#237 Diabetes Pro Tip: Setting Basal Insulin
Diabetes Pro Tip: Setting Basal Insulin
Scott and Jenny Smith, CDE share insights on type 1 diabetes care
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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 everyone and welcome to Episode 237 of the Juicebox Podcast. Today's episode you know by the title is with your favorite guest, Jenny Smith, Jenny and I are here today to add an 11th entry into my diabetes pro tip series. Please don't let the fact that this is the 11th episode in this series make you think phased array testing probably not that important. If it was they would have moved it up sooner. Not even close. Having your basal insulin correct is the core of everything you're doing with insulin. You can't trust that your Bolus was right or wrong. You can't understand why you got low or why you got high. When your basal insulin isn't correct. Everything you see coming back to you from your blood sugar experiences from your glucose monitors from your meter testing. None of it is actionable. None of it is valuable. If your bazel isn't right. Every time I speak with someone privately we start with basal insulin doesn't matter if you're pumping or injecting, and most people's basal insulin is significantly incorrect. If you're seeing blood sugars that you don't understand, it's easy to see a low blood sugar and think that means less bazel. But that's not always the case. At the end of this episode, I believe you're going to have a firmer grasp of what basal insulin is, how to make adjustments to it and why it's so important. You really need to listen to this one. This is where it all starts. This episode of The Juicebox Podcast is made possible by Dexcom ami pod and dancing for diabetes Dexcom. Of course the makers of the G six continuous glucose monitor on the pod makes the only tubeless insulin pump in the world. And dancing for diabetes is the organization bringing joy to children in Florida and touching people all over the world. With their generosity, you can find out more dancing for diabetes.com dexcom.com forward slash juicebox in my on the pod.com forward slash juice box. My friend Jennifer Smith is not just the CDE. She's a person who has been living with Type One Diabetes for a very long time. Jennifer holds a bachelor's degree in human nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer I'm most makes and models of insulin pumps and continuous glucose monitors. Not only that, but she's my guest in every episode of the diabetes pro tip series. If this is your first one, you have to go back started episode number 210. From there, it goes to 11 and 212 then jumps to 217 1819 diabetes pro tips picks back up at Episode 224. With mastering of CGM to 25 to 26 to 31. And of course, you are listening to Episode 237. This is the 11th in this diabetes pro tip series. And in my humble opinion, it just wouldn't be the same without Jenny. Last thing, actually last two things. First one's easy. You know, I'm gonna say nothing you here on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making changes to your health care plan. Becoming bold with insulin. And the second thing is that Jenny does this for a living. You can check her out at integrated diabetes calm, or her email address is right in the show notes of your podcast player.
A funny thing happened the other day, I felt like we did such a great job of outlining everything that everyone would need to know. And I was so comfortable with it that I started supporting the podcast episodes with like social media posts like Hey, don't forget how important your basal insulin is. And the right the amount of notes that I got that were like, Hey, you didn't do an episode specifically about setting up your basal rates. And I was like I didn't, I felt like we covered it all with what we talked about. But okay, if you want it like so let's add one that's about setting up your bazel testing and getting it right. And I was like, Alright, well, we'll definitely do that if the people are asking for a journey, then we have to deliver.
Unknown Speaker 4:02
That's right. That's what I'm thinking. That's what we're thinking.
Scott Benner 4:06
So, so I wanted I would like to do that. Now, here's how I imagined this. And I'm recording already. So this will probably all end up in episode. I'm assuming there's a super like specific way, because I remember being taught it like, you know, in the doctor's office, like very specific don't eat food for this much time, like make sure to like this whole thing, and this is what your basal rates gonna be. Now, there are times when I think that's antiquated and as much as if you have a CGM, you may be able to figure out your base more quickly. But I'll cover that when we get to my less technical way of doing it. But I really do want to start with what is the accepted medical process for figuring out what your basal insulin should be? Check out dancing for diabetes at dancing for diabetes.com that's dancing the number for diabetes.com you can also find them on Facebook and Instagram. Fantastic organization, you should check them out at the very least get involved if you like what you say. What is the accepted medical process for figuring out what your baseline slash obey? Go crazy, Jenny, because I feel like you're gonna get to talk a lot.
Jennifer Smith, CDE 5:21
The I mean, the accepted, ethical way to do it can also vary. You know, I've heard, I've heard a lot of different but I've also heard enough similarities for you, I guess, our best ethical way to do it within integrated when we start working with somebody brand new. As a first and foremost question, have you verified that your bagels are working well, and bazel evaluation can also be done using injected basal insulin as well. Not in the same way or as extensively as a pumped Faisal rates, right. But you can evaluate the whether or not your basal injected insulin is working pretty solidly to Okay, so both of them can be looked at. As far as pumping, we always start with an overnight evaluation. And the reason for doing overnight testing first is one majority of people, unless you're a shift worker, or overnight truck driver or something, most people are sleeping in that overnight time period, there's no eating, no exercising, there's no food going in anyway, it's like one of the easiest times of day to actually get a bazel test in. Okay, the biggest thing heading into any bazel test is that there isn't any food that's going to be impacting in that bazel time period. And there's no lingering impact of your bullet. So for an overnight test, we aim to say, have your dinner and bolus by 6pm. Because by 10pm, when most people are going to bed, give or take depending on if you're a little kid or an adult or whatever, by 10pm that bolus itself and 99% of that food impact should be gone by 10pm in out kind of the bell curve of effect, right? So from 10pm overnight and into your normal waking time, then we get a true look at what is bazel doing to hold things steady. Now, the other variables in episode about variables too, right? Dude that comes into play with testing. You know, if you are in those couple of days before your period is starting, if you have a nasty cold if you have a lot of exercise because of training or practice or something you don't want to be able to tap on an overnight when any of those pieces are.
Scott Benner 7:54
Right, you know what I wonder, too, is I'm starting to believe that there's a different bazel rate that my daughter needs depending on our site. So I think there's a leg bazel rate for her and I think there's a belly basal rate for
Jennifer Smith, CDE 8:07
that's actually funny I use when I use my upper bulat for my knee pads prior to looping with a Medtronic pump. Okay, I noticed that on my bus, I need about 10% more basal insulin. And so I set up a bazel profile that I call but
Scott Benner 8:32
I could definitely say But
Jennifer Smith, CDE 8:34
yeah, I called it but and I had it 10% higher than my standard tested Faisal rate, right that ran on my other normal sites, which seemed to work the same, you're not crazy and thinking that it could be the case. And it's something I bring up with people too, especially those use Omni pod, which can you can wear it in a lot of different places compared to conventional tube pumps, right. So overnight, the goal of diesel testing then is to have fair stability, and not like this entirely flatline. But the goal is to not have more variants than about 20 to 30 points up or down from where your finger stick value at 10pm is. And the goal at 10pm. One set bolus from dinner and the dinner food is pretty much gone. 10pm your blood sugar you're aiming for it to be somewhere between 80 and 250. I know that looks like a broad range, right? And you're thinking well, gosh, if it was like 150 i'd totally correct that at that time because I don't want to sit at night All night at bedtime, you know, 150 you let it lie. You don't touch it. You don't take corrective. Just let it sit. So if you go to bed at 188 you leave it alone, because the bazel job is to not correct that. The bazel job is to hold you pretty steady. If you're not going to have more than a 20 to 30% variance up or down from that. That means all night long. shouldn't really go more than like, a little bit above 200? Or maybe down to like the 150s? If you started at like 188.
Scott Benner 10:09
Push that then you imagine that the bazel is pretty steady, correct?
Jennifer Smith, CDE 10:13
Correct. If you accomplish that with little variants, but not a lot, and you wake up, let's say at 169, awesome, your bazel, we would hold it, check marked off in our box of records as stable tested, it's good. Let's move on to the next testing period. Now, let's say your bazel does show that it's not right. Let's say that 10pm, one at blood sugar, but by 1am, you're starting to see a drift up. That's significant. And by two or three o'clock, you're like 50, or 60 points higher than you went to bed at? Absolutely, there's something wrong. Now, where do you adjust? That's the next big question. People are like, Well, I was high at two o'clock. So I changed my bazel at two o'clock, so that it wouldn't be high anymore. It's actually it's kind of missing the boat, right? Because where you really want to adjust the bazel is about one to two hours prior to the drift being too high or too low start. Okay, so if you're too high by 2am, you probably need a basal adjustment, at least by 1am. Or maybe midnight, that's higher, so that you don't have the drift up in the next two hours. Yeah.
Scott Benner 11:27
And that's the end for people listening to get confused by that. If you think about Pre-Bolus, and you put insulin and it doesn't begin working for a certain amount of time, either does basal insulin, and you're using much less of it. So to get a real impact from it could take some time for it to build up its efficacy, I guess, right? And then not be able to hold you stable.
Jennifer Smith, CDE 11:48
Okay, correct. Yep. So that circulating insulin level at the great description, it needs some time to bump up or bump down right to the rate that's going to be then effective an hour to two hours from now at that rate.
Scott Benner 12:01
It's the same reason, same reason why when we tell somebody if your blood sugar is super stable at 70, and it's been like that for hours, and you haven't had any food or you know, insulin, and you want to try to bring it up by doing attempt down, you can but if your blood sugar's falling at 70, shutting off your bazel is not going to do anything to affect what's happening right now. Wow. You'll make your blood sugar high, two hours later, right after your seizure.
Jennifer Smith, CDE 12:24
Right. Exactly. Right. Yeah. Or after you had, you know, a 30 grams of a juice box or whatever. Yes, exactly. Yeah. So it's Same, same thing, you know, if you're drifting down, you adjust the bazel down a little bit, fill in the same timeframe, one to two hours prior to that drift, starting, so that you don't get too low, later. Now by how much? I mean, again, this is where it does vary a bit. But usually, you know, if the drift up is somewhere between like, if the like 30 to maybe 60 points higher or lower than you want to be within that time period, and adjustment by point 05 to the basal rate could be enough to make a change so that you're not drifting up or down. If it's more significant drift, and you're really rising like 100 points, you started at 188 by two as you're at 280. That's, that's a pretty big change. Yes. And again, we would probably adjust the bazel at least by point one, maybe even point one, five. Depending,
Scott Benner 13:32
you know, what's interesting is that I know this isn't like any kind of hard and fast rule, or it is, and I've found that by mistake, but I talked to a lot of people with kids, you know, younger children. And it seems to me that the rule of thumb is point one per 10 pounds of body weight with kids. I don't know, I don't know if that ends up working for adults or not. But the more people I talk to, the more I see, like that's what makes sense. And I don't know if it's an anomaly for me. But when you have somebody on a phone call with you, which you know, telling telling you something about themselves. And it's like, you know, I'm doing this and it's not working and blah, blah, blah, and you need somewhere to start like it doesn't you don't even you need somewhere to start. And I always ask like, well, how much do they weigh? And most the time it bears out but then recently I spoke to somebody, it wasn't even close. It didn't matter. The weight was unimportant that that child just did not use the insole in the same way. Right.
I think of bazel in a completely odd way. I think of it like volume. Right, like on a on a stereo. And I just think if you can't hear it, or if the base is not working, turn it off. And if it's too loud, turn it down. And because Arden's using, you know, a dexcom, g six, I, I just turned it up until she gets where I want to be, and then I dial it back a little bit. Is that a bad thing? Am I doing that wrong? Is that is that irresponsible? Which by the way, in the last 10 years has become a word again, I don't know if you know that. You're irresponsible. There was time grammar people would be like, that's not a word. You can't say that. And all the sudden, it's been come acceptable in like the last half a decade or so. So now I feel comfortable to speak improperly again. So you're responsible? Is it irresponsible?
Jennifer Smith, CDE 15:47
irresponsible? Well, I actually use that word with my six and a half year old all the time. So I guess I've been using it more appropriately now. And I thought, yeah, that is irresponsible to do that. Do not do that, you know. So,
Scott Benner 16:03
anyway, I
Jennifer Smith, CDE 16:04
don't think I don't think that that's irresponsible. I mean, you're doing again, and again, in the topic of bazel, specific adjustment, we talking about temporary bazel adjustment, we do that a lot, to dial it up to dial it back to kind of you know, and that's also the concept of looping, right, is that the system works according to what it sees happening to the blood sugar and the insulin that's active in the food that's active, and it may dial things up, and it may dial things back. So that's, I mean, definitely not irresponsible. When you're talking about setting through bazel, though, we really want to make sure that we set the the bazel rate itself in the profile the right way, and you can dial it up, you know, if you want to be truly bold with insulin, you may want to dial it up a little bit more than you think you may need do another bazel test, and then it doesn't work quite well, because now you're ending up lower than you want. And great, just dial it back a little bit in the adjustment that you made. But at least it'll be a better picture. Um, you know, overall, and you can always test over and over again. Most people hate vehicle testing, myself included.
Scott Benner 17:17
Listen, that's I remember getting the sheet of paper handed to me when Arden was two, and they're like, the first thing we're gonna want to do is bazel test. And I looked at the sheet like, Well, I'm not doing any of this, but okay, and you know, looking back, it really should have done it, you know, especially back then when there was no CGM, and you know, none of that stuff, and I really shouldn't have done it. But, you know, no food being digested, you know, no active insulin, like, how am I going to get like a little kid not to eat for five or six hours? And I did eventually figure out that overnight was the place to begin. And you can, to some degree, infer the daytime from the nighttime meaning meaning, you know, if it takes a unit an hour overnight, you're probably not five units an hour during the day, you're probably somewhere near that unit. Right. Right. Right. And it could be I mean, it could be significant i right now Arden is more like a unit overnight and more like two units during the day. Right. So in, but that also will go back and forth. The just, just I will say this, because you you alluded to it earlier, and you were just talking about the idea of bazel testing, like I know a lot of you don't want your blood sugar to be 180 or 200 overnight. But for this test, maybe that's what has to be, I'm really coming to realize that an incredibly flat line one that's 85 for 24 hours a day, is really not reasonable. It's doable, right? And sometimes you'll get it and maybe you'll get it for days in a row if you're really dialed in. But you can't be upset if a blood sugar goes to 160 for 45 minutes and comes back again. It just my blood sugar goes to 160. Like if I sit down to play two pancakes today, my blood sugar is going to be 160 probably for a couple of hours now. different situation, right? And I don't have the other impacts of Type One Diabetes like people with type one, two, and I get wanting to limit it. But everything we've talked about on this podcast for the last number of years, I've seen it intersect with Arden becoming an adult. And so do I think you can keep a 90 blood sugar forever if your kid hasn't hit puberty yet? I bet you can. Right? I think it's super easy. I think that when you get to puberty, I don't think you should beat yourself up if that doesn't happen. And and I can still do it most times you don't I mean, like don't get me wrong. But I don't know. Like it's it doesn't seem as important to me. It almost seems like a video game. Now when I step back, and I watch people online, do it, for instance. And they're like, look at this graph, and I'm like, That's amazing. And then there's part of me that wants to say show it to me 10 days in a row and then I'll get excited right like don't Just show me one in the middle of May and go, Hey, look what I did here. And that's why, you know, on my blog, I tried to put things up that are like, Look wrong, everything went today, Arden say onesies still under sick? You know, I don't know, I just I want you guys to realize that we don't want spikes when we get them, we want to bring them back down again. But if they happen, you cannot run around like you've lost some, you know, game that that's attached to your mortality somehow, you know if your blood sugar is always 200 Yes, but you know if it jumps twice, come on, like ease up a little bit. Okay, right. So how reasonable is it that once I bazel test, I'm actually going to know what my basal rates are. Normally, I tell you about the dexcom g six continuous glucose monitor about the share feature, you know, you can see your kids blood sugar when they're not home. Or you know, if you're an adult, and you'd like your parents still or a friend to be able to see it, you know, sharing files amazing. It's available for Android and Apple and blah, blah, blah. And you should do that. Wouldn't you be great if you could see the direction of your blood sugar and the trend lines and how fast your blood sugar's moving up, down all that stuff that you hear me talk about all the time, hundred percent true, but with the time that's left in this Dexcom ad, I'm gonna say this year, you are listening to the bazel adjustment episode. By now if you're still listening, you must believe how important it is to have your basal insulin correct. And while you can do it without a dexcom It is so much easier with one I mean, oh my god, it's so much easier. Go to dexcom.com Ford slash juice box to find out more about the Dexcom g six continuous glucose monitor. Let me sweeten the deal by telling you this story. It's summertime now Arden's home from school. Last night, she was up facetiming with friends from all over the country. And they were up way too late. So Arden needed to sleep in today. She slept till 130 in the afternoon. And I was able to keep her blood sugar from going below were high. While she slept all of that time away. All that think about that
6am 789 10 1112 one, no food, no intervention, just the information from the Dexcom to help me make decisions about her basal insulin. And those decisions kept her blood sugar between 70. And you know, 120 is where we get I alarm. But honestly, I never saw over about 95 dexcom.com forward slash juice boxes, links in your show notes at Juicebox podcast.com. Get started today. But before you do, let's talk about on the pod, the only tubeless insulin pump in the world, the insulin pump that my daughter Arden has been wearing since she was four years old to 11 years ago. And it has been nothing but the best friend we've ever had in diabetes. last day of school, Arden went to a friend's house to go swimming, had around the pot on last night, need to make an adjustment to her blood sugar picked up her PDM button button button. Just like that No tubing, she's laying in bed facetiming she's not wrapped in tubing, she doesn't have to bounce her controller on her head or stick it in her pants that doesn't exist on the pod was over on the dresser right there. just just just there, just reach over and grab it, push a couple of buttons, give yourself some insulin, take some insulin away, maybe a Temp Basal decrease. I don't know what you're doing. But trust me, whatever you're doing, you want it to be easy, and you want it to be good. And you want it to be wholesome and fulfilling and make your life better. And that's exactly what on the pod does. The best part is on the pod wants to send you a free, no obligation demo, they call it a pack a pod experience kit, they'll send it right to you right to your house. So you can try one on the pod for yourself before you make any decisions. My omnipod.com forward slash juice box or the links in your show notes or Juicebox podcast.com. No more ads, talking about basal insulin the rest of the way.
Other times I bazel test and then I don't have any better of an answer.
Jennifer Smith, CDE 24:05
There might be especially if like I said before, if you're doing some bazel testing, and there are variables at play that you didn't really think to pay attention to in that time period, then absolutely though that bazel test could be not very purposeful. It could be kind of null and void. And this is something I encountered a lot with women. And something I bring up when I work with them to begin with. And in a first visit is one you said you've done beta testing, but to see you know your cycle impact if you have one and two Did you bazel test in that sweet spot of like two to maybe three weeks whether women are on birth control or not. They're sort of like this two to three weeks of sweet kind of plays of management without significant hormone impact. And that's where beta testing used to happen. It needs to happen without the impact of Pre cycle or oscillation hormones kind of coming into play. So if you haven't been tested in those sweet spots, and you're completely wrong, what's happening and what your basic needs are. And once you do have that sweet spot to put into play, and other, this is an important piece that a lot of people ask about too, is great. So then I need to test in these other times, well, that really, you know, what we find is that women mostly need like a 25 to maybe 40% increase in a hormone specific time period of the month. If you know that what you can do is use the Temp Basal, ie How well does this work? And what you can do because the time periods during the day that your Basal goes up or down, physiologically, those times will remain pretty stable. Those shouldn't need to change, it may be that you just need 25% more between 6am and 10pm. Right. So you can plug that into a bazel profile, set it and turn it on or enable it when you need to. But those time periods of the day, they stay pretty stable. Once you've designated Oh, my basal needs go up at 2am. Up, they shift down again at ADM, they're pretty stable until four or 5pm, they might go up or down again. Another piece for bazel testing is that most most people, again, your diabetes may vary. But most people will have about Orwell, most people have one Valley and one peak to their bazel during the day. So let's say they start midnight at point six, it might go up to point eight by two or 3am. Maybe it goes down around 8am 9am to like point six again. And then through the day, it's phase kind of lower, and then it may shift back up into the evening time. Okay, so you kind of had one dip, but one rise through the course of a 24 hour time period. Again, that's most people, not everyone. Most people also have about three to five basal rates through the course of the day or bazel time periods. So, you know, midnight until 6am 6am until 4pm 4pm to 9pm 9pm to midnight, those time blocks. Most people have about three to five different segments of rate need. Through the course of a day,
Scott Benner 27:25
you have to stay flexible too. You can't just say to yourself, look, I've set this basal rate, it starts at 3pm, it ends at 7pm. It always works. And then Thursday comes in at five o'clock your blood sugar starts to drift up, and it won't stop drifting up. You can't lock yourself into that doesn't make sense because my bazel always works. It's not working now. And the reasons you know, I'll be talking about this throughout the years of the podcast, but the reasons are almost unimportant in the moment. The truth is your blood sugar Yeah, yeah, right. You need more insulin, use more insulin. And and I've come to start, I've begun to start saying privately that that the diabetes, your blood sugar, it's requiring more of you. So give it to it. You know, he's telling you something your blood sugar going up is is your body's saying hey, I don't have enough insulin. Don't like wonder why just believe it. You know, like, there's no reason to, I don't know, if you came up to an intersection. And there was a cop standing there with his hand up it says don't go around the corner. There's a guy with a gun there. Just believe the cop and don't go around the corner. There's no reason for you to peek your head around the building. Oh my god, there is a guy shooting there. Like just take his word for it and walk around the block. And so. So when your diabetes is telling you, Hey, I don't have enough insulin, just believe it and give it more insulin. I got this beautiful note this morning from someone who said they were listening to the last episode. And she said, I think she called it like a bat in the head moment where she was just like, oh my god, I'm an idiot. Why am I not using more insulin like like, you know, running around all day looking at her blood sugar going, what's wrong? What's wrong? What's wrong? What's wrong? And she said, We must have said something on the podcast. And she just was like, oh, but sometimes that that happens like because you get so narrow, focused on the things that are supposed to be happening, that you can't break away from them for a second and look at actually what's going on. You know, listen, this is good life advice, too. If you're fighting with a spouse or a girlfriend, and you're saying to yourself, I have the best intentions here. Why is she upset? It doesn't matter. She is you know, so you're doing something wrong. Forget figuring out what it is. You're wrong. Stop or you're wrong. Right. That's it? Yeah, I've given you a number of ways to think about this. Now, when your blood sugar is going up. Give yourself more insulin. As a matter of fact, Jenny my next t shirt is going to say more insulin. That's the next t shirt. I'm going to print if I can ever figure out how to have one absolutely deserves a T shirt. All right. Everybody's always like telling me it's so easy to print t shirts. How can you not figure it out? It's like I'm very busy. Leave me alone. But I'm trying. Anyway.
Jennifer Smith, CDE 29:59
Yeah, I do. That's also a really good point. Because if this is where you could also say, is it a trend now? It Like you said, 5pm, my blood sugar is going up. I don't know why I don't have any active food. I don't have any active insulin shouldn't be going up. I felt like things were pretty good up until today. Great. Well, you know what, tomorrow if it's happening again, the next day, if it's happening again, something shifted. Why? Again, don't play with the why I mean, you can go back and evaluate and look at some things and whatever. But in the moment, you say, you know what, it looks like my blood sugar starting to go up by 435 o'clock every day, and I'm high by six o'clock and I keep adjusting and correcting. Don't do that. Right? adjust it, make an adjustment and go forward. And then you know, what if it shifts back down, right? If a couple of days, you're ending up low, then you shift it back down again?
Scott Benner 30:50
Yes. See, you're you're highlighting something that I've never understood when people say to me how many days till I think it's a trend, and I should change. And I'm always like, Who, what, like by the time you by the time you suss it out three days later, it might go back again, now you've given away three days of your blood sugar at that level, get just learn. Don't ask your wife Are you really gonna wear those pants, like she doesn't like it when you say that to her right leg, Sue, so stop and don't don't do it again, like, my blood sugar went up at five o'clock, I did something about it. Tomorrow, it went up at five o'clock, I did something about it. The next day, I'm not even letting us get to five o'clock, right? I'm just gonna decide, I'm going to expect that what I know is going to happen is gonna happen. And I'm gonna deal with it ahead of time. And if it happens to not go that way, well, then I can dial it back again. But it's so much easier to ramp up your insulin and bring it back than it is to sooner than later.
Jennifer Smith, CDE 31:46
Many times doctors will say, Hey, you know, follow a trend over the course of a week, well, that's five to seven days, then that you have chunked out higher or potentially lower than you want blood sugars, because you're trying to find a trend. I mean, in pregnancy with the women that I work with, we say two days of a trend, we're making an adjustment. And you know what if we need to dial it back again, for whatever reason, we will, but we're not leaving things travel higher or lower. For more than that time period, we will adjust and then we'll adjust again,
Scott Benner 32:18
and for all of you who have ever said to me, yeah, I'm going to handle that the next time I go to my doctor three months from now, you make my brain hurt when you say things like that. Okay, just please do not wait three months to address something even. I just yesterday, had a person who won a giveaway that I did with dancing for diabetes, and they you know, we had a phone call together. And this person, this is great. A person in their 60s who decided to get a CGM and a pump and you know, very excited for themselves. And then she said, You know, I have a doctor's appointment July, I said, No, no, don't wait till July. I said, write an email right now. Hey, Doc, guess what, I'm getting a dexcom g six, and I'm getting an omni pod. Go ahead and send those prescriptions in for me, I want to do that right now. And when we get I'm excited to come to you in July, and I'm going to bring my new stuff with me, you can show me how to do all of it. And I said if you never make it there to show or maybe you figure it out on YouTube or somewhere, whatever. And you know, and and, you know, but or maybe they'll send a trainer to your house. I think that is the appropriate thing to say right? And and but but I was like don't wait till July. So because July is six weeks from now, six weeks from now you're going to tell the doctor what you want. They're going to wait a week because people don't do things right away for you. They're going to send in their prescriptions for you, then you're not going to get this pump for six months. If you get that like start today. Go right now. Be proactive.
Jennifer Smith, CDE 33:38
Yes, with technology the way that it is and electronic medical records and things like my chart and things that you can send back and forth. There is no to not communicate between with a doctor and you know what if you don't get a response from them within 24 hours, you call that office and you ask to talk to their nurse and you say this needs to get to the doctor needs to be saw and it needs to be taken care of.
Scott Benner 34:01
Arden's endocrinologist and I have been adjusting her Synthroid are just taking Synthroid and site ml now and we've we've been making adjustments by email. But what's taking and it's still taking a long time to get it straight. Imagine if I only made the adjustment every three months when I saw her art, it would be like a puddle on the ground. When Arden doesn't have enough Synthroid. She can't pick her head up off of the ground. She just slumped over and she's like, her blood pressure, her blood pressure gets incredibly low. And she looks like she's dying the whole time. And and so once she has more Synthroid, she sits right back up again. It's it's literally like grabbing a marionette bytestrings when she has an Synthroid. But if I had to only make adjustments to her medication quarterly, it might take us two years to get it right. And we might never because she's growing and gaining weight throughout that time.
Jennifer Smith, CDE 34:53
And think of her education in this time period to what would she be getting out of her classes and the ability to perform And any athletics that she likes to do and enjoyment of fun with friends and everything. I mean, that puts a major cramp in any age, whether you're a child or an adult trying to perform in work or whatever. I mean, any adjustment, it needs to be addressed in the here and now not waiting three months to say, Oh, well, Doctor, you can see my is such a child. I've been having a lot higher blood sugar's I didn't know what to do. But I knew I had an appointment. So I waited until I came at that.
Scott Benner 35:30
Yeah. All right, Jenny. We're standing in front of your house. And you had your garden hose in your hand, and your porch caught on fire. Would you stand there with the hose thing? Or the fire coming? You'll be here soon. I don't need to squirt the hose at this porch. Why would I do that? The fireman is coming. He's a professional. I'll let him handle just hold the hose. Get started
Jennifer Smith, CDE 35:49
with my hose.
Scott Benner 35:50
Yeah, why don't I just see what I can get accomplished here. All right. So bringing this all back to your baseline slim, because no one thinks about their basal insulin with nearly the importance that it is I spent the first 10 minutes of a conversation the other day explaining to a person what it was. And after I explained it, I had to explain it again. And and so and you can still hear people go so that's the level here like people on empty out there like so. And I get it like they're newly diagnosed maybe sometimes, or they never got a firm explanation. But we treat basil insulin. Like it's not important. And it's everything. It's it's so much more important like it. Can we say it all the time. Everything starts at bazel phaselis not right, nothing else works coming off of it.
Jennifer Smith, CDE 36:35
Well, and so many people think that bazel job is to bring blood sugar down. Right? Oh, many people I mean, people I've worked with who've had diabetes long term who've come in and you know, I look at their records to begin with and they are confused and annoyed that their basal insulin isn't letting them wake up at a target blood sugar. I just stay high all night long. Well, you're starting the night high. So something I mean, time chunks of the day. Usually where you are now it's because the hours ahead of that. Something isn't right. Yeah, it's not the here and now. It's the what happened before this that got you here. So let's look I wanted my diesel should is here, here and here. And it should be bringing me down. No, that's not fatal job Faisal. dabit. The whole just it if you didn't eat all day long, you shouldn't have much.
Scott Benner 37:24
Diabetes is like a time travel movie. I've come to think of it this way. Right? Like it whatever is happening to you in the moment when the cameras pointed at you has nothing to do with what's in the frame with you. It's not a it's not a murder mystery. It's not somebody stabbing you and going, Oh, this is what's happening right now. It's the guy in Act One, set something down on a table and enact 325 years later that thing is how come you blah, blah, blah, blah, blah. There are things in the past. And there's decisions you're making right now with your diabetes that are going to affect you in three hours, or six hours. And and it's not now so much like it's interesting to how people overreact to the idea of Pre-Bolus Singh originally, because when their blood sugars are out of whack when they're really first starting to get things together, and they're jumping up and down. They're so reactive to everything they see I did something and then this happened. And I always tell people, if you Pre-Bolus and two minutes later, your blood sugar starts dropping that has nothing to do with the Pre-Bolus nothing. That's why when you know when you guys hear me say Arden's blood sugar was at five and I Pre-Bolus there. Because she was stable at five for three hours, the Pre-Bolus isn't going to start working right away. I only needed her to get to lunch 10 minutes later.
Jennifer Smith, CDE 38:38
The only reason it would start working right away is if you physically had that canula in a vessel. Right on it was literally going right into the van tapping into her bloodstream. Right?
Scott Benner 38:48
So in normal situations, which Jenny's bringing up, probably because she knows we actually had a pump. Probably Nick a vein in Arden one and for two days. I couldn't we couldn't get her blood sugar to go above like 50 most of the time, until we finally just changed her sight and everything went back to normal. But that was anyway that had never happened before. That was crazy. For the I'm texting Jenny, like you should have seen that texted Jenny, I sounded like you guys sound but you email me I was like, I don't know what's happening. I wasn't with her. I was in Florida doing dancing for diabetes. My wife's at home going? Seriously. This is what's happening when you leave. And I was like, I don't know how to explain any of this. I said I've looped in Jenny, we're gonna figure it out, you know, but, but anyway, yes. The point is, is that timing of your bazel just as important as the amount of your bazel. And to Jenny's point, for those of you who are thinking that bazel is in charge, you're bringing your blood sugar down. It's not it's in charge of keeping your blood sugar stable. And I say all the time, it's a stupid thing. But do it with me here. Unless you're driving. Hold your hands together in front of you like you know in like the classic, you know, prayer prayer motion, right. Imagine yourself Body function and, you know, sugar on one side and your and your and your bazel on the other side, and they're both pushing each other towards the center. And when nobody wins, right, when your hands don't move to the left or your right, that's a good basal rate, when you start moving towards body function, then your basal is too high, and when your body function starts pushing you away, then your basal is too low, you're trying to just give the bazel enough strength to fight off the background things that are happening in your body. If, right, and when you eat, you know, a reasonably normal meal, that bazel should also, you know, help with your Bolus. But don't expect that if you're going to eat like an entire pizza that your point six bazel rate is going to be okay. Because it's not. And then so that's, that's another thing. So once you get done bazel testing and figuring out your bazel for all your normal times when you're just standing around being you amazing you. That's one thing, what about your basal insulin while you're eating? And those tests have to happen in real life, while you're eating? You have to say to yourself, when I eat a salad with a burger, my blood sugar tries to go up. I wonder what would happen if I did increase my basal rate during that? And you know, I mean, for those you've been listening for a long time
Jennifer Smith, CDE 41:15
or after that
Scott Benner 41:16
we're right, right, maybe it's pizza, it doesn't hit me for 90 minutes after I've eaten it, you know, or any other thing like French fries, or had french fries the other night, it must have made her high like four hours after she you know. So
Jennifer Smith, CDE 41:29
it's not the nothingness is understanding again, that's why we also start with the overnight test it because if you can wake up in target, you are not fighting being too low from excessive insulin dropping you and you're not fighting being too high and having to correct and add insulin in a time that you're most people are insulin insensitive in the morning, right. So we talked about things like adding fat in Yes, your background bazel. If you know it's solid and set to begin with, then you know how to play with that temporary bazel feature to accommodate for long term impact like that, that causes essentially a stress factor, it releases triglycerides into the bloodstream, which causes insulin resistance in the aftermath, it can last as long as 10 hours after eating high fat. So most people need a bazel increase. It's like fat almost causes your basal insulin dose to be reduced by 50%. So if you're running at a rate of 1.0, overnight, and you have this big ol awesome like cheese, meat lovers pizza night, you go to bed thinking man, I nailed that Bolus, I'm going to bed beautiful. I'm like a 103. I'm going to sit here all night, it's going to look awesome. At two o'clock in the morning, you're at 300. And you're like, what the heck, you know, where did this cut, its fat, usually fast starts to impact by about three hours, you get this like drift, and then you get stuck by and you nail it with insulin and you nail it with insulin and you nail it again. And then finally you might start drift down. By the time you wake up the next morning, you could have fought it ahead of time by using a temporary rate adjustment. If you know your bazel to begin with is set Well, you can increase using temporary bazel and offset the impact of that
Scott Benner 43:12
fat. I wonder if I can explain what's in my head correctly. Because when your blood sugar gets elevated, imagine it's 250 coming off of the pizza and you think oh, a unit brings me from 250 to 100. So I'll put it in a unit. That's great. But what Jenny just told you was you're at 150% need for your Basal. So the unit really just keeps replacing the bazel you don't have. So you put the unit in, replaces the bazel keeps you stable at 250. But you still haven't addressed the number. And so then you wait an hour and you go I can't believe that didn't do anything and you put it in another unit. It doesn't do it again, because you're still just replacing the bazel you need a yak up your basal rate and Bolus for the number. And remember, the turning up the Basal at midnight doesn't make doesn't mean it's going to start working really maybe until one or two o'clock in the morning. So what So in the end, let me get very close to the microphone. What you need. And I don't want to oversimplify diabetes is more insulin. That's what you need. You do not have enough insulin. It's your union that T shirt. I'm talking right now. I can't do this podcast forever people more insulin if your blood sugar is high. Hey, if your blood sugar is low, guess what? Let me just go at it right now. Less insulin. There you go. It's not difficult, right? It's difficult to imagine the whole thing, which is what this podcast episode is about. Like we're talking through a number of different scenarios where your basal rate means something. But I think that i think that's it at the beginning here. Jenny explained a more clinical way to do basal testing. I think if you have a CGM. I tell people when we're speaking privately, and they're like, how do I figure out you know, how much more bazel to use? I just go well, you know, if it's a kid and they're like, at point three, I'm like, well turn 2.4 and see what happens. You know, and as they start getting low, Put it 2.35 you know, and it has because your kids blood sugar's sitting at 200. You know, like, with point, you know, point three going in every hour, point four is not going to make them nothing, it just doesn't stand to any reason. Common Sense and diabetes is, you know, just like I tell people all the time, one of the best pieces of technology for managing someone with diabetes is text messaging. It is a absolutely, like pivotal way in how art and I deal with our blood sugar if you don't, if text messaging is a is a diabetes tool, and it the same way, right? Just trying things is a diabetes tool, like give it a shot and see what happens. You know, point four, Okay, now let's see what happens. Not enough. So
Jennifer Smith, CDE 45:46
even for little kids, you know, even the incremental of the smaller rate, you know, the point 05, or the point 025. You know, all of that is an option. It's not an omni pod, but it is an option on the tandem in the Medtronic pump. So that is an option to get smaller, incremental adjustments, depending also on what your sensitivity kind of seems to be. I think the only thing that we didn't really is like the daytime testing, honestly, you know, daytime means that if you really want to know what's happening behind the meal, to make sure that the bazel is doing its job, the meal can't be there, right. So if you wanted to look at morning time, you really have to, for adults, you can skip a meal, because you can deal with that. You can just you can slug it out until lunchtime, and go ahead and eat your lunch and just see what happens in the morning when you wake up. You know fasting blood sugar, you let it sit you don't bolus you don't take caffeine, you don't eat anything. You can have water, herbal tea, or whatever. Don't go for a 10 mile run either. Look at what happened. Oh, kids, I usually say you know what, if you can get them to sleep in a little bit longer, maybe on a weekend, at least you're going to get an idea behind what their normal breakfast time is in that morning time to see did the bazel carry them pretty well, or what I had one mother I worked with, not too long ago. She's like, he woke up and he just started playing with his Legos right away. And he played with his Legos for a long period didn't even care about eating breakfast. I'm like, awesome. Yeah, that was a bazel test. I was like, there was nothing there. no food, no balls, he was sitting and playing with Legos. Fabulous. We've got information.
Scott Benner 47:28
That's cool. That's excellent. Yeah, whatever you can do, just just but do it. Because you need to know. In the end, if you've ever spoken to me privately, what I'll tell you is, in a perfect world, if your Basal is right, your blood sugar is gonna be 90, it's gonna be 85 or 90. Now, I don't expect it to always be that. But that's your goal. And if that's your goal, then it's when you're at 150. It's not correct. And also, when you're bouncing all over the place. If you're one of those people who right now is struggling and your blood sugar flies all over. You may turn your bazel up and get a low blood sugar and think oh my gosh, that's because I turned my Basal up. But it again, it might be about the Bolus you use before. So you know, there's one thing I say all the time. That I think is how you start your Basal rates. First thing you have to do is find a level, just find a stability point hasn't really almost matter where it is just get your blood sugar to sit still. And if you have to nudge with food, to do it, or nudge with insulin to do it, it's fine. Get stable somewhere and start over even when things go crazy here. I'll say that the Kelly I'll be like, Listen, I said we're out like everything's out of whack. Like we got to find a stable points where we can start over again. And you know, you just can't I don't know. It's like It's like trying to catch up. It's like trying to catch up on you know what I mean? Like he you gotta wait till it lands. Anyway. All right, um, do you feel like we've covered it?
Jennifer Smith, CDE 48:53
For the most part, I don't think
Scott Benner 48:55
we have to. I appreciate everyone who reached out and asked about a more specific episode about bazel testing. This was it. I hope you liked it. Goodbye, Jenny. Ah, thank you for listening to the 11th installment in my diabetes pro tip series with Jenny Smith CD. Don't forget that there are links in your show notes to email Jenny or you can go to integrated diabetes.com if you'd like to hire her personally, and have these conversations private like with her. Thank you also to Omni pod Dexcom and dancing for diabetes for being such wonderful advertisers. And sticking with the show weekend and week out really makes it possible for you guys to get the show. And I appreciate honestly how easy they are to work with. You wouldn't see that behind the scenes but they're good peeps. If you just found this diabetes pro tip episode, go back and listen to the rest they start around Episode 210. Also something new you may not have noticed last Friday, I began to post a second episode of The Week called defining diabetes. In the short episodes, Jenny Smith and I will define a phrase from your daily life with type one diabetes. If you're a subscriber, this extra episode will just show up like you're used to seeing everything else, it will just populate your podcast player, you can listen to it whenever you want. Thanks so much for listening. I hope you have a great day and a better week. And a special shout out to all of you on Instagram who share the podcast so much there. It's amazing. Thank you so much. You're helping the podcast grow in ways that you can't even imagine. Before I go, I'd like to share something that I imagine that most of you who have been listening for a while understand. It took so much restraint not to call this episode Jenny's but but I did it. I'm an adult. And I use the diabetes pro tip series because that's what this is. But when Jenny said she made a bazel rate called but I was like oh my god. This episode should be called Jenny's but, or but bazel or Jenny's but bazel I don't know. But I just so hard not to do that.
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