#660 Defining Diabetes: Black Holes

April 8, 2022Scott Benner

Scott and Jenny Smith define diabetes terms

Scott and Jenny Smith define diabetes terms In this Defining Diabetes episode, Scott and Jenny explain Black Holes.

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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 friends, and welcome to episode 660 of the Juicebox Podcast.

Over the years on the podcast, I've come up with terms that, you know, don't exist in diabetes management. One thing I can think of off the top my head is trust that what you know will happen will happen. It's to me it's a diabetes truism. It's a tool. And some of these terms give you another way to think about an idea. Once in a while on the defining diabetes series, we get off of words that you're like Bolus, I know Bolus, that's a medical word. And we do one like today. Today's term that Jenny and I will help define is black hole. Don't worry, it's all going to make sense soon. Please remember, while you're listening 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 healthcare plan, or becoming bold with insulin. If you have type one diabetes, and are a US resident, or are the caregiver of a type one, and R US resident, please head over to t one D exchange.org. Forward slash juicebox. Take the survey, you'll be helping people with type one diabetes, and supporting the show.

This episode of The Juicebox Podcast is sponsored by us med. US med is the online diabetes supplier that you've been looking for. They have a dedicated 800 number for Juicebox Podcast listeners. And you can call today to get your free benefits check 888721151 For or go to us med.com forward slash juicebox us med wants to bring you better service and better care than you're accustomed to. For today, I think I'd like to do a couple of like my terms, like dictate the pace and black hole, I want to start there. And then maybe we have time, we can definitely

Jennifer Smith, CDE 2:12
your terms. They're not the I don't use but actually my boys talk about black hole, but they're very much referring to black holes in the outer space.

Scott Benner 2:23
Well, so I mean, it's at this point, it's been a number of years. And so I don't even know if you remember the first time I said it. I kind of remember the first time I thought it and it blew my mind a little bit when I realized that a Temp Basal off was creating a void in the future. Right. And that good term for it? Yeah, right, like so. So I guess I guess we're talking, we'll just keep going. The way I see it, and I'm sure the way you see it, too, is that if you're using insulin, if you have diabetes, your blood sugar, as soon as you introduce any carbs, or you know, body functions that push up blood sugar, your blood sugar starts to go up, and it wants to continue going up. It is only stopped by the introduction of manmade insulin. And in my mind, that's a I know, people have probably heard me talk about all kinds of different ways. But you know, you could think of it as the the offensive and defensive line meeting in a football game, you could think of it is, you know, what is that called mimes when they pretend they're up against the wall. They put their hands up right being inside of like the box, yes, I just think of it as equal force from both sides. So the blood sugar is trying to come up. And you need to meet it with enough force to stop it from coming up. But to stop it and hold it at a level that you desire. So some people that might be 80. And for some people that might be 120, doesn't matter. But we've talked about it over and over again, that basil when set very properly. Hold your Joe at that spot, wherever it is, you know. And so I know this, these things might seem disconnected for a minute, but I think they'll it'll come together in a second as we're talking. But I think of that as okay, I know that it exists. If I have that, right. That's one thing I can count on. And then I start thinking about the timing of insulin. And you know, you said all the time as anybody who's paying attention, right, you get a Pre-Bolus your meal because insulin doesn't start working right away. Right? And then you're always very quick to like come by, if I say something about that and say Don't forget basil takes time to start working too. Yeah, right. So if you're on a pump, and you just shut your basil off at noon, you're not going to see the impacts of that at noon. So you could do that right now. You could be super steady or whatever your number is. Shut your basil off and your blood sugar is not going to immediately start going up because beta has been going in slowly over the time. And it takes time for it to begin working. So if your pump is giving you Basal insulin, I mean, how does it break down? And in some pumps, how frequently do you get it in an Omnipod, for example

Jennifer Smith, CDE 5:15
Omnipod, you get a pulse? Well, it depends on what the Basal rate is at, right? Each pulse from a pod is delivered as a point 05 pulse of, of insulin. So depending on what your Basal may be, if it's only point one per hour, you're only getting 2.05 boluses, essentially, pulses over an hour's time. The higher the Basal rate, the higher the pulses so incrementally that adjusts over the course of an hour. Based on how many pulses you should get to add up to your Basal in an hour.

Scott Benner 5:51
So if your Basal is a unit an hour, you're going to get 20 pulses an hour of the point oh five,

Jennifer Smith, CDE 5:58
and divide that into an hour, which is 60 minutes, it could give you exactly how many minutes between pulses. Exactly.

Scott Benner 6:04
Okay. So that, that that the rest of that math, I don't care about the idea that it's going to happen. It's going to wait, it's going to happen. It's going to wait, it's gonna happen. Each one of those little pulses, lives in its own timeline inside of your body. Yes, yes. Ah,

Jennifer Smith, CDE 6:20
absolutely. It's like starting a new if you imagine the timeline, that's a really good example. You know, I mean, even grade schoolers, like my child who's in third grade already knows a timeline or a line of, you know, something in math to break it down. Yeah. So if you say, Okay, over this timeline, I'm getting a dose here, I'm getting a dose here, I'm getting a dose here. And then each of those has its own. If you imagine like a bell curve of action, right, got its own timeframe of start and finish each pulse does.

Scott Benner 6:52
Yep. So if you've been on a Basal drip for hour, I mean, you don't have to be on it for about an hour for them all to be active. And then you shut it off, it would take I know this is audio, but the first point oh, five at the top of the hour, lives its life goes through its bell curve and in dissipates. The one that happens after that starts a little later than that ends a little later than that. But if you just shut your Basal off, eventually, all of those little pulses would live their lives and be gone endpoint and have an endpoint. And when that happens, then there's a void. There is a black hole where there is no longer any gravity pulling down on your blood sugar or pushing down on your blood sugar. I know the gravity doesn't exactly work like that. But it's not the point in my head. It does Jenny. So when I'm thinking about insulin, this is how it works. So, you know, that's where you, you know, you can you hear me say, Well, if you're low now, but not too low, what if you shut your Basal off for half an hour, maybe an hour from now that 70 That's been holding, but not going down might drift up to I don't know a little bit more, right. And you put the Basal back on and you kind of catch it. It's, um, I'm Hope I'm being clear, because in my mind, it's crystal clear.

Jennifer Smith, CDE 8:15
It's, well, you're bringing up a really good point, because I think as people get more, they want to become more aggressive, not an I use aggressive, not as a bad word, but they want to get things in target more often. Right? So we learn how to manipulate and micromanage with insulin. But the biggest piece that you do have to remember is that the timeline of insulin isn't rapid. Rapid is I think one of the sets a horrible name for our insulin today, it certainly works a lot faster than ages ago, thankfully, but it is not a stop it now, it has a now effect on what could happen. Right? You have to remove it with enough time to build up in circulation more or in circulation less to impact the time in the future that you want more or less. So if you are low right now. Do not suspend your insulin.

Scott Benner 9:23
It's not gonna help you need sugar. It's not gonna work fast enough to stop a like a falling blood sugar. Right? My and I appreciate you pointing that out. Because my my thought there was if you're 70 and your hours beyond your meal, insulin, and you know you're not getting any lower, but you really wish you were at five and you don't want to take in carbs. Taking your basil away for 30 minutes. Could be enough. Yeah, but it's not going to also happen in that moment. Like you can't shut the basil off at noon and expect the 70 to turn into 85 you might see a slow drift up over the next hour. Right That's my guess. So right over an hour, and you also those of you who hear this and are like, I'm going to try this one day. Also remember, you can't be shutting your basil off forever. Like if you have to shut your basil off for three hours, you have bigger problems, then a small little nudge might help. And and you want to fix that problem. You also don't want to be without insulin for that long, just No, not a good plan.

Jennifer Smith, CDE 10:24
We usually say no, no suspends, or no disconnections from insulin for or Basal insulin right. Even if you're on injections, and you haven't taken Bolus is all day but you did take your Basal you're not without insulin. So that's a different scenario, right? But completely disconnected from all insulin. We don't want it longer than two hours,

Scott Benner 10:44
right, basically. And that would be in a situation where you're talking about, you know, you have too much to begin with. So you're trying to kind of horse trade, which I'll talk about in a half a second. As soon as I answer Arden's tax play, this hasn't happened on the podcast in a while, because the COVID, where I talked about Hardin, about her food. So Arden is in a situation now where she is in a Chinese restaurant. And she says she is having sesame chicken and white rice. But Arden is also on a steroid pack right now. So we stuff we have her insulin jacked up to work on this. The problem is, is that we're using the algorithms the algorithm is set at a 200% increase right now all the powers jacked up to 200% of its settings. So if she puts in the right carbs for this, it's going to double her meal insulin and probably I'm guessing killer in about a half an hour. So we're gonna,

Jennifer Smith, CDE 11:42
we're gonna, probably not she'd she'd do something, she would do something about

Scott Benner 11:45
it, but it would try to get her. So I'm gonna tell. So what I'm basically doing is I'm telling her to take, I'm telling her to tell it half the carbs of what I think it is. Because it's going to double it. So I think that will make a Bolus that is so

Jennifer Smith, CDE 12:00
you really only need with the steroids. You only really need more basil. It doesn't sound like Bolus does need to be what's increased. It's more just a Basal level, she definitely needs a heck of a lot more.

Scott Benner 12:10
Absolutely crazy. She's on the steroid pack. Her Basal is basically at four units an hour for the last couple of days up from 1.1. But no change in her meal ratio was necessary at all. Wow. So I mean, I don't know. Like, I'm just going with what works at this point, you know, right. So hold on one second. So I've told her that get her back to this. Okay. All right. Now I got to try to find I'm getting too old to skip around in thoughts, Jenny, hold on a second. What the hell were we saying before before she texted

Jennifer Smith, CDE 12:43
talking about insulin, and it's action time.

Scott Benner 12:48
Yeah, don't turn it off. Because we were talking

Jennifer Smith, CDE 12:51
about the timeframe to not turn it off for which was about like, no more than two hours is typically what we

Scott Benner 12:57
write. And I was gonna bring up that if you're using an omni pod specifically, it's always Temp Basal decrease, because you can set an end time to those and it kind of turns back on turns back on. Whereas if you suspend the insulin and you do not remember to turn it back on, your insulin is not coming back on. But my bigger point here was going to be that if you think about, if you think about this, the way we're talking about it, you can flip it around and think about the other way. So I'm just going to kind of go through it again. If you shut your insulin off your Basal insulin off on your pump at noon, and you leave it off for an hour, sometime about an hour or a second, she's saying 19 year, let's just dial that back a little bit.

Jennifer Smith, CDE 13:44
I'm always, I'm always interested in I have a lot a lot. I have a lot of teens that I work with as well. And I am always amazed at the amount of insulin that they take for meal pie. Like I oh my gosh, that's like 80 to 90% of my total daily insulin. Right there in a meal. Oh my goodness,

Scott Benner 14:09
she's about to have white rice and sesame chicken in a in a Chinese restaurant. So I told her to make it 16 I gotta be honest with you. I don't know what's too much. Maybe I don't know what's about to happen. But we'll see. And she's got my car. So not only am I worried about her personal safety, but I'm worried about my card. So so we're trying to be

Jennifer Smith, CDE 14:33
very clear. Text me when you leave the restaurant. Yeah. Oh, gosh.

Scott Benner 14:36
Okay, so anyway, so turn it off at noon. It creates, you know, it takes a while for all those timelines of those little pulses to finish up. And now at some point in the future, probably around an hour, you're gonna start seeing a drift up. That's a that's a ninja level move. But what you're really doing is you're manipulating the insulin to be where you Wanted end to end and, and sometimes to not be where you don't want it. So if you so you probably people have probably heard me talk about even using Temp Basal increases during carby your meals and and that's a good way to like up your basil so that an hour from now you have more resistance, you could do that to meet a fat rise from French fries, you know, you could do that I see Arden's fat rise from fries, and a burger hits her in about 90 minutes after she starts eating. So there's a world where 30 minutes after she starts eating, I can jack or basil up to try to get ahead of the fat rise. Just as simply you can also kind of just, you could you could flip it around and do it the other way, right? Like you could take it away to create a void to create a black hole. You could also add it to give yourself a I don't know, I don't know enough about space. What's something that sucks you when it gets really powerful? I have no idea. But but you can change the power in the future by making decisions. Now, super important to say that I think everything you do right now with insulin is always for later whether it's a decrease an increase a regular Bolus, no matter what you do, it's for later, right.

Jennifer Smith, CDE 16:21
Absolutely. And that's I talked about that a lot with people in terms of adjustment. They might say, well, everything is lovely after midnight, in terms of like basil alone, right? Everything is lovely, as long as I land at midnight where I want to. But last night, you know I or and or I've been floating around at 170 overnight, but it's really nice and stable. Well, good. It's stable, because your basil isn't wrong in this time period. Right? Where it's wrong is in the hours before this, which is impacting this time. And this basil is holding it where whatever happened before. left off. Yeah, so let's address this time period. Right. But the same thing for exercise. Again, I work with a lot of people around exercise and how to manage and manipulate and it's don't adjust right now as you're going to set foot on the football field.

Scott Benner 17:15
Right? Yeah, well, and the other ways to think about it, because really, this is just about striking someone in their mind in a way to think about it. You, you can create stability over 24 hours, by having all of these decisions, right? And people are like, Oh, that's too much to do. But it's not really you're talking about having your basil set well, understanding, you know, if there are certain times of day where your basil needs to be stronger or weaker, knowing when that is starting that Basal program prior to when that happens. But I'll try to make sense of it a different way. If you're on a football team. And you're on the offensive line, you have five guys on your offensive line, but I rush six, someone's not getting blocked, right, and you're getting sacked. So the way to think about that is if you have, I don't know 20 carbs of insulin in your meal. But you somehow Bolus for 30, you've sent more rushers than you have blockers, correct, right. The other way to think of it is if you bring in a tight end block, and that guy's only rushing for, there's no way he's probably getting to you because now you're you got six guys blocking four guys, it's all about putting the right amount of resistance on the other side of the attack. And in truth, both sides are attacking, right, the insulin is trying to pull that, that sugar out of your blood. And the carbs or your body function is trying really hard to push your blood sugar up. So this is usually the time excuse me, when I'm on stage and talking about this, I tell people just to take their hands, put them out flat, put your palms together and push together. And you just need to push so that your left hand can overpower your right hand and your right hand can overpower your left hand. And when you do that, you have stability. You take those palms that are probably in the prayer position right now and you turn them sideways. And that's a flatline. So the thing pushing from the top can't overwhelm the thing pushing from the bottom to thing pushing from the bottom can't overwhelm the thing pushing from the top and your insulin. And your insulin need is now in this just fight that neither of them can win. And that's what that's what a flatline on a graph is it's just, it's the need of insulin, those carbs, and the resistance of that insulin, that insulin, both dialed in, in a way where neither of them can win the fight. And if you have too much insulin, you're going to get low. And if you have too many carbs, you're gonna get high and honestly I don't think there's too many carbs I think of it is not nothing solid. Right? And

Jennifer Smith, CDE 19:51
that's a good point to make because quite honestly, we were too carb centric. And if you really understand food in general Yes, we're taking insulin to work with carbohydrate. Otherwise it wouldn't be called an insulin to carb ratio, right? But anytime there is more food there, and more food usually means more of those other macronutrients to things like proteins and fats. And so learning, learning by watching your trends around things can teach you how to create enough for later, when those other things may be impacting. And you want to keep control.

Scott Benner 20:32
Yeah, you have to meet the need, like I've, I think, throughout the years of making the podcast, I'm most happy with that statement meet the need. Because the need may be lower, at times, it may be higher at times. But if you don't meet it with the right amount of insulin, you're gonna lose one way or the other higher? Well, it's just but somehow in my mind tying together, the idea of the timing of the insulin, and how to how you can make it not exist in the future, gives you the power to make it exist, excuse me, gives you the power to make it exist even more in the future, if you want it to correct. But what ends up happening to most people, is they don't get themselves into this mindset, that everything I'm doing now with insulin is actually happening later. And then they're always I don't know, it's like, you're, it's like you're chasing the flash through time. And you're always ending here always ending up where he was 15 minutes ago trying to fix the problem. Right? Right, you need to be ahead of it. And, and I think that, to be honest, that's gonna transition really well into the next defining episode. So I want to make sure that you don't have anything else you'd like to add to this. I know, this is not like a standard diabetes term, or idea. It's just an idea that makes my mind right about using insulin?

Jennifer Smith, CDE 21:52
Well, I think it's a good point to bring up especially considering the way that people have started to learn more about manipulating their use of insulin. And in terms of what we now have access to technology wise, many of you know the algorithm driven systems utilize this, this watch, right, this predictive nature. And so that also works with how insulin is going to be put into the picture now based on what it's predicting to happen. Coming into the next hour, two hours into the future. Yeah. So it's, it's definitely something to, to know. And understand.

Scott Benner 22:38
See, I love you, because I didn't know what you were about to say. And then what I had planned to say was, I've learned so much about this watching, Arden's algorithm work. Yes. Right. And so yes, you and I are just people and the people listening are just people, our computing powers, not quite as high as a, as an algorithm and algorithm, right. So I'm not, I'm not asking you in your mind to track you know, 20 different timelines of point oh, five boluses, just to understand that, that's how it happens that they kind of feather and layer on top of each other. And then in a regular situation, without algorithm, you could use that information to make some good decisions. But where I really learned to believe in it, is watching the algorithm watching it, you know, I tell the algorithm, hey, her blood sugar requires 1.1 unit events on our for for basil. And it goes, Okay, that's my starting point. But there are times when it decides what you know, it looks and it says, Well, what I think is going to happen in the future, an hour from now indicates to me that if we change her Basil 2.7, right now, we'll be able to keep stability off in the future. And you watch that algorithm, give insulin, take it away in the form of a basil over and over and over again. And even really good settings. Like even if you have rock solid settings, and your day hasn't been full of too many variables, you know, exercise or tough foods, the balls for whatever, you still see a rise and fall of basil throughout the day, because this thing's making these automated changes. And in some algorithms, also bolusing it'll make its decisions. And then it looks up and goes, Oh, this didn't work. You know, like we need we need more and it'll Bolus or Ooh, Jesus didn't work, you're going to get low, and it'll rip away your basil for long periods of time to try to stop below in the future. And it's not always successful. But it's successful so frequently. It just really made me believe that I know it's the best we can do when we're injecting to inject once your Basal insulin during the day and you get what you get you manage around it or even with a pump or you set your your Basal rate at something certain or try to make some adjustments to get ahead of problems that you see happen every day at a certain time. But it's just not it's not enough. Right? Yeah. No, it's a great start. It's an amazing tool, but it is not everything that you're going to require. And so the rest of that has to be you. And, you know, seeing these trends and being able to make adjustments to it to hopefully stay ahead of problems, so that you're not always chasing a problem. Like, if you keep showing up 15 minutes after the bank robber leaves, you're never gonna catch them, you know, you got to you got to be inside waiting for him. And anyway, in my mind, understanding how to create a black hole in the future with insulin is, is the first big step and understanding how to manipulate it in a number of different ways. So guys, this is where the episode ended. But then Jenny, and I kept talking about it, it was gonna be a private conversation, but I thought you might want to hear it. So I'm going to include it right after this word from us, but

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Wow, that's so heavy. And then Arden texted twice in between it was like it really is like a time travel movie. It's it's like, you know, you're trying to understand you're like Wait was that in the future? The past you get kind of like twisted up. It's not easy, but the people who end up understanding it really understand it.

Jennifer Smith, CDE 28:34
Right. You know, and that's the that's the that's the Kenny facts maybe not necessarily exactly that level. But that's the person who is really looking and understanding especially the algorithm driven pumps. I don't know how many people I look at their data initially on talking to them. And they're like, I don't know, I thought it was gonna be all so much better. But I still have this big standard deviation. It's all roller coaster. And I was like, Yeah, because your pump is taking away this much insulin. And then it's like jamming you full of extra insulin because it took it away. And now you're sky high riding right? And then it's got to take it away again, because now you're drifting. I'm like, we got to stop, stop the deficit.

Scott Benner 29:16
Everybody. Listen, we're still recording, I think maybe this gets to stay in. You still have to Pre-Bolus it's, you know, and I know that already. But it's interesting that people are seeing it right away and thinking, oh, gosh, the thing, the machine will just do it. Like, in your point earlier, the insulin doesn't work rapidly enough for you not to Pre-Bolus your meals, you're always going to get behind and then the thing is going to come along and try its hardest to stop it. Eventually it's going to stop because the food's gonna digest and then you're gonna get low afterwards. And you know, and then it's not much different. It's everything is I don't know it's real. vibey you just have to, you gotta find it. You know, it's like dancing. It's like Dancing with a woman. Like you just got to close your eyes and just, you know, you gotta go with it. Yeah, you sit there and try to figure it out all the time, because you just look like that weird guy in the middle of the floor trying to do the right thing. Her hips, move your hips move. Yeah, that's it, you know. So together, yeah.

Jennifer Smith, CDE 30:17
And, you know, when you said, you know, watching an algorithm work, I think that's a really good way, if you have the chance to kind of pay attention and watch, it's a really good way to see a lot of people are also, you know, I don't love my active insulin time that my algorithm is set for, I think it's way too long. We had it set for like, two or two and a half hours in our conventional pump. Well, your explanation, or you know what, we talked about all those little pulses. In algorithm driven systems, those little pulses are now seen by the algorithm as new starting places. Yeah, it's kind of a long term finish line, right? Yeah. So it needs the length, the time period to be able to predict into. So

Scott Benner 31:03
I think that's why the first day of on the pod five, they say that very first pot the first time you put it on, it's collecting data at that point. Now, it doesn't happen at the beginning of every new pod, like every time you switch it. It's the very first time you put that algorithm on it needs that first pod to figure things out. Yeah, it's all fascinating. Okay. All right, hold on. I'm all worried No, I'm warm.

Jennifer Smith, CDE 31:30
I'm glad you're warm.

Scott Benner 31:31
Cool, you're in. You're up there in Wisconsin. You're lucky you're alive. You're gonna be living inside of Han Solo is TomTom to stay alive at some point up there.

First, a huge thanks to Jenny Smith. As always, for being on the show and sharing her knowledge with us. Jenny works at Integrated diabetes comm if you want to hire her, you can also want to thank us med the newest sponsor of the Juicebox Podcast and remind you to go to us med.com Ford slash juicebox. To get your free benefits check find out if US med is right for you. Or you can call them at 888721151 for better service, better care. Get your diabetes supplies from us med

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