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Scott Benner 0:00
Hello friends, welcome to the sips series.

These foundational strategies were nominated by listeners. They told me, these are the ideas in the podcast that truly made a difference for them. So I distilled them down into short, actionable insights. There's not going to be any fluff or complex jargon, just practical, real world diabetes management that you can start applying today. And I know your time is valuable, so we're keeping these short. Another small sip will come out once a week for the foreseeable future. If you like what you hear, check out the Pro Tip series or the bold beginning series for more. Those series are available in the menu at Juicebox podcast.com and you can find complete lists of all of the series in the featured tab on the private Facebook group. Please remember that nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your health care plan or becoming bold with insulin. The questions you have, I guarantee you there's answers to them in the Juicebox Podcast, and it's all free. You

Oh, it's time, Jennifer, it's time in our little series to talk about the tug of war. Oh, oh, that's fun, okay, but we got to keep it short, because it's small. Yes,

Jennifer Smith, CDE 1:42
the tug of war and, well, this is just, it's easy. Yeah, you think so? Well, I think I hate the word easy in diabetes, because I think when you're starting out, it doesn't seem easy. And then as you move further along with things, easy is a word for some pieces of it, but other parts of it change, and it isn't quite easy until you figure it out. So anyway, tug of war,

Scott Benner 2:04
I always tell people, diabetes is never going to be easy, but one day you might be so good at it, it could fool you into feeling like it's easy. So this has come up in episode 156, 214, and 1220, but, and I know we're trying to do this quickly, I'll do it as fast as I can. I was once on a phone call helping a young mother of a small child with the kids diabetes. And I realized that the mom was not in any meaningful way pre bolusing meals, and I tried to explain it to her, and then she asked why, and then I tried to explain to her why, and I thought I had done a pretty good job. And she said, I'm sorry, I don't understand, Bill, don't get it, yeah. And I was left with a moment of, like, this person, like, I'm, first of all, I'm not a doctor. Like, somebody put me on the phone with this girl, you know, but she was, like, 2021, years old, and she had already had, like, a three year old baby. The baby had type one, and I just felt like, I can't, like, if I hang this phone up and don't find a way to help her, it's gonna be horrible for her. It's gonna be horrible for the kids. Like, I felt very responsible, sure. So I just reached down into my wherever and started talking, and I said, Have you ever, like, been in a tug of war like at school? And she was like, Yes. And I go, okay, so, like, instead of there being people on both sides, and I'm freestyling this whole thing, I'm like, instead of there being people on both sides of the of the of the rope, why don't you imagine on one side is insulin, and on the other side is carbs, or anything else that tries to make your blood sugar go up. And she goes, okay. And I said, now there's that flag in the middle of the rope, right? And at school, you're trying to get the flag on your side to win. And she said, Yes. I said, Well, this game is different. We want the flag to stay in the center. And she's like, okay, so I'm like, just, you know, I don't know what I'm saying.

Jennifer Smith, CDE 3:54
Well, you're trying to find the right way, the simple way to explain that will make sense given you had tried a couple of different ways of explaining how insulin and food work against or with each other, right?

Scott Benner 4:08
I was just, as they say, grabbing at straws. And I had, I launched on this idea, and so I just stuck with it. And so I'm making it up as I go. And I said to her, I'm like, so here's the problem. I said, if we just blow the whistle and everyone starts pulling, the insulin starts pulling one way, and the food starts pulling the other way. The problem with insulin is it's not really super powerful at first, right? Like, it's not at its full power when you inject it, but that food, you know, like you eat, and you see maybe 510, minutes later, you start seeing your CGM go up, right? And she goes, Yeah, I said, so the food's going to end up pulling before the insulin. So if we blow the whistle and everybody starts pulling as hard as they can, the food's going to overwhelm the insulin and win. And then, instead of thinking about this, like east to west, like, you know, pulling the rope, kind of flip it so that the insulin is. Pulling down, and that the food's pulling up, right? And she goes, okay. And I said, so if you let the food pull first, you're going to get higher and higher and higher, and then suddenly, who knows how long into it, this insulin kind of comes online for real at full power, and it just starts pulling. But the problem is, you Bolus for the number and the carbs. Say your blood sugar was 90 when you ballished, and you know it was two units for whatever you ate. Those two units were meant to have a fight at a 90 blood sugar with carbs that were not overwhelming them, that didn't have momentum, that weren't already winning, I said. But the problem is, when you don't pre bullish your meals, the food is not just winning, but it's creating a higher number. The higher number needs more insulin. You suddenly don't have that amount of insulin. The food has momentum, meaning that numbers flying up, and now you're trying to stop it with amount of insulin that was really only meant to keep a 90 blood sugar stable during this eating excursion, right? And then I went through the rest of it about how to, like, you know, put the insulin in first, let it get working, so that that rope is moving in, you know, we have momentum going towards the insulin, not enough to make a low but just enough so that when the food starts pulling, that flag comes back to center. And then you've got the food at full power. You've got the insulin at pull power, they're both pulling as hard as they can, but neither of them can make that flag go left or right and flip that in your head north and south, and imagine that flag rolling along that 90 number for two hours. That's a straight line on your CGM. That's when you see people who like Bolus and have a straight line in their CGM, that's what's happening. And she just goes, Oh, I understand that was like the end of it. I was like, Okay, great. So it works so well for her that I said it in the podcast, and then I said it again. And then one day, and I mean this sincerely, Jenny might not remember this, but one day, Jenny complimented me about it, and it was like one of my nicer moments around diabetes. Oh, you remember that? By any chance? I

Jennifer Smith, CDE 7:07
think so. Yes, you think so. You don't remember. We talk about so many things. I know quite sure that I did, because it is, it's really easy. It's an easy way to understand, because if you were the person who is very interested in looking at all the documentation of every device and every medication, and you pull out the little insert that is inside of your vial of insulin package, you will see a graph of how insulin is supposed to act, how it's supposed to work, what its timing of action is. Nobody, nobody reads that. I don't read it. I think in my 36 plus years of having diabetes, I've maybe opened that little packet two or three times, just out of like, I don't know, curiosity at the moment, whatever. But majority of people are not going to read that. They're not going to put it together with the reason that they take insulin, which is primarily for food coverage, right? And you do? You have to understand it in a way that that marries the two and gets them to work in unison. It is. It's a great description of keeping that flag once the insulin is working where it's supposed to in a timeline, in its action profile of creation, you're getting a stable flag in the middle, which is holding your blood sugar in a good place.

Scott Benner 8:31
If that flag is a stable blood sugar at 90, then the insulin can pull as much as it wants, and the food can try as hard as it wants. You know, if you want to think, I think of the food as pulling the number up, and the insulin is trying to pull the number down, and the balance of the timing and amount of that insulin against the food done correctly, just doesn't allow either side to win their stated goal of making the number higher or making the number lower. But you and I'm going to sound weird saying it myself, but you said to me one day, you said, this is the best explanation of Pre Bolus thing I've ever heard. I really was touched by that. So thank you. Oh, you're welcome. And yes, as you can tell now, I can tell the tug of war thing with my eyes closed, because I've done it a couple of times, but I appreciate very much you doing this with me today. Thank you, of course. Yes, thank you.

Are you starting to see patterns, but you can't quite make sense of them? You're like, Oh, if I Bolus here, this happens, but I don't know what to do. Should I put in a little less, a little more? If you're starting to have those thoughts, if you're starting to think this isn't going the way the doctor said it would. I think I see something here, but I can't be sure. Once you're having those thoughts, you're ready for the diabetes Pro Tip series from the Juicebox Podcast. It begins at Episode 1000 you can also find it at Juicebox podcast.com up in the menu, and you can find a list at. In the private Facebook group, just check right under the featured tab at the top, it'll show you lists of a ton of stuff, including the Pro Tip series, which runs from episode 1000 to 1025

thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. If you're not already subscribed or following the podcast in your favorite audio app, like Spotify or Apple podcasts, please do that now. Seriously, just to hit follow or subscribe will really help the show. If you go a little further in Apple podcast and set it up so that it downloads all new episodes, I'll be your best friend. You.