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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

Jenny, let's talk about using your CGM graphs for more than just the number. Oh, you up for this? Of course, okay, apparently we talked about this in a number of episodes. Episode 37 with you, Jenny Smith. It's called Jenny Smith, type one diabetes guru. That's crazy is that, like the first year of the podcast,

Jennifer Smith, CDE 1:50
it must number 37 you said 37 really

Scott Benner 1:53
early. Yes. And we also spoke about it in episode 1006 called Mastering A CGM, and in the bold beginning series episode 1271, but the person that sent this idea in is saying, Look, I came to realize that I could infer things from the graph and not just count on the number. Now, yeah, I will say this. Do you think that that changes from system to system. Or do you think it's pretty consistent throughout them, meaning

Jennifer Smith, CDE 2:23
brand to brand of CGM,

Scott Benner 2:27
yeah, and maybe even like, g6 to g7 for example. Like, does the pitch of the line mean something different to you in g6 than it does on g7 that kind of an idea. Or do you think, generally speaking, this conversation could cover all these ideas? I think it could

Jennifer Smith, CDE 2:41
cover all of the ideas, because the systems all have some type of an arrow directive along or associated with the number that is your considered current glucose value, right? They all have a graph that indicates rising, falling or stability. I think it could be used across the board.

Scott Benner 3:01
Okay? Because I used to say to people Dexcom g6 and prior, I used to say, set your graph to three hours, and then look at the last three dots on the right side. And if they would bend one way or the other, it was a good indication that you were about to get an arrow that way. And I have to admit, I don't find that to be the same in g7 anymore. Oh, that's interesting. I don't know why exactly. Maybe some people still use it that way. But whether I think it is or not, these, to me, are the little things you're looking for. Like, what does the graph tell me is happening? You know, for instance, we all know about compression lows with CGM, right? You roll over you, lay on the CGM, all of a sudden, your blood sugar looks significantly lower than it was five minutes before after. That's happened to you a number of times. I don't know about you, but I can look at the graph and say to myself, being fairly confident, oh, this is a compression low Yes, because I can see it on the graph

Jennifer Smith, CDE 3:57
well. And there's a very on the graph, again, in terms of talking about those, the graphical view, the compression laws are very evident, because they look like a pretty stable looking line of trending dots, and one dot veers off in a very different, abrupt manner. It's almost, I kind of describe it akin to a cliff dive? Yeah, you're on the cliff, and all of a sudden you're like, at the bottom of the gully or whatever. And

Scott Benner 4:29
sometimes you'll lose connection for a second. It'll almost look like a couple of dots weren't there, and then, like, Listen, I'm not saying this couldn't happen, but it's fairly unlikely without insulin that would, you know, make this happen for your blood sugar to go from 100 to 40 correct in a couple of minutes, like, you know, when you look and you go, Oh my God, it just went down 40 points. And then that panic hits you. I'm not saying you shouldn't check on it immediately, but what I am saying is you might think I'm just going to test my blood sugar because this could. Be a compression, low, correct, right? And then after that happens a number of times, I still think you're gonna check. I would still like you to check, I guess is what I'm saying. I'd like you to whip out your meter and make sure, but at the very least, maybe it could keep you from having that heart dropping into your stomach feeling correct

Jennifer Smith, CDE 5:15
and or treating when you really don't need two grams, four grams, eight grams, whatever. You've gotten used to treating something like that with. You're likely to not really need it if that value is not truly that low.

Scott Benner 5:29
So instead of the panic putting a juice box into your hand, let the panic. Put a meter into your hand and go. No, look, you know what? I am 100 maybe I'll just wait a second to see what happens here. Now, similarly, using the graph after a meal, for example, I think of that line sometimes, like on a protractor. I don't know if people have ever used a protractor before, like, when you're like, put in a little, I don't know, Pre Bolus for a meal, and you've got a nice little drift happening, and then all of the sudden, it looks like a bent arm, like shot up into the air. All of a sudden, I say to myself, well, I don't think my Pre Bolus was long enough, long enough. And okay, so let's next time to take a little look at that. Now, if it jumps up very quickly, and then, you know, levels off and then comes back down to me that says, Oh, I'm close, like, I almost have this, right, you know. But if it goes from, if you bowl us at 100 and you're at 80, and then all of a sudden it's jumping up like a rocket. You're 121, 4160, and it goes up over 200 you might have missed on your pre balls. You might have missed on the amount of insulin you needed. Like this, to me, is an example of I have to look at the amount and timing of the insulin that I'm using, it, but I'm pulling out art and CGM just so I can look at it and think about it. I think often you can look at your CGM and say, Oh, I see the mistakes I made, but I don't feel that way about it. Like I feel like you should look at it and say, Oh, this is what happened. Here's what I did. I know what I should do next time to stop this from happening. Like, those lines tell you a lot

Jennifer Smith, CDE 7:00
well, and that's a good differentiation of passing judgment on yourself or your decisions for yourself or for the child or the person that you're caring for, trying to take the emotional piece out of it. Don't judge your decision. Instead, I always recommend once a week, not every day, maybe, but once a week, take a look at your data. Look historically back and see okay, I can see where I might need to make an adjustment. I can see where some things aren't falling into the target ranges where I really would like them to be. Again, don't judge. Just say. I can take a look at breakfast. It looks like there's not enough Pre Bolus, I could take a look at lunch knowing I have enough Pre Bolus, I'm still getting higher or lower than I want. I need to make an adjustment in something. So,

Scott Benner 7:50
yeah, I should have it with me, but I don't. But there's this great little graph that people made from the podcast. Apparently, you and I said things over the years, and people like put them out, like, if this happens, it was too short of a Pre Bolus. If this happens, it was like, like, so probably, yeah, I'll find that, and maybe I'll put it into the end of this episode. Again, your blood sugar doesn't jump up right away, but drifts up slowly over, you know, the last 45 minutes. Maybe this was just not quite enough insulin. Like, if it didn't jump up initially good Pre Bolus, but if it does, then continue to rise, not enough insulin, right? If it just jumps up out of nowhere, but then levels off and stays super steady after that might have been the right amount of insulin with not enough of a Pre Bolus. Like those are the things that you can and I hope you do infer from the graph and teach yourself with because in the end, this whole game is timing an amount. It's using the right amount of insulin at the right time. And that graph can teach you a lot about it. Yes, sure you can get used to like, what does a compression low look like as a more valuable tool? It's that. It's going back and saying, I put the insulin in here, then this happened. What would happen if I put the insulin in five minutes sooner or five minutes later, there was a little more, a little less, and really learning from it.

Jennifer Smith, CDE 9:09
I know I was going to say, go along with that. That really is, that's assessment of your information. I think a lot of people value whatever continuous monitor they're using these days for the alerts the here and now. I'm getting an alert here, or I'm getting an alert here. It gives you something to react to. But if you get into looking at your information, like I said, even every seven days, just taking 15 minutes to look at your trend in the last week, you can then learn to be proactive and make the right adjustments so that your alarms and alerts don't become a nuisance and they aren't going off as regularly. I

Scott Benner 9:50
think the two things I hope people take away from this one that you shouldn't just look at and go look what it's doing, because it's not doing anything like you're eating and putting it in so. And it's showing you what's happening. So, you know, just don't look at it when you see the peaks and the valleys and go, Oh man, diabetes just I don't know, you know. Trust me, you could know. And the other thing I would say, this will sound crazy to people who are not at a place yet to feel like they can keep their blood sugars in a range that they're shooting for, but having a lower, high alarm and not treating your CGM just like a don't die. Advice is, like a device is a big deal, like, please don't just treat it as a low alarm, right and then push your high alarm up to 400 and ignore it like you'd be surprised. The way I usually think about it is often after you have good ideas about your settings, and you know how to Bolus insulin. And you get better at that, you start to get what you expect. So if you expect your high blood sugar to be high at 150 you'd be surprised how often you stay under 150 so if you've got a 400 you know, and listen, I'll go over very quickly. If your highest set at 202 5300, 400 wherever it is the amount of insulin that it's going to take to bring you down from one of those big numbers is much more. It's much more. It's harder to know. It's more likely to cause a low later. And I think it puts you in a three hour fight with this high blood sugar, instead of getting an alarm at 140 or 150 and going, oh, what would fix this? A quarter of a unit, you know, and then putting it in, and now all that other stuff doesn't come with it. There's so much you can do with that CGM that will make your life easier. I think

Jennifer Smith, CDE 11:28
too a lot of people are with the tightening of people's ranges, the goals getting tighter than what the ADA recommends that 70 to 180 right? People want maybe 80 to 150 or 70 to 160 they're tightening their range that they want to see their overall averages in which is a healthy thing. But you have data now to be able to do that much more precisely. And so with the concern about high blood sugars many times, if we're reactive to just the CGM alerts, what we end up doing is creating more roller coaster we're creating more variability. And so, like you said, if you have your high alert set really high, rather than a bit lower, to be able to see what's happening sooner, you may end up giving more insulin creating a low. The low most often creates another rise up. And so you start this up, down, up, down, up, down. It's very difficult to get off of that roller coaster. So if you instead of focusing so much on highs, look first at your reports for where are the lows. And if you can filter out a good majority of the lows, you're often going to decrease the height of the highs. And that may take some adjustment to, you know, insulin doses, strategies, all of those types of things. But yeah, often lows are really the end result is, is a high that you didn't want, and then it just keeps going.

Scott Benner 13:04
Well, there's no doubt that most of the people listening, who are like in need of this information, probably see some sort of stability overnight, right? And then they get up in the morning, they miss time or miscalculate their first meal. Whoop up. They crush it with insulin. Whoop down. You panic about the low food in too much back up. And I know it sounds crazy, but I've seen people get on that roller coaster and not get off it for years, right? I'm not even kidding. Like it's not like, oh, Monday got messed up. Sometimes, if you're doing the same thing over and over again, expecting a different result, I guess that's the definition of insanity. In the end, it really is just, I promise you, it's, it's about timing and amount. Like, go listen to the Pro Tip series. I don't know how many episodes it is now. It starts at Episode 1000 in your player. It's Jenny and I talking about big ideas, more, you know, long form conversations. I genuinely think if you listen to it, you'll understand by the time it's over, and you can make this stuff happening for yourself. Yes. Thank you. Awesome. 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 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 if you're newly diagnosed. Check out the bold beginnings series. Find the. At Juicebox podcast.com, up in the menu in the feature tab of the private Facebook group, or go into the audio app you're listening in right now and search for Juicebox Podcast, bold beginnings. Juicebox is one word. Juicebox Podcast, bold beginnings. This series is perfect for newly diagnosed people. If you're not already subscribed or following in your favorite audio app. Please take the time now to do that. It really helps the show and get those automatic downloads set up so you never miss an episode. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. You.