correcting for highs and bolusing for food when you're sick. Unless of course there's nausea and vomiting, which we'll talk about that later in the episode. Definitely just call your doctor. Like if you're unsure, just call your doctor, especially if there's keytones and vomits involved, for sure. Call your doctor, try to push a lot of liquids. Clear caffeine, free liquids maybe lower in sugar, but not. Necessarily sugar free cuz sugar free. The fake sugars can upset your stomach, but he says that kids should be taking in a half cup per hour when they're sick, which I know that when my kids are sick, it is like pulling teeth just to get them to like sip on something. So what's been your experience, Valerie. Have you guys experienced any significant illnesses

Valerie: 28:10

Nothing significant. I mean, we've had a little bit of this little bit of that. He was recently sick. It was probably the worst sickness he's had. He had a fever for a couple of days. And he did throw up one time. It was not it was fine. I gave him Zofran and he was fine, but all of the feelings came running back to me and I was not handling it well I was a wreck. He was fine. He never had keytones or anything, so he was doing great. So we haven't had anything we've never had keytones since diagnosis, which I may lose my mind if we did. It's it like the memories it's so stressful. So I'm thankful that he doesn't get them easily.

Katie: 28:48

absolutely. That Sarah has also, we have never seen keytones in her since diagnosis. She's not, she hasn't been now. She did have COVID. I mean, she tested positive for COVID. She was asymptomatic pretty much throughout the whole thing, other than being a little congested, but we didn't really see much of a difference in her numbers. Like they weren't super high or super low. It was kind of just normal for her. So it obviously must have been one of the very mild forms of COVID, which thank goodness. Right. But yeah, I just I don't know. I'll, I'll, I'll have to like come back and do an episode when we, I hopefully would just never will actually, I would prefer that, but if we do and get through it fairly successfully, I'll have to come back and report. All right. So the next thing on the list is reduced physical activity. This is also called couch potato syndrome Being sedentary for more than a few hours, or really even just a few hours. Like if you're watching a movie can result in a temporary decrease in insulin sensitivity, which basically translates into you might see elevated numbers. I mean, this kind of makes sense, right? You're not moving, you're burning less glucose and you normally would be a lot of times your, you know, road trips, movies, you're probably snacking on something which doesn't help the situation. So again, like other things that you might like shows, maybe plays that are a few hours long airplane, airplane rides could do it where you're not able to move around much. So the author suggests if you're on a pump, use a temp basal increase of 20 to 40. If you are on injections, you can increase Boless amounts by 20 to 30%. And then if you're on injections and you know, you're gonna be on a really long flight or a really long road trip, you may wanna consider bumping up basil a little bit too. Maybe like just a small amount, 10%. You know, the night before you travel or the morning before you travel, depending on when you give your long acting just to avoid those high numbers. So do you guys do this? Do you adjust for anything like this road trips, movies travel?

Valerie: 30:41

Yeah, when we go on, like we go to the coast for vacation and it's six or seven hours away so that we definitely have to increase our basil four to get through. Movies or there's a little bit, but because his pump it'll kind of catch it for me. He doesn't like go so high that it's out of control.

Katie: 30:57

We also go on a couple big road trips every year. Well, at least once a year, we go to North Carolina and that's about a seven or eight hour drive. So I do, I actually do like a pretty big tent basal increase for road trips. I'll do like an hour before we leave. I'll do like a 30 to 50% tent basal increase. We're getting ready to fly actually in a week, which is gonna be a long day of travel and I'm gonna probably do the same and just cancel it. If I, well, loop is different. They use things called overrides, but basically it's a temp basal increase and I'll just cancel it if I need to. but I will say we went to a movie. I don't even remember what movie it was over the summer. No, over Christmas break. So about six months ago. And that was the, it was not because Sarah was sedentary. I mean, that played a role, but it was because she was eating ridiculous amount of popcorn and, and we brought M and M's with us too. And I will say, I, I felt like I really deserved some sort of a trophy after that night because I just kept, I just held her pump, her PDM, and I just kept pushing in the insulin and she stayed in range the whole time, but I had to end up giving her 20 units of insulin over the course of four hours. Um, And I should also mention that right after the movies, we went to go get pizza so it was really, it could have been real bad, but it was, I just gave her the insulin that she needed and she actually stayed in range, which was phenomenal. So,

Valerie: 32:22

Yeah. We went to a movie on Sunday and we did not stay in range, but it was, again, it was the popcorn. It was not the movie it was the popcorn of the movie.

Katie: 32:30

Yeah, yeah, yeah.

Valerie: 32:32

you share that with anyone else? And he's like, well, they had a little mm-hmm yeah,

Katie: 32:36

mm-hmm

Valerie: 32:37

yeah,

Katie: 32:37

when you say a little, do you mean like a half a handful? Cause

Valerie: 32:40

yeah. Probably like it's his favorite snack? And he's like, can I put butter on it? Uhhuh? Sure. You sure we don't go to movies often?

Katie: 32:49

sweating inside.

Valerie: 32:51

it's fine.

Katie: 32:52

Now I will say like, that was not our first attempt at a movie. I mean, we, I, I think the experience of having major failures at movies leading up to that particular movie um, is I was just like, I went in, I went into it with like, you will not defeat me this time movies. So see you just gotta, gotta keep trying, gotta keep trying okay. The next section is all about rebounds from Lowe's, which this is a very interesting. Concept of me. So the symptoms that come along with like a low blood sugar, so shaking, sweating, rapid heartbeat are all caused by adrenaline, which is a stress hormone. So as we've already learned, stress, hormones can cause the liver to secrete more glucose into the bloodstream. So also adrenaline and I didn't know this, it can also inhibit insulin's action for several hours after it's been released into the bloodstream. So after you experience a low and all that adrenaline is released into the system from, you know, just kind of the, the. Trauma of the low blood glucose can usually be high for hours following a low and corrections given to bring them down may not be as effective since the adrenaline inhibits insulin's action. So a rebound low that occurs overnight is called a, oh gosh, I've already said it in chapter six, but now I forget Smoy smokey smokey phenomenon. That's what it's called. And then I made a note, it says C page 2 32 for a list of symptoms that may indicate you are experience Amoy phenomenon overnight. And then if you were, you would also be seeing high blood sugar levels when you wake up. Obviously in this case, like taking more insulin. At night to account for the highs that you're seeing in the morning would only make the problem worse, cuz you'd be dropping lower in the middle of the night, which would make the rebound low, more significant. So the author has a few suggestions to avoid rebound lows. If the lows follow highs at bedtime, you might wanna consider increasing the insulin sensitivity factor in your pump or just in your own calculations, starting after dinner. So you will receive less insulin to treat those highs. You might want to increase the dinner or pre-bed times snack insulin to carb ratio, which when you increase a ratio or make that bottom number bigger, it actually means you're getting less insulin. If lows take place in the absence of bolus at bedtime, then you probably, your Basil's probably too high and you probably need to reduce that. he also makes a important note that you wanna try to avoid overtreating the low, which would only make the rebound high, even higher. Cuz now you've, overtreated the low that's gonna make you high and you have the rebound high. A lot of people claim to only experience rebound highs after symptomatic lows. So the lows that come along with shake, sweats, rapid heartbeat, et cetera. So again, if you can predict it, you can prevent it. So if you notice a pattern of that, and this is an extremely bold move but if you notice a pattern of that, you may want to actually give another dose of rapid acting insulin. Like once your kid has recovered from the symptomatic low or if you're on a pump you could consider increasing your basal rate by 50% over the next three to four hours. Again, once you've recovered from the symptomatic low have you guys ever experienced rebound lows or rebound highs? I guess after a low.

Valerie: 36:09

Usually only when I over treat, the only time I can think this might have happened was right after diagnosis. It was his worst low. He had, we were on day three home, no decks come yet. And he like shriveled into this fall and he was like 45. And we've been at 45 since, without this reaction, but it was like, He'd been so high for so long, right? It was a big drop, all the sweats. And I did the 15 carbs because we were new. So I I'm, I don't know if I overtreated or if it cuz he was high for hours after that, he threw up from going up, it was a mess because we were new and I was terrified. That was like lots of calls. It was overnight like it was like five o'clock. So it was like call the doctor at, you know, out of office hours and things. Thankfully the doctor that answered that called me was the doctor that discharged us. So she had just seen me and was like, oh we got this. You're gonna be okay.

Katie: 37:05

Geez. Oh my gosh. But in that moment, you really don't think you're gonna be okay. Especially three days after diagnosis. Yikes. That's very scary. Ugh. We had a very, it wasn't right after diagnosis, but we had a similar situation. I think the, the meter just said low. So I don't know what number is that? 30 like

Valerie: 37:25

Dex comes under 40. Yeah.

Katie: 37:27

under 40. So it, she had to be 40 or less. It, it doesn't matter the situation. We overdid it on the insulin and then she was swimming. So that's not a good situation. And also she had eaten a heavy meal before that. So So, okay. So now we're dealing with three things. We're dealing with the rebound high. After the low we're dealing with me, freaking out and giving her three juice boxes. And we're dealing with the delayed rise in from all, you know, from the fatty meal, the delayed rise from all the carbohydrates from the fatty meal. So it was real bad. I mean, I don't remember her number, but literally the entire next day, she was high all day long. And I, I mean, like over 200, so it was not pretty. But we've learned from those mistakes and we have never experienced a low like that before I have learned my lesson, the hard way of being very conservative when there's gonna be, especially when there's gonna be like a heavy exercise activity after a meal, you really don't, you don't don't overdo it again is gracious. Yeah. Okay. A few other things that probably don't apply to many of our kids. So I'm just gonna breeze through'em real quick. Hypothyroidism is something that can cause elevated numbers. It's actually, thyroid disease is actually really common in people with type one diabetes. So. A lot of people end up getting some form of thyroid disease when they already have type one. Hashimotos is an autoimmune condition that causes a low production of thyroid hormones. I actually have Hashimoto motos. That is my autoimmune condition or it's my only one at the moment. Hopefully it remains my only one But it slow, this slows down metabolism. And then after that blood sugars tend to go up. So you may need to increase both basil and Boless amounts until the doctor. And you can kind of just work out like what the appropriate dose of thyroid medications. You need to normalize your hormone levels. And the author just suggests, you know, take basil and Boless amounts up by about 10% until. You see, good fasting in pre-me blood sugars steroid medications. I've heard that these can reek havoc on blood sugars, especially the injectable ones. So like cortisone and prednisone used to treat asthma arthritis, emphysema, and muscle joint inflammation can create significant insulin resistance that can raise sugar levels and it can do it for days on end. So it's not just like for a couple hours that can last for like a couple days. And then inhalers containing albuterol and topical steroids can also cause numbers to go up, but it's usually not quite as dramatic. And then like, we've already mentioned, some steroids are more potent than others and the book does take a minute to compare different kinds, but I'm not gonna do that here. The book also provides a sample schedule of just if your kid is on any of these medications of how you may need to make adjustments or increase basal and bolus during this time. So he goes into a lot of detail on that, and I'm not gonna do that here. So again, by a copy of the book, you can check it out. So some other medications that may increase blood glucose include diuretics, Dilantin, estrogen, testosterone, epinephrine, and certain antibiotics, as well as lithium and many beta blockers, which is for certain heart conditions. Have you guys had any experience with any of those medications?

Valerie: 40:44

No.

Katie: 40:45

Yeah. Okay. Oh, the, the the author does suggest that you're probably gonna need to make some adjustments, but you also probably wanna take the medicines for a couple days to kind of see how it affects you before you start making adjustments. At least not so much with the steroids. Like that's usually pretty guaranteed that it's gonna increase your numbers. But with the, with the other medications I listed so same thing with surgery that can cause your blood sugar to go up, cuz you know, think about what's going on when you have surgery, you're nervous. So that's gonna cause anxiety, stress, hormones. Um, It's also a physical trauma that causes pain, which can make numbers go up. You have to heal from that trauma. You are typically a lot more sedentary for a while after you have some sort of surgery. So all of those things can lead to higher BG values. But which really stinks because when you're recovering from, from surgery, you really need optimal sugar levels to promote proper healing. And fast healing. So the author maps out several ways to adjust insulin accordingly depending on what your insulin program is. So he talks about like, if you're MDI taking rapid acting insulin, if you're taking NPH or if you're using an insulin pump, but basically kind of what it all boils down to is start by correcting the highs with bolus insulin. Right? So start by doing that first. And then if you notice that that is not enough and that things are still elevated hours or days after the surgery, you wanna start increasing your basal amounts. And then of course consult with your doctor, if you have any questions or concerns, and he recommends after surgery to check your keytones more often. Because um, you're more likely to, to seek keytones after a surgery. I, we haven't had any surgeries, nothing, no dental work. I mean, other than like a cleaning, actually Sarah did have a cavity filled and her numbers did go up a little bit, but it wasn't anything crazy. I just gave her a Bo list to correct for it. But no major surgeries. What about you guys?

Valerie: 42:40

No major surgeries. He does have a tooth that needs pulled. So we'll see how that goes,

Katie: 42:45

Yeah. Is he just gonna get the local anesthetic or?

Valerie: 42:49

Yeah. And they do Niro sock side. So we'll see how that affects his blood sugar. I don't know.

Katie: 42:53

Sarah had both of those things when she had her cavity filled and we only saw a, a little a bump up in her number, so it wasn't too bad, but again, everybody's different. So who knows,

Valerie: 43:03

right.

Katie: 43:04

who knows how your son will fair? Hopefully. Well, Now we're gonna move on to the um, secondary factors that tend to lower blood glucose levels. So we just did all the ones that elevate it. Now we're gonna do the ones that lower it. So previous heavy exercise, delayed onset hypoglycemia, which the author abbreviates frequently as D O H it's is a blood sugar drop that occurs several hours, usually six to 12 hours after high intensity, long duration activity or an exhaustive workout. So heavy exercise makes muscle cells very sensitive to insulin. It's kind of like. It's kinda like free insulin, right? Cuz they just suck up all the glucose in your system and they don't even need insulin to do it. So super sensitive to insulin. It can also deplete the glycogen or the sugar energy stores in the muscles, in the liver. So as the muscle in the liver is trying to like recover from that and trying to replenish its stores of glucose. It can take it all outta the bloodstream and cause numbers to drop too. Again, he says, if you. Predict it, you can prevent it. And he recommends kind of like what you were doing with the pizza situation. He recommends starting to keep a log of what exercises you notice. Cause a delayed, delayed onset of hypoglycemia. And then when that delayed onset starts to take place. So he gives four options for making adjustments. First, he says, reduce basil an hour before the time of predicted drop. So that would be if you're using a pump you can lower your bolus for the meal proceeding that expected drop. So like if you've been exercising for a long time, you're gonna eat dinner and then you kind of predict that overnight, you might have that delayed onset hypoglycemia, then you wanna reduce. The amount of insulin you would give yourself for, for dinner? He also says another option is reducing long acting insulin. If you're on MDI, that will be active at the time of the expected drop. And then last suggestion is having a slow digesting snack prior to the time of the expected drop without giving a bolus or giving a reduced bolus. I believe one of his suggestions was chocolate and I was like, sign me up. I'll I'll do that.

Valerie: 45:18

For me.

Katie: 45:18

every time. Yeah. So what about you guys? Well, first of all, does your son play any sports?

Valerie: 45:24

He doesn't play any team sports, but he is a super active kid. We have lots of things to play in the yard, but he doesn't play on any teams.

Katie: 45:31

Yeah. Yeah. But have you guys ever experienced this like Sarah dances, which I would not consider a long duration, like heavy exercise it's it classes are like 45 minutes to an hour, maybe an hour and 15 minutes. So we don't really see this when she has dance. But like if we're at the beach all day long, or if we've gone to a theme park and we've been walking around then, yeah, we've definitely, we've definitely seen this where like, it's usually overnight, you know, or maybe the next morning that she'll start to go low. And it's just, it's like those stubborn lows that you like are here, eat some more Skittles, have some more juice and you just can't get'em to come to come up. So, you know, if we can predict it, like we, we were recently went to universal studios for three days straight and we were, you know, doing so much walking. So every night. It was tricky because, you know, then we're going out to eat, right? We're eating at restaurants, we're eating heavier meals than we normally would. And so for that, she would need more insulin. But then with the delayed onset hypoglycemia, she would need less. So it's tricky, it's tricky. We found a pretty good balance. We, most of our nights were, I think one night she actually was running a little higher than I would've liked her. But other than that, we, we kept her in range. For the most part I did a, I did a small decrease in her, like basal insulin basically to prevent it so glad you guys ever experienced anything like that.

Valerie: 46:53

So I feel like it happens like at the beginning of summer, mostly like before, not like summer, like springtime when you have a nice day and then it rains for a week and I haven't like gone, oh, it's gonna be nice. Let's back off your basil, cuz you're gonna be really busy outside. back in March we got a trampoline and I didn't even consider the effect it would have on his blood sugars. Like it just skipped my mind.

Katie: 47:16

mm-hmm

Valerie: 47:17

Who knows why I should have known right away. And he, the very first day that whole. And the next morning he was low. Like, I just couldn't keep him up. Because he played on it like the whole day, it was a beautiful day and it was new. And so he spent like hours on it. And so that's now that it's not as new and he just spends a little bit of time, multiple times a day. It doesn't happen as much. in the beginning I had to like figure out how to catch it, but now I figured out if you don't have insulin on board, we'll be fine. It's it fluctuates a little bit more, but it's that first day it was terrible. I, I didn't even consider. And it was all night long and I was like, oh no, cuz then I was like, shoot, did I do something terrible by buying this trampoline? And we're gonna never have a sugar under control. Cause I messed it up. Oh no. Like it was a panic mode because he was all night long. I was just feeding him sugar. But it's better now. We figured it out. I don't even make changes. Now if he doesn't have insulin on board,

Katie: 48:17

Mm-hmm

Valerie: 48:17

I don't have to make cuz it's he it's these small bursts of energy instead of like a long period of tag.

Katie: 48:23

Right.

Valerie: 48:24

We also have experience on vacation though, like you were saying um, when we go to the ocean, so the drive there you're super sedentary and then it's like crazy and we walk everywhere and walk on the beach and do all the things. And so then it's a whole nother, like figuring out,

Katie: 48:41

yeah,

Valerie: 48:41

you know, we were really high yesterday because we travel all day and now you're really low because,

Katie: 48:45

right.

Valerie: 48:46

so

Katie: 48:46

Yeah. That's a good, you make a good point about, well, we're, we're gonna talk about travel in a second, but like, if you do increase basal or however you decide to adjust for, for being sedentary while you travel, like you might wanna consider ending that increase like an hour before you get outta the car, because once you, yeah, cuz we're when you're traveling, like you're going somewhere exciting for the most part, usually. So when you get outta the car, all of a sudden it's like a new place and you're moving more and, and that can cause numbers to drop quickly. So you might wanna cut off that increase like an hour before. Before you get to your destination. All right. Aging. Hopefully our kids won't have to deal with this for a real long time, but if any adult type ones are listening aging, just a natural part of aging is that your body begins to produce less hormones, which is a good thing, right? Because hormones drive me insane. you know, things like growth hormone, you're not producing that very much. But in growth hormone causes your blood glucose to rise. So this is rarely seen in middle age. It's usually seen in people over 65 may result in falling sugar levels during the night and between meals. And the author just says, be prepared to cut back on basal needs after the age of 60 hypos. So low blood sugars are particularly dangerous in the elderly, which I'm like is he calling over 65? The elderly, that just doesn't seem elderly to me. but maybe it is, I don't know. Okay. So hypos are particularly dangerous in, in the elderly because the body also starts to lose its ability to effectively come back from a low, which I think is, is interesting. There's also an increased risk of falls and heart attacks in the event of low blood sugar when you were older. So that sounds real fun. Doesn't it?

Valerie: 50:26

No. Um, I find it interesting though. So my father-in-law is over 65 and I found this, this information really interesting because I'm seeing some of this, these things and he's like, why is this happening? I don't understand, like, is my pancreas suddenly working? Like every afternoon he gets these lows and he is trying to figure it out. So it's interesting information to be able to share with him and be like, well, maybe this is what's happening.

Katie: 50:49

That is so interesting. Is he on a, what does he do?

Valerie: 50:52

Yeah. He's on a pump. Yeah. He's on a Medtronic pump. It's not, I don't know how to use it. Like, it's weird. I'm like, I dunno how to help you.

Katie: 51:01

well, it probably operates the same. Right. He's got a basal rate and

Valerie: 51:06

it's similar, but yeah, I'm hoping to, he's considering moving to Cohen's pump, just so that. when I have to take care of who I can.

Katie: 51:13

oh, that's a great idea. Yeah, well, yeah, nevermind. I was gonna say something, but I won't say it. But that is a good idea. Thinking forward into the future. Weight loss is also something that can cause blood sugar values to drop. We just talked about weight gain being like the number one reason why you see insulin resistance. So it would only make sense that weight loss would make you very sensitive to insulin. So that reduces your insulin needs. This is pretty STR astounding. He says a 10 pound loss In weight obviously will most likely require a five to 10% reduction in insulin across the board. So both basil and bolus, which now that, now that I say that out loud, I guess it's not that as astounding. Cause I think it, the same is true for the opposite, right? For every 10 pound gain, he suggested increasing basil and Blu by 10%. So. It's just the opposite for if you are losing weight, heavy brain work is something that can cause blood sugar numbers to go down. And the reason behind this is because your central nervous system, which includes the brain and your nerves, a lot of your nerves, they only, they burn a ton of glucose for fuel and they only burn glucose for fuel. Other things in your body can burn other forms of energy. But nerves and brain and muscles, while you're exercising, they will only burn glucose. So if you're in a situation where your brain is working extra, extra hard and the situations, he kind of list, as examples are like, if you got a new job or if you're studying really hard and, or you're multitasking maybe you're adjusting to new surroundings, like you just moved or you've gone on a trip and now you're somewhere new. You're hosting a party. You're attending a busy party or wedding or you're just being, you're just in a place where there's lots and lots of mental stimulation, and I'm sure that's probably different for everybody too. But he's saying, you know, again, if you notice a pattern and you can predict it, you can prevent it. So you either wanna reduce the amount of insulin that you're taking or you wanna increase your food intake to help cover those lows. I thought that was interesting. So can you guys, can you think of a time Valerie, when you've seen like decreases in blood sugar levels because of heavy brain work?

Valerie: 53:19

No. So many of those things are usually accompanied with stress or anxiety for him. And so.

Katie: 53:26

That's very, we Sarah. I feel like when she's at a party, especially at a party where she, where there's a lot of people even if it's people she knows, like if there's just a lot going on and she she's kind of an introvert. So if she's with a big group of people, I think that's, that requires a lot of mental work for her to like interact at a high energy level with a lot of people. So I've noticed that when we are at birthday parties, she tends to run low. You know, you you'd think you'd have to give her more insulin because birthday parties usually involve like junk food and whatnot. But for Sarah just giving her, her regular amount of insulin, or maybe even less, a little bit less like 20 to 30% less than what we would normally give her seems to work pretty well for her. Cuz she's just whatever it is about, that stimulation just makes her drop. So

Valerie: 54:15

that's interesting party. He is ridiculous at parties and doesn't sit still. So I, it could be that it's the party, but usually I just assume it's cuz he is running around like a crazy person.

Katie: 54:25

that sounds fun though. He's having a good time,

Valerie: 54:27

He has a great time. He's very active.

Katie: 54:31

Yeah. That's a good thing, right? That's a good problem to have, I guess. I don't know. I guess I'd rather want my kid to be very active than like a couch potato, the next thing that can lower your blood sugar is alcohol, which I did a whole episode on drinking and diabetes. It's episode number 60. So I don't think I'm gonna, I'm gonna talk about it a whole lot here. It's very interesting. Basically your liver cannot do multiple things at once. It is not a multitasking organ. So when you drink alcohol, it focuses just on processing the alcohol and it can't respond to anything else. Like it, it can't respond to glucagon coming from your pancreas. It can't respond to glucagon. You know, coming from, like, if you had actually had to inject glucagon or use the nasal spray, it, it doesn't respond to stress hormones that would usually prompt it to secrete glucose. It just does the alcohol. So the author does, I would go back and listen to that episode. If you're listening now, episode 60 drinking in diabetes. But the author does offer several good suggestions for keeping safe, staying safe while you're drinking and how to kind of adjust insulin accordingly to keep you from going low in the middle of the night, cuz nobody wants to be drunk and. Hypoglycemic at the same time, it's actually hard to tell the difference between the two of those. A lot of the time so yeah. Yeah. Heat and humidity is something else that the author lists as something that usually causes blood sugar levels to drop. I've actually heard the opposite of this from people too. They say my kid goes high in the heat. So again, your diabetes may vary. But heat and humidity just speeds up the absorption of insulin into the bloodstream cuz your blood vessels are dilated and things are moving through them more freely cold temperatures. So this isn't just heat and humidity. This is actually just climate in general. So cold temperature is also cause the body to work harder to keep you warm and it uses up more glucose to do that. So that can cause a decline in numbers as well. The author suggests that you may need to decrease your basal and Bolut doses by about 10 to 20%. But as always, you just kind have to see how your child responds at first to like a change in the climate. Have you guys seen any major changes with heat and humidity or cold temperatures?

Valerie: 56:45

I feel like they're always accompanied by activity. And so it's really hard to tell what's causing it. Um, but I do know that if he's out in the snow, even if he's not like being crazy, he's just out in the snow, he will go lower. He runs at a lower level which was terrifying that first winter we don't get a lot of snow, but we did that year. And so it was. It was hard to figure out while I was learning everything else that, oh, it could just be that he's cold, you know, so, but I just, because he's usually active when he is in the heat or the cold, I just give him some food and then don't go have fun.

Katie: 57:24

yeah. Sometimes that's just the easy way to do it. Cuz with kids, you know, the author obviously says, if you can predict it, you can prevent it. But some, so many things are hard to predict with kids. I mean, if you know, you're going to the beach in an hour, then that's one thing. But you know, you never know when your kids, somebody's gonna knock on the door and ask if your kid can go outside and ride bikes or play or jump in the pool. So, you know, sometimes adjusting insulin just isn't gonna work and you're just gonna have to give him food and that's totally fine. Like who cares? I'm sure your kid will be perfectly happy.

Valerie: 57:54

We have a pool too, and it's like, constantly like, just drink a juice box. I don't know what to do with you.

Katie: 58:00

Yeah. Sarah was in the pool yesterday and I handed her Popsicle. She's like, do I need to get out? I'm like, no, just eat it while you're swimming around. Oh, okay. Nausea is the next thing on the list. And again, we have not really experienced this, so I feel like I can't really speak you know, about it from. Having experience obviously, but if your stomach is upset, then it makes sense that the food you've eaten, it just might not get digested much or completely, or it might get digested more slowly. And then of course, if you're like vomiting that food isn't going to even reach your bloodstream. So all of those things can lead to hypoglycemia. So the author gives some really great suggestions on how to adjust for that. He says, consider taking bolus insulin one to two hours after eating when, you know, for sure. Or at least you think, you know, for sure that your food is gonna stay down. He says like, there's things like glucose tabs, or dextro containing candy, like Smarties that you can just put under the tongue or like in the side of the cheek. So it can actually. Dissolve and be absorbed through the lining of your mouth rather than actually have to like swallow it and be digested by your upset stomach. If you are on a pump in your, if your kid is on a pump and they're nauseous, you may want to reduce basil by 80 to 90% for a few hours, but definitely check for keytones first, because if you're, if your kid is sick and ketones are present, you don't wanna cut back on the basal. He says, drink low sugar, but not sugar free drinks, like diluted juice, or maybe a sports drink, like Gatorade which I don't consider that low sugar, but whatever. But he says no sugar free because those fake sugars usually cause stomach upset anyway. So you don't wanna make it worse. Definitely ask your doctor. I just asked ours the other day to write us a prescription for one of those old school glucagon kits or you could ask for the prefilled glucagon syringes for time, specifically for illnesses. So you can just kind of microdose the glucagon. So your kid doesn't have to swallow anything. If they, you know, absolutely have to this is not possible with nasal spray glucagon, it's all or nothing with the nasal spray. So you can't really microdose it. And then again, always when somebody is sick with type one, check keytones regularly. Okay. So this one is interesting to me because we just talked about illness in the previous section. Illness usually causes your numbers to go up. But now we're talking about nausea and vomiting, which can cause your numbers to go down. So I feel like those, like I remember the, the episode I recorded on sick day management, which I don't have the number of what that was in my head right now. But if vomit is involved, just call your doctor and see what they, they want you to do, especially if there's vomit and keytones involved like that may warrant a trip to the emergency room, unfortunately. But so you, you guys have not had a tummy bug since, or I guess he threw up that one time, but no major tummy bugs.

Valerie: 1:00:43

Yeah, no. And if he usually, if he throws up it's something else and he just hasn't eaten and then his stomach gets upset. It's not like undigested food. That's gross. I'm sorry.

Katie: 1:00:55

that's OK. It's OK. We can handle it. We're one moms.

Valerie: 1:00:58

There's a difference though, when like a tummy bug and you're not digesting your food versus just throwing up because you feel yucky, you know, you know, like your body is different. So we haven't had one where he's been super sick. Thankfully.

Katie: 1:01:11

Me neither. Thank goodness. Okay. There are apparently some other meds that can lower your blood sugar. That's the next thing on the list? So things like antidepressants, nicotine patches, and some antibacterial agents can reduce your need for insulin. So just whatever doctor prescribed that to you or to your child. Just talk to them about like, does the dose that you've given me, do you think that warrants a change in, in insulin, you know, to prevent those lows? So high altitude I'm in Florida, the high altitude is next on the list. So being a Floridian, we do not have to deal with this I mean, Florida is pretty much at sea level or maybe slightly above, but we are getting ready to go to Arizona in a week and Arizona is. Almost, I think it's like 12 and a half over 12,000 feet above sea level. So we're about to see a very significant change in our altitude levels. We have been to Colorado with the kids, but it was before Sarah was diagnosed with type one. So I am very interested to see how her body responds to being at higher altitudes. So apparently because your body is working so much harder and your metabolism is up in order to deliver more oxygen to your cells that can cause your blood sugars to go down. He does say that usually like if you're gonna be there for a while, your body will adjust within a few days and then your metabolism will return to normal. Also interesting to know that some blood glucose meters do not test accurately over 10,000 feet. So check with the manufacturer, but thank goodness most CGMs still test accurately, even at higher altitudes. So he says be prepared to reduce basal insulin by 20 to 40% for the first few days when traveling to a higher altitude. And then if you're exercising in that higher altitude, then you probably are gonna need to reduce it even more. So I'm just gonna go. As soon as we get off the plane, I'm gonna go ahead and do this, or maybe even an hour before we get off the plane and then just see how it goes for the first few days with a lower basal rate. I mean, and we're doing a lot of hiking on this trip, so it'll be interesting. It'll be interest. This, well, I'll be back from the trip before I publish this episode. So in the show at the end of the show, I will pop on and give people an update of how that went. So this is me telling myself to remember to do that. when the show's over, have you guys experienced this? I don't. Where, where are you? Where do you

Valerie: 1:03:29

Uh, so we live in Washington state. We live in a valley right on the board with Idaho. So

Katie: 1:03:35

so

Valerie: 1:03:36

we're low. And I mean, when we leave the valley, we go, hi, it's not high's hill. Like we just go over a hill. And so we haven't really been into any high altitudes vacation consists of the ocean. So

Katie: 1:03:54

yeah. Yeah. You're at sea level. No. Need to worry about that. Yeah. Okay. Gosh, I love Washington state. My dad used to live in Walla Walla, Washington. And I visited him once when he was out there. I loved it. And it was super fun.

Valerie: 1:04:06

it is beautiful well, we live on the east side where it's like it's not the pretty green side of Washington that everyone thinks of. When they think of Washington, we don't get the rain and it's dry in the summer and not as pretty,

Katie: 1:04:19

yeah, but okay. You're really close. You're on the board of Idaho. Aren't you really close to? Yellowstone.

Valerie: 1:04:24

no we're so we're on the other side of, was on the other side of Idaho.

Katie: 1:04:28

Oh really? Oh, so you'd have to drive all the way through Idaho to get to Yellowstone.

Valerie: 1:04:33

It's about 10 to 12 hours in the car.

Katie: 1:04:36

Wait, cuz Yellowstone's not actually in Idaho, right. It's just right on the border.

Valerie: 1:04:40

Yeah. So you can go, you could go through Montana and then down to Wyoming or through Idaho, it just depends which way you wanna go. You go this way, this way.

Katie: 1:04:49

Yeah, that was actually before we planned this Arizona trip, that was our second choice was going to actually flying into Washington state, seeing a few things around there, like Mount Rainier and stuff, and then driving through Idaho and doing a few things there to, in ending up in Yellowstone. Um, My, my daughter had to do a project on Idaho last year and I was like, she had, she was just assigned a state and I'm like, Idaho, this is so boring. Like, could they have not given you a more interesting state? And we started researching Idaho and I was like, well, we need to go on vacation to Idaho because this looks amazing.

Valerie: 1:05:22

Idaho's I was raised in Idaho, obvious loosens were on the border, but it's cool. And it's not just potatoes.

Katie: 1:05:28

well, of course I that's what I was stereotyping Idaho to be on like potatoes. That's all they have. And then, you know, it's beautiful. They have so many things. So I wanna go to Idaho sometime.

Valerie: 1:05:39

Northern Idaho has lots of water and lakes and beautiful things. So.

Katie: 1:05:44

okay. Okay. Gonna put it on the list. Okay. We're gonna quickly go through the last section of the book, just cuz I know we're, we're getting to be on the longer side. A lot of these things know, I've done previous episodes on the first thing is impaired digestion and we talk about that in chapter seven. So I'm not gonna really touch on that here so much. You can go back and listen to, to that episode. And I think we, I think I talked about it also in one of the earlier chapters, maybe two or three then menstruation. I also did an episode on. Insulin needs in teens, just like in general. I will say what episode number that is at the end of the show. Cause I don't remember off the top of my head, but it talks a lot about the menstrual cycle and how insulin needs to be adjusted, you know, kind of before you start your period and after you start your period, so I'll just kind of leave it at that. And then of course, if you have a copy of the book, you can go back and read what the author have to say. Travel we've really kind of already touched on. Right. Like, everything's just jacked up when you travel time zones are different. You're, you're sedentary while you're getting there and then you get there and, and you're more active and there's lots of mental stimulation cuz everything's new and exciting. So you know, you just might have to adjust accordingly throughout, you know, you, you might need more at times less at times. He does make a very big point on making sure if you're on a pump to change your, the time on the pump, when you get to your destination to change the time to accurately reflect the time zone that you are in, cuz otherwise it'll mess up your insulin delivery. You know, like if you were, if you had one basal rate that starts at 7:00 AM in Florida and you fly out to California, now that basal rate is gonna be starting at what like 4:00 AM or something like that. Yeah. I could have, I could have done that math wrong, but you get the point. It's gonna, it's gonna mess things up a little. Especially if you're, if you're on long acting insulin, make sure you read this section in the book, cuz he gives some good suggestions on how to adjust for, for the timing of that. Irregular sleep is a big thing that can either make your numbers go up or down, depending your sleep regulates your appetite, your energy use and your weight. So lack of sleep can lead to stress hormones increased appetite insulin resistance and weight gain. So you would obviously see your numbers go up with all of that. And then he says that if you are losing sleep, because you're staying up late to get stuff done, like maybe you're working extra around the house or whatever, it may be picked up an extra shift at work, then you're gonna be moving more than normal and you might experience low blood sugars because of that. Menopause. I think I'm, I think I'm just gonna skip over that one. Obviously our kids aren't going through menopause right now, but it is interesting. So if you're an adult type one and you wanna read about it, take a look at that in the chapter hormone it's again, y'all, it's the hormones. They they're to blame sometimes you're low, sometimes you're high. Okay. Pregnancy is another thing that I'm, I just think that's beyond the scope of this episode. You know, pregnancy is so individualized, and obviously you need to be under the watchful eye of a physician while you're going through that. Especially if you have type one really what it boils down to is when you get pregnant, you might see a dip in your numbers at first, which an increase in your insulin sensitivity. And then after that though, not long after that, you're gonna see a very steady and often very steep and dramatic rise in your blood sugar numbers. Like to where at the end, it's like crazy how much more insulin you're gonna need. At least that's what I've heard. And then immediately after delivery, it's like you jumped off a cliff because your insulin needs just go crashing down. it's, it's crazy. And then apparently a few weeks after delivery, your numbers, numbers will kind of stabilize again for the most part, but we won't go into detail here. He, he goes into a lot of detail about how to make adjustments, but I just personally feel like that's a little bit beyond the scope of this episode at the moment. So I feel like the last thing on the list that can cause your numbers to go up or down is sports and exercise. We've already talked about, you know, physical activity and how to make adjustments for that. There are certain exercises that will actually make your blood sugar go go up temporarily, which are, he gives examples of weight lifting, especially when you're doing like really heavy weight and low reps. Intermittent burst of activity like basketball, golf, or baseball. So y'all golfing the golfing family. Sprints in running swimming, rowing, or skating activities that are being judged, like figure skating or gymnastics sports where winning is the prime objective, and then almost any form of exercise performed in the early morning. So the reason why you would see your blood sugar go up is because of like adrenaline, like the stress response from the body. But overall he says that exercise any type makes your body more sensitive to insulin. So even though you might see this temporary burst in in your numbers, it, you know, that those are the activities where later you might see the delayed onset of hypoglycemia. So, anyway, just keep that in mind. He gives the example in the book of one of his patients who I forget the sport, but when during practices for this sport, the patient didn't really see much of a difference in his numbers, or he would see a drop, but then when it was actually time for games and it was became really competitive, his blood sugar would go way up. So, you know, the author suggested that his patient take just an extra bolus of rapid acting insulin to before the, the game started to cover for the rise that he was seeing. So you might, I've heard a lot of parents say that. I remember one mom telling about her son playing hockey, that he, he usually goes high during hockey games, cuz it's so competitive and there's all those short bursts of movement. But adjustments for long duration exercise lasting longer than 90 minutes may need to reduce basil by 50% starting one to two hours before the activity for more intense exercise may need to reduce basil by 80 or 90% starting one to two hours before the activity begins. So for us, that is swimming and going to a trampoline park. That is when I have to take Sarah's basil down by 80 to 90% to prevent her from going low. And I do have to do that about an hour before it starts, if I actually want it to be effective. For those on injections, if the activity is going to be like all day, like you're going to a theme park or you're playing in a soccer tournament, you might wanna consider a 25% reduction in basal dose the night before, or the morning of the activity, you know, just depending on when you take your long acting insulin. We, Valerie and I have already talked about snacking to prevent lows. Sometimes it's really just the. It's really just the only choice. you know, the other, the author gives other examples of when it would be better to prevent lows using food extra food intake rather than reducing insulin. So you wanna check that out? Let's see. Yeah, I feel, I feel like we've, I feel like we've covered all of that. He, the last thing I will say is that the author makes a very important point of, you know, again, sometimes it's normal to see elevated blood sugars when you're exercising, especially in those activities I mentioned, and that's fine. Like rarely is it dangerous to, to exercise when your numbers are elevated, as long as there's not keytones present. So if there are keytones present before you exercise, you do not, you definitely do not want to exercise, cuz that can lead to DKA pretty quickly. Is there anything else you wanna add to that, or, or kind of, include in that comment about the, the sports preventing lows or highs during sporting events?

Valerie: 1:12:57

The only thing that I found that really. Kind of helped me is I I'm in a separate setting in his pump, like, so we have like our normal settings and then I made another one for when he's gonna be really active. And it just, it, instead of doing a temporary basal, it just makes it lower. And then I don't have to think about it because sometimes that's hard. So I just reduced it. I don't remember how much I reduced it anymore. I can't do that math fast enough.

Katie: 1:13:20

but it's, it's just a button you push basically.

Valerie: 1:13:23

Yeah. We just go in and change it to a different setting. And so then, and it works better than like the activity mode, which just changes the target to one 50 because it's still getting the basil and that he needs less. So

Katie: 1:13:36

right.

Valerie: 1:13:36

it's just easier

Katie: 1:13:38

We, with DIY loop, we can use an override. And so with an override, you can tell the system to give your diabetic either a certain percentage, either less or more than what they would normally be getting. but with, with loop, they recommend not. Going below 50%, less or above 50% more just cuz it can kind of like mess up the algorithm. So for swimming, I don't know that that has also been tricky with loop cuz for swimming, you know, I can only set it to where she'd be getting like 50% less insulin, which that's not enough of a decrease for her. I can also change the target range with that override. So not only would she be getting 50% insulin, but now her target level is like that the pump is shooting for is like one 50 instead of, you know, 80. So I can do that, but still it doesn't seem to be quite enough to prevent lows while she's swimming. So the best thing for loop that we found to do is to take her out of loop. So to open the loop and then just suspend insulin for a little while or just temporarily change her basal rate. But the thing about the loop is that if you do that, if you kind of try to mimic a tent basal decrease you can't enter in the duration. So you have to like, remember to go in there and, and cancel the tent basal when the activity's over.

Valerie: 1:14:54

Yeah. See, because he has the tea SL we just take it off to swim. So I don't have it, which isn't always enough either. Like it needs, you know, I need to work on this summer about like decreasing his basil before he gets in and then take it off and see if that, cuz I haven't figured I was swimming yet either.

Katie: 1:15:12

yeah.

Valerie: 1:15:13

So maybe that would help with lows.

Katie: 1:15:15

Swimming is tricky. When I did our, I did an episode on swimming with with Adrian, whose Instagram is team London. She's like a big, low carb person. And she asked me, she's like, when you turn the insulin off, while she swims, you don't see a rebound high after that. And I was like, no, not really. But then I started paying attention and I, I feel like I do, like when Sarah's insulin has been completely suspended, even if she's really active and it's keeping her in range once the activity's over, I've noticed that her numbers will go up. So what I've learned to do is that when she gets out of the pool a little bit after that, maybe 30 minutes later, if I start to see her numbers start to creep, I will, I'll just give her like a, a bolus right then and there like a unit or so kind of like whatever she missed while she was swimming, like whatever basil she missed while she was swimming. And that seems to help prevent those kind of like rebound highs.

Valerie: 1:16:07

I'm gonna have to just assumed I gave him food.

Katie: 1:16:11

that? I mean, it could, that could be one of the factors who's to say there's not multiple factors, Valerie. yeah, that's right. There's usually more than one. All right. Well that was, I know that was a long episode, but I, it really was a great chapter cuz it's just all those little things that they don't tell you about in the hospital. And they're so important and UN unfortunately you have to think about all of them, if you wanna stay or at least attempt to stay in range. So but thank you for your time. You were a fabulous guest. I appreciate your insight and your help. So

Valerie: 1:16:43

It was very fun. Thank you for having me.

Katie: 1:16:45

You're very welcome. Bye.

Valerie: 1:16:47

Bye. They.

Katie: 1:16:49

All right, everybody. That's it for our show today, I will link in the show notes again, to where you can buy your copy of the book. Think like a pancreas. I will also link to the episode on alcohol and type one diabetes that I mentioned, and the episode on insulin needs in teens. That one has all the, the information on the menstrual cycle and hormone fluctuations and whatnot. And then it was fun for me to go back and listen to and edit this episode because I talked a lot about our trip to Arizona, that at the time of recording was only a week away. But now that this episode is published, it was 10 weeks ago. And it was fun for me to listen to myself, talking about that upcoming trip. There's actually a lot to update about that trip, about travel and flying. And we had our first major, major illness while we were on that trip that actually warranted a trip to the emergency room for my sweet Sarah. So I think what I'm gonna do is just record a separate episode. That's like a summer 20, 22 kind of recap and review. We had a lot of major things going on this summer, including switching over to the new Omnipod five system. I wanna do an episode on how that's going as well. So be on the lookout for those in the near future. all right, you guys have a fabulous week. I will chat with you soon, but until then stay calm and Boless on. Bye.