#226 Diabetes Pro Tip: The Perfect Bolus

Scott and Jenny Smith, CDE share insights on type 1 diabetes care.….

I am thrilled to welcome Jenny Smith, CDE back to the show. Jenny will be joining us for an extended series of conversations that focus solely on the management ideas that we discuss on the podcast.

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

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

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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 and welcome to Episode 226 of the Juicebox Podcast. Today's episode is called the perfect Bolus, and it is installment number nine of my diabetes pro tip series with CDE Jennifer Smith. I'm gonna make this episode ad free, but I'll probably give them a mention here and there, you know, not a whole like big sell, but still, I really love the advertisers. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And the Always consult a physician before becoming bold with insulin or making any changes to your medical plan.

If you find yourself loving Jenny as much as I do, and you'd like to hire her personally, you can go to integrated diabetes.com. To find out more. There's also a link to Jenny's email address right in the show notes of your podcast player. And at Juicebox. podcast.com.

Hey, everyone, Jennifer's back. And we're here today to talk about the perfect Bolus. So that already sounds like a topic that everyone's gonna get upset about when they hear but i think but there's a lot of different ideas here. So Jennifer, what I was thinking was, Bolus is different differ depending on situation, right? You might have a high blood sugar a low you might be falling, you might be rising, you might have a new site. There's

Jennifer Smith, CDE 1:39
exercise, you might Yeah, keep going. Right? You may have just exercised you might have you might be ill you might have your period, you may be coming into having your period, you know, your dog might have eaten the other dog next door and like you're dealing

Scott Benner 1:54
with a little bit of anxiety going and there's a different tick, Good dog, maybe your next door neighbor's dog Jennifer, Has that ever happened in your life? So psychologists say that if you make up something like that, it comes from something. I don't believe that because my my humor is so bizarre that I look back sometimes. And I think, but that was something really strange. I just said does that have any real connection to my thoughts? And I've really looked closely because I've been worried in the past. But I don't think that's true for everybody.

Jennifer Smith, CDE 2:22
I got a chocolate lab and I don't think that that's even in there. Totally not in the nature. So anyway. No, it's never happened, thankfully.

Scott Benner 2:31
So you people have already learned the chocolate labs are not carnivorous. At least towards other dogs.

Unknown Speaker 2:39
Pog, Oh,

Scott Benner 2:41
my gosh, okay, yeah. So anyway, so I want to start with I mean, we're just going to pick one, right? Let's say your blood sugar's where you mean for it to be your bezels are in check, they work? Well, you haven't eaten in a while. It's the perfect scenario, the one that they described you in the doctor's office, the first time you're diagnosed, right? Your blood sugar is 95. And you're hungry. And you're thinking, What am I going to do? So? Ideally, we know at this point, now from listening to the episodes, we have to figure out what our length of time for our Pre-Bolus is. Right? But how do we know? How much to Pre-Bolus? And I think the answer always has to be, I can't tell you, Jennifer can't tell you it's situational, but that you'll learn through trial and error. So but let's make this one general, right, it's a it's a nice balanced meal, you've got some vegetables, some carbs, there's protein, it looks like it looks like a plate from a superfriends episode that the government told you how to eat in the 70s. The food triangle, it's called

Jennifer Smith, CDE 3:47
a triangle.

Scott Benner 3:48
So so if you're a nice steady blood sugar, if if my daughter was at 95, and I thought this was a pretty, you know, average meal, as far as what I expect, as far as impact back from it, I might put in all of the insulin, you know, in the beginning, but I also might even say, hey, there's bread in there a potato that might stretch out the action of the impact of the carbs over more time. So maybe I'll put in, I don't know, 50% or 60%, and stretch it out over a half hour an hour just to create, like we've talked about in the past that kind of blanket of insulin to cover the entire impact timeline of the carbs. I think that the thing to remember is, is that there can't be really a set idea for what that means. Like maybe you'll figure out a meal eventually and say it's 70% and 30% over an hour. You might get to that point at some point.

Jennifer Smith, CDE 4:39
And many people do many people who have pretty consistent intake, or like the same things over and over. But the variables would be around that will sometimes change even near more standard figured out meal.

Scott Benner 4:54
Yeah. And so I think so my first my first step, I'm telling you Any good Bolus, that one that has any chance of working, I think it's a nice simple way of saying it has to have a Pre-Bolus. Like you have to start, you have to start getting the momentum of your blood sugar moving down, so that when the carbs start acting, they move up. So so that's that, to me, that's step one. Now, do you talk about or do you in your own life use combination of Bolus and Basal in situations like this?

Jennifer Smith, CDE 5:29
Ah, in some situations like this, perhaps more often, more often what I do and more often what I eat is Pre-Bolus based on some of the meal content, because some of that does. It does work together things like glycemic index. And also, as you brought in to begin with the where the blood sugar starting, is it coming in standard at your target? Are you coming in, but it's already dipping down? Are you coming in, in target, but it's already drifting high. All of that is where you can also look at Bolus timing, and how much Pre-Bolus you may need. So you know, coming in at a blood sugar of 95 with a straight horizontal line the past hour, awesome, that looks great. But the minute you put food in, that, that blood sugar line is gonna start to change a quick after that, if there's not time for that insulin to talk first to begin with, right?

Scott Benner 6:33
Yep, I hear what you're saying too, about, like, understanding the glycemic load of different like foods, if you have something like you know, using Chinese food, such a great example, because it normally incorporates rice, which stays for a long time and hit you hard, and usually some sugar that'll hit you fast. So if there's something sugary in there, you may need a real, you know, push of insulin in the beginning to combat that initial rise. But that initial rise could get beat up by that insulin very quickly. And now what's left over is the, you know, the rice they can linger in the back, right? It's an excellent, good.

Jennifer Smith, CDE 7:08
So yeah, yeah, yeah, I was just gonna follow with Yes, you could, in that instance, then have the potential for meeting both Bolus and bazel. Potential change, and also where we talk about Basal. And most doctors are like, well, Basal shouldn't ever be used for food or covering anything. Well, we've learned very differently, especially with fat. Fat requires a huge amount of bazel change in the aftermath of eating your typical pizza, or, you know, burger and french fries, or mac and cheese that's homemade, or whatever it might be. Oftentimes, you need 4050 60% of an increase in bazel for many hours after that meal, or you're gonna stay stuck high,

Scott Benner 7:50
right? Or you could end up hitting it with so much insulin up front that you think you've avoided that and then three or four hours later, you start rising, and you think it's for no reason. Right? And it's still that fat. Is it still the fat? Yep. So I like a in what I call karbi situations, I, which is not a word, but

Jennifer Smith, CDE 8:08
hyrecar in our world, in our world, karbi is absolutely a word.

Scott Benner 8:13
So with carbee foods, there's a couple different ways I use Temp Basal, and we talked about it before, but in this situation, if I thought a meal was 10 units for sure, but I wanted it to be spread out more Arden's basal rate being 1.4. I might double Arden's bazel for an hour and a half and catch two and a quarter units that way, and then take some of that out of the of the bottom line, right?

Jennifer Smith, CDE 8:37
Absolutely. Because we get a lingering effect from the bazel. And you get less upfront, but you're still getting the whole bolus you determined you need it. Okay,

Scott Benner 8:46
same meal. Jenny rapidfire, same meal, but I walk in the door from work, and my spouse says dinner's ready, and it hits the table. I can't Pre-Bolus I didn't know this was gonna happen. What do you do? And that's where I'd like you to lay out the idea of overhauling for people here.

Jennifer Smith, CDE 9:09
Yeah, and that's over Bolus thing. Essentially, that's a good Super Bolus, as you can kind of be talked a little bit about before, that's a situation where 100% unless that meal is like a plate of broccoli, in which you would never need a Super Bowl, or Pre-Bolus. right in your typical meal that we're saying we're having 100% of Super Bowl, this would be beneficial, where you actually do take a load of insulin that would be your bazel behind you added on to the suggested bolus for what you're going to eat. And then you may actually knock off the bazel behind so you don't go low later, but you've gotten the load of insulin, the push up front, right. The other option that many people do in that situation too is they take the bull and they may actually turn their bazel off 100% for an hour.

Scott Benner 9:56
Okay to also try to spike

Jennifer Smith, CDE 9:59
right in actly so that they're getting a bolus, they're maybe not quite sure if the food in the bolus, even though it's happening at the same time is going to cause as much of a rise. But they're definitely saying, I know I need a lot more because I wasn't able to give that 2030 minutes before this.

Scott Benner 10:14
Yeah. And, and I think of over bolusing in two situations. So the one I don't have time to Pre-Bolus. So in my mind, the way it strikes me is I now need the insulin for the food for the high number I know is going to come because I didn't Pre-Bolus and some to stop the momentum or stop the arrow, right? And so if I thought the meal was definitely six units, but I thought, wow, there's no way this doesn't go to 250. I Bolus the six units. And I Bolus like I'm trying to bring down a 250 at the same time, right? Well, that's again, listen, we're calling these you know, we're calling these this series diabetes protests. So this is like ninja level stuff. Like you don't don't try this on day one. But at some point, right. On day one, don't go I didn't Pre-Bolus I'm gonna double my balls, please. Right. Yeah, right. But as you're figuring things out, that's a great place to do. As you've heard in past episodes. There's a very famous book called, is it pumping insulin?

Jennifer Smith, CDE 11:13
pumping insulin is john Walsh. And he's the one who lobbies for bowling. Yeah.

Good. Oh, you got you know, you call it something else? Yeah, we call it

Scott Benner 11:23
I call it over bolusing. But I don't know why.

Jennifer Smith, CDE 11:27
No, I was gonna say the other. You know, the other concept that kind of comes in here that you'd sort of just alluded to is, where is the blood sugar going to likely be? And that trajectory, you know, assuming that okay, I might be 95 right now. But if I haven't Pre-Bolus, I could easily be to 50 in the next 30 to 60 minutes. Okay, you're taking that value. And it's looking at the trajectory of where it will probably be, and using that glucose value to add on to the current Bolus. So you're avoiding that really high blood sugar.

Scott Benner 12:00
And what I say on the podcast, which people might remember is I just say you have to trust that what you know is going to happen is going to happen, right? So you can't just pretend this will be the time this doesn't happen. You know, oh, I'll get away with not Pre-Bolus thing today, there's, that doesn't make any sense. It might happen once in a while. But that's some random reason from something earlier. That's not you know, that's not

Jennifer Smith, CDE 12:20
me, I ran 10 miles and don't usually ever do that. And now, look at that my blood sugar doesn't.

Scott Benner 12:26
So now another place to use an over Bolus as a Pre-Bolus is a is a place where this the concept in my mind is the same, the situation is different. What if I've been fighting with my blood sugar all day, and I just can't get it down. It's 200. But I know I'm gonna eat an hour, like it's dinnertime and an hour and I've been, you know, pushing and pushing little boluses little bays or anything, I can't make this 200 move for whatever, maybe it's a site not working well, whatever it is, in my mind, I Bolus the meal. I Bolus the number I over Bolus upfront and create a fall that I then catch with the food. So I reverse. I we're going to talk about this in the next episode. But I reverse the way I think about I think most of the time we consider how does the food impact my blood sugar? How does the insulin impact my blood sugar? We don't often enough think about how does the food impact the insulin? Right. And that's, and we've talked we talked about that in earlier episodes where we put a little, you know, we put a little boy's blood sugar into a freefall and got it by eating at the right time. So all we're talking about any of these situations is timing, right? It's the right amount. It's the right amount of insulin at the right time. And if your blood sugar's 300, and you have to eat an hour from now, well, the right amount of insulin is now and you know, it's it is now and you can't you can't just wait and do your 15 minute Pre-Bolus on the 300 blood sugar because you've lost already. Right? Right.

Jennifer Smith, CDE 13:58
And you know, something that that kind of goes along to with the concept that catching catching the potential drop while also sort of avoiding or taking care of a higher blood sugar. in pregnancy with the women that I work with. It's kind of similar, we actually at some point get to bolusing. That's like a split a split meal where you actually load the front of that meal time with the whole bolus. Yeah, but you only actually eat about 70% of the food now. And you catch the drop about an hour later with the rest of the meal.

Scott Benner 14:29
Interesting.

Jennifer Smith, CDE 14:30
So what you get is not a spike, not going above those post meal ranges for pregnancy. But you also catch the drop on the back end and you never go low.

Scott Benner 14:40
Yeah, that's very similar to how I handle days like Christmas or Thanksgiving. The idea that there's always going to be eating. So I all I'm always Pre-Bolus in the next grazing opportunity, right like that's interest

Jennifer Smith, CDE 14:56
you for holidays is I actually knowing I'm coming into a grazing time period that's going to be a lot less than precise, a lot less. And a lot of little nibbles along the way behind any holiday where I know I'm going to be up hours of nibbling and eating 25% increase in bazel. And then again, I Bolus along the way. And depending on where glucose is, I might nudge that along the way, too. Yep,

Scott Benner 15:23
yeah. Okay, so now, what happens if dinners taking a little too long to make, and my perfect 95 is turned into a 90 that turned into an 80 that turned on 85. And now it's 75. And now, now someone's yelling, dinner's gonna be ready in five minutes. I know that for most people that makes them feel like Well, I'm too low to Pre-Bolus. But No, you're not. And and so you have to get some insulin moving. And you'll learn how much you can do over time. But in the in the interim, it's got to be some subtle, right, you're just you're drifting low. I'm not even talking about FedEx computer, somebody we're talking about diagnol down, I'm just this, this blood sugar just is kind of drifting down. Your Pre-Bolus still takes as long as it takes to eat to excuse me as long as it takes to work. So if you're 75 and drifting down, Pre-Bolus thing right now is not going to make you start crashing down. If that does happen, that was a coincidence. That's not you. Again, the insulin didn't just start magically working like that, right? Science didn't change. So you still need a Pre-Bolus. Now I get if it's a it's a big meal, and you're like, well, I can't put in eight units. While I'm 75 diagnose, you're right, you probably can't. But you could put in some 20 20% of it even. And we do this a lot while Arden's at school because we Pre-Bolus 20 minutes ahead of Arden's meal at school while she's still in a class. I'm still Pre-Bolus if she's 85. So if I give an ardent gets a big bolus at lunchtime, that while she's in school, much larger than most any other times in her life, 12 sometimes 13 units right for 145 pound kid. So I might do a zero percent upfront, and the balance over a half an hour. So it's all kind of getting squeezed in. But it's not all going to come on line and be active right away. It might be 20% up front, but you have to get some sort of that momentum happening again, on the on the action of your insulin, your insulin to be pulling down when the food goes in. Right, right. Okay.

Jennifer Smith, CDE 17:22
And that's important even for kids, I think in what you're doing that is important, especially for little kids, where you're not quite sure. I know a lot of the people I parents I work with, what I don't know how much Billy is going to eat, or Susie is a really slow eater or, you know, today's she might love spaghetti and she'll love it for the next three days. But then she hates it and I prepared it and I Bolus for it. And now what's going to happen, right? You, for the most part kids and teens will always eat as you said a percent. Let's say that you always know they're going to eat 10 grams of something, even if you have to change what it is they're going to eat something for you. Yes. So if you can Bolus for that little bit up front, it's giving insulin again, more action before you put food in.

Scott Benner 18:08
And one of the many, many reasons that Jenny is on the show is because if Jenny wasn't here, that would have been the next thing I would have said. It's perfect. You, you parents of little kids, it's a perfect idea. Get something moving, even if it's a little bit, just get something moving, give yourself a fighting chance. And to Jenny's point, there's an amount of food if you look back at your kids meals, they always eat at least a little bit. And by the way, if they really flake out and don't worry if, as in the case of the interview I did yesterday with a mother who said she was so excited, she put the insulin in, grab some like fast food and drove away and the kid fell asleep while they were driving away. Right? You know, okay, that might happen. It's happened to me, but still a little bit of juice, right? You only put a little bit in all you've done is Pre-Bolus a couple of sips of juice, you don't have to worry about the food. The point is, is that the Pre-Bolus is always important. It's it's Listen, if you're crashing down as the foods hitting the table and you're literally 50 and your blood sugar's falling. Okay. That's your Pre-Bolus. Right. Right. Okay, you're now prepared.

Jennifer Smith, CDE 19:14
Because there's already insulin that's causing the crash.

Scott Benner 19:17
Yes. Something whether you meant for it or not. You have been Pre-Bolus by so long, right? So good. So see that put the food in. And as soon as that stops, right, as soon as that down arrow goes away, it is time to get your insulin in. You absolutely cannot then say well, I don't know. I'm 60. And that seems dangerous. Now what's dangerous is that you've put all that food in your body and it's going to start hitting you the other direction happened to us last night. And I had to Bolus I had to make a significant bolus at a 75 diagonal up blood sugar because I was like, well, this is I know what's gonna happen. Let me get let me stay ahead of it right.

Jennifer Smith, CDE 19:59
I'm the hardest about using CGM now, as wonderful 100% as they are, the hard thing is that CGM do lag in times of quick change. And so if you have been diagonally down and you're waiting for, you know, you want to Pre-Bolus, but you're not quite sure, sure, go ahead and eat as. But as soon as you see that horizontal or a bit of a trend up, I guarantee your finger stick is higher in the sij than the CGM is showing you. You're already at a deficit of insulin.

Scott Benner 20:29
Yes. Yes. The deficits an important way to think of it and you. And this is again, something you'll learn over time.

Jennifer Smith, CDE 20:35
Well, yeah. It's a bit like the first month. Again,

Scott Benner 20:39
not on your first day, right? Yeah, listen to all the episodes of the podcast to really absorb everything, go through the pro tip stuff, and then say to yourself, I and then you have to see it, right, you have to recognize it. There's a way for CGM users, you have to be able to look, there's like a bend in the line. It's hard to put into words, right. But on the three hour graph on the Dexcom, the last three dots on the right side, tell a story about what's happening. And you will get to be able to glance at that at some point and say, Oh, this is heading down. This is heading up, I can tell I know what and so it's not day one, and it might not be the first month. But if what most of you report back in your emails is anywhere close to true for most, somewhere in the three to six month range. This all just starts making sense in a way. Yeah. Early on the podcast, I used to talk about it like in the matrix, when Neo stopped the bullets. But that has become such an old reference at this point. I'm afraid right now there's like a 19 year old going to what what are we talking about? Now?

Jennifer Smith, CDE 21:39
I'm old enough. I totally know at

Scott Benner 21:41
some point, at some point, diabetes makes so much sense to you, the bullets aren't even moving, you can just walk in between them. And so you get there at some point, right? Okay, so I'm low, I'm high, I'm falling like in the end, I think you're hearing. It's all about the right amount of insulin at the right time, just like we've been saying over and over again, a new site is a good example of, I'm gonna put this in here, even though it doesn't sort of fit, but it does fit. And so if you put a new site on, and you find that your sites don't work as well, immediately, once you put them on, or you know, you just have a site that doesn't seem to be as reactive as you're accustomed to. You still have to do what you have to do. You might have to do it sooner, you might have to do it more aggressively. And I know you're gonna say But what happens when that site starts working? Suddenly? Well, then it does. But you can't not be aggressive when something like that's going on. Because then you that's how you end up at 300 all day long, staring at it wondering what to do next. Right,

Jennifer Smith, CDE 22:44
right. I think the biggest the biggest piece of that Pre-Bolus message is unfortunately, really learning. And it's a daily relearn in the beginning of starting the Pre-Bolus. Rapid insulin is not rapid. Rapid is a bad word for it, it's a better word than our regular insulin used to be, which they called short acting, and I'd actually call that longer than short. I mean, rapid is not instantaneous rapid, as they tell you it is it takes a minimum of 15 to 20 minutes to really get moving.

Scott Benner 23:24
Yes. If you don't leave this episode, and in general, this series, believing that understanding how insulin works in your body is the core of this entire thing. You are not paying attention. So go back and start again.

Jennifer Smith, CDE 23:36
When you get a slap on the hand. Well,

Scott Benner 23:39
I didn't go to Catholic school, but I mean, if I did, yeah, well see Jenny's like, I know what happens when I don't listen, someone hits me with a ruler. So now I guess the last piece of this right about this perfect Bolus thing, right is in my heart, it's about remaining fluid. Now, you know, a lot of people are going to tell you, you really have to count your carbs correctly, right, which is true. You can't use the wrong amount of insulin like you know, you can't have a 50 carb meal in front of you and only put in 30 carbs and then act like oh, I don't know why this didn't work that but you know from listening for me and for a lot of people have been around type on for a while like you just I don't think about it as much as carbs. I think about it as units. I look at a plate and I think that looks like eight units to me. But if I'm wrong, and I am frequently for reasons that I don't care why, right like maybe it's a bad site, maybe I missed on my Pre-Bolus maybe Arden sick I don't care why but I miss then I readdress immediately, right based on my historical knowledge of how Arden acts I know that if I see a double arrow up after a meal bolus, I screwed something up pretty big. And I go more insulin. That's when you guys are starting to hear this. I'm starting to see you on online like talking to other people that people are just going more insulin. I'm like, Yes, I know. That's one of the podcasts and so But is she diagonal up, well, then maybe I missed by a lot less so a little more insulin, or I'll try to bump it back down again, or try to just try to stop the arrow. But staying fluid is the rest of it. Mm hmm. 100% staying fluid as the rest of it. And I know that I heard someone say this the other day. And I like the way they put it, that the idea of stacking insulin in a glucose monitor world is not quite accurate anymore, like you. But this person kind of went a little farther and said, You can't, you can't really stack insulin, when you have a glucose monitor on because you're seeing that you need more insulin. Right? I thought, Boy, that's a big idea. I agree with it in totally in theory. But most of you are going to be taught when you're diagnosed, don't stack and so on. And what they mean when they say that is don't put insulin in at one o'clock, and then put more in it, you know, 130, because you're gonna get low eventually. And if you're not using a glucose monitor, that very well may be true. But right, you can't follow it. Yeah. But if you can see your blood sugar, the direction and the speed it's moving in, you'd have to be incredibly insane to stack to the point where you'd call it some sort of a low that would make you incapable of responding.

Jennifer Smith, CDE 26:13
And that's where even you know, in the CGM, one that we talked about, I had mentioned using those event markers. And the event markers can be hugely beneficial now that they also show up right on your screen. So you can actually see, where did I put the insulin and you don't even have to go back to your pump to look at that. Or remember, when you took your injection, if you just mark it, you will know when those injections went in, you can follow the trend line and you see, okay, do I need more? I don't need very much more. I need a little bit more or a lot more, right?

Scott Benner 26:44
Yep, I've been this is gonna get away from this. And we'll stop in a second go to the next idea. But I've been talking to college students a lot through Instagram messaging. And if you just heard that and think oh my god, that's me. You're adorable. It could be any number of you. But but but but this one person just had a long, protracted high blood sugar that wasn't coming down. So finally, I just said, Look, you you have to like, crush this number, and crank up your bazel like do a Temp Basal raid for hours, like six hours, let's do 30% more and put in however much insulin you think is going to bring this down. And it took most of the afternoon but they got there. And then just with that idea of oh my gosh, I don't have enough basal insulin. The next day, here comes the 24 hour graph hundred and 30 blood sugar, because they're trying to live with not enough base. So as much as as much as we're talking about the perfect bolus here. Remember, you can't make the perfect bolus if your basal insulin is wrong. Correct, right, you'll never be able to. Because you'll always be replacing bazel that doesn't exist. Or if your basal is too high, you'll be causing lows and thinking oh, this is the bolus when actually

Jennifer Smith, CDE 27:59
it might not. Or if you are trying to really be aggressive with your Bolus thing. Then you're Bolus thing and Bolus thing and then finally Bolus thing too much. And that actually brings you back down. In which case then you might be eating, you're sending yourself back up. The Basal isn't enough in the background. So it becomes a roller coaster.

Scott Benner 28:16
So infuriating is this is going to be and then we'll we'll end up this episode. But if you're bezels, right, and you haven't had insulin or food for a few hours, your blood sugar's like 80 it's sitting right there. That's how you know you have your bazel right, and

Jennifer Smith, CDE 28:31
so be stable,

Scott Benner 28:32
right stable. And so and so if you stability at 140 a little more might have stability at 120 a little more you that's how you can learn to play with it, but I'm just telling you that if it's if it was, you know, as intended, you know, by the heavens, then your blood sugar would be around 85. without food or insulin. It's not always going to be like that. I'm not saying that. But I'm saying if you're that far away from that number, you've got work to do on your basal rates, right. Okay, so we're gonna wrap this one up, and then record the next one right away. Okay. Thank you, Jenny for taking the time to be here on the podcast. Don't forget, you can hire Jenny at integrated diabetes.com. Her email address is in the show notes of your podcast player, and at Juicebox podcast.com. As always, I appreciate the support of the sponsors Dexcom on the pod dancing for diabetes and real good foods. You can save 20% on your entire order at real good foods calm by using the offer code juice box. This was the ninth installment of my diabetes pro tip series with Jenny Smith. There are more coming in the beginning I call it like a 10 part series. It might go longer. What do you think of that? If you're enjoying the podcast, please go to iTunes and leave a rating and review. The Five Star kind are the best where you say nice stuff. The better the podcast is reviewed on iTunes the more searchable it is for new people looking for Type One Diabetes support. Thank you very much. For those of you who share on Instagram, Facebook and privately, I love that you guys are telling your endos and your friends and anyone who will listen about the Juicebox Podcast. It's helping us grow. I appreciate it immensely.

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#218 Diabetes Pro Tip: Temp Basal

Scott and Jenny Smith, CDE share insights on type 1 diabetes care.….

I am thrilled to welcome Jenny Smith, CDE back to the show. Jenny will be joining us for an extended series of conversations that focus solely on the management ideas that we discuss on the podcast.

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

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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 and welcome to the fifth installment of my series diabetes pro tip. Today, in this short but very important episode, Jenny Smith and I are going to talk all about how to manipulate your basal insulin.

Jennifer Smith has a bachelor's degree in human nutrition and biology from the University of Wisconsin. She's a registered and licensed dietitian and certified diabetes educator and a certified trainer and most makes and models of insulin pumps and continuous glucose monitoring systems. I first met Jenny when I had her on the podcast back in Episode 37, an episode called Jenny Smith diabetes guru had her back in Episode 105. And she and I talked all about a one C's really breaking down what they meant, what was important about them and what wasn't. One day, I just had this idea to bring Jenny back on to talk about all the concepts that we talked about here on the podcast, but real granularly just, you know, really break down ideas in a way that I thought you guys could absorb and remember and share and revisit. And that's what this series has been. Hopefully you've been enjoying it. This is the fifth installment of the diabetes pro tip series with Jenny Smith CDE. And please remember that nothing you hear on the Juicebox Podcast

should be considered advice, medical or otherwise. And to always consult a physician before making changes your medical plan for becoming bold with insulin, temporary basal rates, do a number of different amazing things

Jennifer Smith, CDE 1:45
laugh and laugh compared to what your doctor told you. Yes,

Scott Benner 1:49
and and so here's how I always think about it about basal rates in general, it is bizarre for us to think that we can set up a static basal rate that will always work at 2pm for the rest of this week, or this month or our lives, right. It's just an odd statement. I don't have diabetes, my blood sugar varies based on what's happening in my body or what I eat. And I bet you even though I have no medical training whatsoever that my body is more aggressive with the amount of background insulin that I get the amount of force it pushes on my blood sugar at different times.

Jennifer Smith, CDE 2:24
Because it's got natural compensation. Yes. And I think that that that piece about about measles is also really, really, really important for women. Right?

Scott Benner 2:33
Okay. Yes, because of their periods. Or, by the way now I've been told not to say, Lady time by people that maybe I should say, period. So then I went back to period to make that person happy. Then I got a beautiful note from somebody the other day, you said I think lady time is delightful. And I'm like, I can't win. But that's not the point. So so so here's a couple of ideas. We get Chinese food coming into the house, right or not so or something that's high carb that breaks down slowly in your system. Oh, my Pre-Bolus for Chinese food is this Temp Basal increase 95% for two hours, boom, I start right there. Then I get a healthy Pre-Bolus in you know, and I start the I want to decline when when Arden starts eating her food. Chinese is a good example. Because it's not it's simple sugars and complex carbs at the same time, right. So the coating on the meat might have a lot of sugar in it like the sauces will hit you quickly. But that rice could sit in your system forever and take hours and hours and hours to to break down and to go away. So I think of it as carpet bombing insulin, I want to I want to cover the entirety of the timeline that this food is going to have impact on art and with an increased basal insulin. It I would also use an increased basal insulin, when Arden's hormones are affecting her. Yeah, we just got done doing that this week, there was a day and a half or Arden ran a Temp Basal increase of 80% for two days straight. Yep, get a straight. Yep. If your basal is not right, your bonuses aren't going to work, right? Because you're just replacing bazel with your bonuses. So even again, you count your carbs 100%, right. But if your basal insulin is set at, let's say a unit, but it should be at two units, then when you make a bolus for a three unit snack, the first unit of it is only covering the bazel you don't have plus you haven't had enough bazel leading up to that. So you're probably insulin resistant and having a higher blood sugar to begin with. None of this works without base when people come to me and say, Oh my God, look at my rollercoaster. I'm 60 I'm 400 Um, but the first thing I say is okay, let's get your basals right. If your bases aren't right, the rest of it doesn't work. Right

Jennifer Smith, CDE 4:54
and temporary visas then are not going to work either because they're working off as a setting. That's not that's not right. To begin with,

Scott Benner 5:00
yep. Inevitably, while I'm talking about basis with people, they say, Well, what about my insulin to carb ratio, and I went, that's not even worth thinking about your basis, right. So now you can think about basal insulin as basal insulin used, you know, in the normal course of your day to keep your body function low when you don't have any food, and but if you really start to think about them around food, that's when they become incredibly powerful. Why. And so, there's also a time where, like I alluded to before, you can bump in nudge with bezels. Right, so not only can you create a hard bazel, that helps you with carb, heavy meals, but you can look at a blood sugar that's at, you haven't had insulin for hours, and then suddenly, it just a 75. And it sits there for a little bit. And instead of feeding that 75, you can Temp Basal back. So Temp Basal is unlike the, you know, when I think about the tug of war with with Pre-Bolus. Basal is I think of this way, I imagine if you and I put our hands out, stood up and put our hands together our palm the palm, and we pushed equal amounts on each other. That's it, you don't fall back, I don't fall back. That's a perfect bazel rate. Right now, there might be a situation where my my blood sugar starting to fall. So I need the body function to push a little more. So I, I take a little power away from the bazel, which allows me to push up. Same thing if I'm at a 90 that's going to a 95. And it's creeping up. But a bolus is definitely even a tiny bolus is going to make me later I might just do a Temp Basal increase to stop that kind of creeping. Yeah, this all occurred to me when I interviewed someone about artificial pancreas, and they told me that most of the adjustments that an artificial pancreas makes is through basal insulin. Yeah, not through boluses

Jennifer Smith, CDE 6:57
100%. If you're doing anything within the looping community to do it yourself, insulin pumps, either open APS or looper, Android APS are whatever that is. That's the gist of the algorithm. It is most of most of the incremental adjustments based on the trend in glucose are being done by positive and negative what's called temping, you get a bit of a bump up, you get a bit of a bump down, he had a bit of bump bump up, and it's all being based on your current bazel setting. Right? Right. But the incremental ups and downs are what keep you stable.

Scott Benner 7:34
This past week, I visited the army pod headquarters in Massachusetts, where they've just moved their production facility. It's about to go live. And I got to tour the floor, where you're on the pods are going to be made from now on, right here in America, right in Massachusetts. I want you to know that what I witnessed in Massachusetts on that assembly line, it didn't just renew my excitement about Omni pod, it shot me over the moon, the accomplishment of bringing a production like that into one facility, putting it under your roof that showed me a real commitment to the people living with Type One Diabetes. Right? This isn't being made overseas somewhere or you know, a bunch of different factories. It's all right there at the Omnipod headquarters, and its state of the art and it's absolutely stunning. This is a company who is behind you for the long haul. I believe that before but I believe it even more now. Here's what you want to do. Go to my omnipod.com Ford slash juice box or click on the links in your show notes or Juicebox Podcast comm when you get there request a free experience kit. That's right up pack. A pod experience kit on the pod is going to send you a pod that is an exact replica of the one you'll get when you start using the product for real, but this one's non functioning, and so it's safe to wear for you to try

Unknown Speaker 8:55
out.

Scott Benner 8:56
You'll be able to find out if you like it where you want to wear it. And you'll notice how after you've had it on for a little while you don't even remember that it's there. Miami pod.com forward slash juice boxes links show notes or Juicebox podcast.com. The Dexcom g six continuous glucose monitor gives you a complete picture of your glucose showing you where it's going and how fast it's getting there. There can be nothing more important. The dexcom g six also eliminates finger sticks for calibration, diabetes treatment decisions, and diabetes management. It also has an automatic inserter. Like it just you know you stick it on and you push the button and the next thing you know you're wearing it. Now you can use the dexcom receiver to get the information from your transmitter. But for those of you who enjoy using your cell phone, it works great with iPhone and Android as well. The last little thing about Dexcom isn't so little How about the share and follow features also for Android and iPhone. Your loved ones can follow your blood sugar anywhere in the world and if you're the pain Or a caregiver of someone with Type One Diabetes, you can be watching their blood sugar as well. You want to know what Arden's blood sugar is right now. It's 82 just glanced up and saw it just like that. Now my results are mine and yours may vary, but my daughter's a one C has been between 5.2 and 6.2. for over five solid years, the decisions we make about how to give my daughter insulin and when to give it to her, come directly from the data that comes from the dexcom g six. And I don't know if you know this or not, but my daughter does not have one dietary restriction. Those numbers are accomplished through waffles, just as well as through salads, through burgers, just as well as through zucchini, it doesn't matter, anything that impacts my daughter's blood sugar, that impact is shown to me by the Dexcom g sex, and then I make good decisions. You want to make some good decisions, go to dexcom.com forward slash juice box and get started today. That's the best decision you're ever gonna make. So when I talk about bumping and nudging, which is going to come up in the future a little more, it's the idea that if you don't use too much insulin, it can't cause a wide swing. Correct, right. So bumping a 120 diagonal up back to 90 takes a smaller amount of insulin than ignoring your blood sugar till it gets the 180. Now you're putting in a bunch of insulin and becomes Miss time and you get low later. So using these little bumps, just make sense that you can accomplish that with Temp Basal. Again, remember, Temp Basal is don't start working right away. You can't save yourself have a 65 one arrow down with the Temp Basal. No, that's, that's juice time. Right, right. But, but but a 70 that's drifting low and has no impact from insulin really could be saved with it couldn't be saved. Maybe it won't be but you try and figure out for yourself, maybe that'll end up being a 90 that's drifting low that you'll eventually use Temp Basal for. But they are, they are such an important tool. And if you're not using them, you're missing out. I I'll say it here, I'll say it again, an insulin pump is not just a way to get less injections. It's also a way to be able to give yourself micro bonuses to be able to manipulate your basal insulin to be able to manipulate your boluses to spread them out. These tools are vital. So please tell me and I know you and I are short on time here. But tell me how you talk about Temp Basal with people like where do you Where do you really focus in on on education about it.

Jennifer Smith, CDE 12:33
So I we I and I usually really, really focus in on all of the scenarios that are likely to come up where temporary bazel is really an important piece of management, that that bumping and nudging that you talk about, you know, unfortunately, most people are only taught about exercise and the benefit of temporary bazel. And they're usually told, well just, you know, just set it for zero percent or turn your bazel off during that time. Well, that's 100% incorrect to begin with. But exercise is one of many reasons that you may want to change your bazel for a, you know, a duration of time, illness, a woman's menstrual cycle, or that woman's time of the month or whatever you're going to call it, that time, you're going to definitely need temporary bazel you're going to need it for sedentary days, I can go to a conference where I'm literally sitting for eight hours. And while I might be walking between conference rooms, the sitting and sedentary, I need a 25% increase in my basil. In order to not run high that whole day. I've figured that out right? I figured out what I need to do to take a five mile run versus a 12 mile run temporary bazel changes. I figured out what to do for different kinds of illness a stomach bug may require a decrease. an illness like a sinus infection or a bronchial infection may require an increase. Even even temporary bazel around food like you mentioned before with the Chinese high fat food, yes. 100% requires knowledge of using temporary bazel because I know we'll talk about extended boluses and things a little bit too but temporary bazel for high fat man that can affect you eight to 12 hours after you're done eating it and it keeps you high and you may go to bed with an awesome looking blood sugar thingy that I made. I nailed that I really got it. What do you get an alarm at two o'clock in the morning where you're 300 and you're like what happened?

Scott Benner 14:37
And those are the examples By the way, when you can't say to yourself, oh, well that's just diabetes. It's not just diabetes, that it's you didn't use the insulin right? And so every time you think diabetes is just this, this, you know, magic fairy that runs around messing with you. It's something happened like you might not know what it is in that moment. But some thing happened. And you can figure out what those somethings are and stop them. And there's a great example high fat, you might need a Temp Basal increase that goes on for hours and hours later,

Jennifer Smith, CDE 15:11
high fat 50% at least 50% increase for at least six to eight hours after the meal. Right?

Scott Benner 15:18
Right. It's just it's, I know, it's a little mind numbing to think that, but that's a lot to think about. But I want to, I think now's a great place to say this. As much as we're breaking things down and really stretching them out. So you can see the tiniest little aspects of these ideas. For people who understand them, I will speak for myself, I do not think about diabetes that frequently during the day, this stuff just kind of happens. I know that sounds crazy. But I look at a plate and I go, Okay, here's what this means. And if and if I miss I readjust. But But I don't spend a lot of time, of course aside of this podcast, but I don't we don't say the word diabetes in our house very frequently, I guess is what I'm saying. We're not always fighting and, and you know, scary lows, and oh my gosh, she's been high for three hours. Like that doesn't happen around here. Right. And you can live that life too, by understanding how insulin works. Isn't Jenny terrific. You know who else is pretty great on the pod and Dexcom. Go to my omnipod.com forward slash juice box to get your pod experience kit today. That's right, a free no obligation demo of the Omni pod is yours to have by going to my omnipod.com forward slash juice box. You want to make these great adjustments, you're probably going to need a CGM. I recommend the G six by Dexcom. Go to dexcom.com forward slash juice box to find out more. These links are also available in the show notes of your podcast player, or at Juicebox podcast.com. I put three episodes out this week, this one Pre-Bolus thing. And the next one insulin pumping. Don't forget, get all three. This diabetes pro tip series was designed to be listened to in order. So if you're finding this one, go back, work your way through them. They build a narrative around type one diabetes. Coming up next month, using your glucose monitor, bumping and nudging and more. You can hire Jenny at integrated diabetes.com. Instead of me talking to her you could be talking to her. You could get Jenny on the phone or by Skype through FaceTime. She talks to her clients in many different ways. Bring up the things that you're struggling with and Jenny will help you go to integrated diabetes.com. To find out more about that. If you're interested in seeing me speak live and you're in the Orlando area, I'm going to be at the touched by type one event put on by dancing for diabetes. Just go to dancing for diabetes.com go to the Events tab click on touch by type one. When you do you can register to attend. This event happens on May 18 2019. It runs from 8am to 5pm. And there are a lot of great speakers not just me. If it's after May 18. Please still go to dancing for diabetes.com. They're a sponsor of the show. They do amazing work with people living with type one diabetes, and I would love for you to find out more about them. They're also on Facebook and Instagram.

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

Donate