#440 Defining Diabetes: Stacking Insulin

Scott and Jenny Smith define diabetes terms

In this Defining Diabetes episode, Scott and Jenny explain Stacking Insulin.

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

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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:00
Hello friends and welcome to Episode 440 of the Juicebox Podcast. Today's episode is the defining diabetes with a Jenny Smith.

Episode of defining diabetes is the 30th installment of the series. It goes all the way back to Episode 236 defining diabetes Bolus, and it leads right up to today, Episode 440. Defining diabetes stacking insulin. The defining diabetes series, which exists here inside of the Juicebox Podcast is me and my friend Jenny Smith. Jenny's had Type One Diabetes for over 30 years. She's a certified diabetes educator and an all around delightful person. Anyway, Jenny and I define the terms that you use in a life with diabetes. And we don't do it in some boring way. Like we're not reading to you out of it. That's not like oh, basil. Insulin is defined as we don't do it like that. You have a nice, interesting, reasonably lengthy conversation that will leave you with a full and firm grasp of the definition of the day. Please remember, while you're listening that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please always consult a physician before making any changes to your healthcare plan, or becoming bold with insulin.

At the end of this episode, I'll leave you contact information for Jenny in case you want to reach out to her where she works at integrated diabetes comm if you're a US resident who has type one diabetes, or is the caregiver to someone with type one, please consider checking out the T one D exchange. Your participation in the T one D exchange will take just a few moments, but the impact of your kindness will last forever. T one D exchanges looking for you type one adults and caregivers who are us residents to participate in a quick survey that can be completed in just a few minutes from your phone or computer. And after you've finished. And trust me, these are simple questions. I did the whole thing in about seven minutes, maybe you'll be contacted annually to update your information. And they may ask you further questions. This is 100% anonymous, completely HIPAA compliant, and it does not require you to ever see a doctor or go to a remote site. And you can opt out whenever you want. The T Wendy exchange began is a nonprofit organization focused on accelerating therapies and improving care for type one individuals. That mission emerged from a heartfelt desire to support a community in need. And the belief that the best way to do that was through a firm foundation of research and cross clinical collaborations from that foundation, the T one D exchange has become a robust Type One Diabetes data platform. And it uses that platform to drive meaningful research and innovation and treatment prevention and hopefully one day a cure. So check them out. T one d exchange.org. forward slash juicebox. So the idea of stalking insulin, I want to describe what it what it I want to describe what it is. And I want to talk about why doctors are so fervent about bringing up don't stack your insulin. And then I want to talk about using insulin in more targeted ways that I think mimics stalking to people who don't understand. Does that make sense? Okay, yeah. So So what is stalking influence something?

Jennifer Smith, CDE 3:40
Absolutely. 100%. That's the correct term. And I think it's one that crosses all everybody with diabetes, for the most part with using insulin, I think they've heard at least the term stalking. And I have not seen an endo that doesn't know what that term means. So it's an across the board understood, I hope.

Scott Benner 4:03
So and so at some point or another, a doctor is always going to tell you and I think very rightfully so. And I have to say I'm not against it. But they just say it like this, you can't stack your insulin, like you can't, because because if you do, you're gonna get super low later, and it's gonna be bad. And I don't that Listen, I purposefully stacked some insulin up on Arden last week. And I knew she was gonna get low later. And she did. But we just got into one of those weird situations where food was piled on top of a site that was bad, like so we were right at the end of a site. And everybody who uses a pump might know this, but you're like in that last, like 30 units that's in the pump. And you're like, this thing is working great. blood sugars are terrific. I can get through one more meal with this thing. And then it just doesn't work out for some reason. And you're like, Ah, so now you have this incredibly sticky blood sugar. It's higher, there's food and you're going up. You've just changed the site. So now you know there's a lag there and basil and everything and you just start like, you know, if you make a small Bolus, it just sits wherever it is 250 is still 250. And I don't want to do the like, little Bolus, little Bolus, little, but I don't stack like that, like, I'm just like, hit it hard. If nothing happens, hit it hard again, and we'll catch if we have to. But if you're not wearing a glucose monitor, or you're not aware that that's gonna happen, something bad on the other side,

Jennifer Smith, CDE 5:26
and I think you described kind of a good point, too, is that if you hit hard with some corrective, right now, you should see a faster turnaround, because you now have a larger amount of insulin to actually hit the issue, right? And then you're not saying, Okay, I'm gonna take four units right now, and then 20 minutes, if it's not moving, I'm gonna take another four units, right, that's not what you're advocating at all. It's, though, hit harder upfront, see if it's making impact, which that bigger amount should, and then you have less weight. Unfortunately, when you do these little micro pulse boluses. And for some, again, another piece to consider is sensitivity, I mean, three units for an adult who needs three units to correct a high blood sugar or a really resistant teen who might need that a little kid, I mean, that might be their whole dose and whole day, right. So you have to consider the person and sensitivity, but these little trickle boluses over like a three hour time period where you're hanging out high, and you keep adding, adding and adding, and some people get very aggressive with the adding in terms of how many, but the doses aren't very big. So you might do

Unknown Speaker 6:44
point 2.1

Unknown Speaker 6:48
out of every

Jennifer Smith, CDE 6:49
15 minutes, and you know, you can see everything in a download, obviously. But you're like, you're not gonna see any change from point one in 15 minutes, right? So but it leads to the stacking component, because the more you do these little incremental doses, now you have each of those little pulses of extra has its own timeline of finish into the future, and peaks. And that's important to understand, right?

Scott Benner 7:17
So if insulin has an initial impact, a peak and a tail, and you go making eight, Bolus is over two hours. There, all of these peaks impacts and tails happening all over you. And then once whatever's holding your blood sugar up there, abates, all these different things. Now, it's like you're being shot from 75 different angles, all of a sudden, you can't get away and blood sugar just starts falling. And then you get into that situation, where how much is going to stop this

Jennifer Smith, CDE 7:48
right? How much carb Do I need to intake now? Because how much is left? I mean, and with a pump, your pump has iob visual for you. But the stacking component makes it harder that i o b and the end effect of when is it really going to finish off? And how much do I need to take in to counter it? Is it a lot more? Is it a little bit? It it kind of is a throw your hands up in the air and just write Yes, which we don't really want to be. And

Scott Benner 8:18
so you don't want to stack and it's a it's just a bad idea if you're blind and you don't know what you're doing. And I want to say too, there's other worlds where you end up stacking and you don't mean it in a dehydrated body where you think, oh, the insolence not working. And so your stack, you know it's point, you know, like you said sensitivity could be point one for one person could be three units for another person, there could be a 250 pound adult doing three unit Bolus is every half an hour trying to change something, right. And if it's dehydrated, I don't understand obviously, the physiology of it. But that insolence in there, it's incapable of moving around, but it's still there. And then all of a sudden you get hydrated, and it all just comes at once that I've seen happen to and that's that can be frightening as well. And then again, you get that same position and people have a difficult time seeing my blood sugar's 250. I've now put in, you know, four boluses over the next over the last 90 minutes or so. And now my blood sugar's dropping like a stone, is it safe to count up those bonuses and figure out how many carbs to put in for that. That's basically what I would do minus maybe a little bit for the number, you know, so if I thought in a normal situation, it was going to take a unit to go from 250 to 90 and I ended up using four units and started falling I'd probably put carbs in for three of the units right leave the last unit to to do it. Yeah,

Jennifer Smith, CDE 9:41
we usually say about 50 to maybe 70 ish percent is for coverage. Okay. Yes. All right. I think another one in terms of stalking comes in for like sites that have been bad and you finally get it you're like okay, I obviously need to change this site will sometimes that site Like you just said it might have that depot of insolence still under the skin that didn't necessarily get absorbed the way you wanted. Thus, you've got a high blood sugar right now. But for some, when you remove that bad site, sometimes that depot of insulin leaks out, you can actually see it like physically coming out of the site when you take it out. And that you're like, Okay, well, I clearly didn't get any of that last Bolus. So I can definitely heavily correct this high blood sugar right now, because I obviously didn't get any, well, if it's not leaking at the site, you likely still have some of that insulin under the skin. And sometimes moving the site or removing that canula can for some get that kind of absorbing under the skin. And so now you've got this big amount that you've been adding for a higher climbing blood sugar, and now you've injected some or you've added a whole big bolus with your new pump site. So now you might have this like whopping drop lead, because you don't really know how much is there circulate. And that

Scott Benner 11:02
story makes me realize that stalking is a lot more scary in the beginning, before you have much time, because I remember that same thing, like, you know, when Arden was super small, we were using syringes, and I'm like eyeballing up, you know, a quarter of a unit, and, and you put it in, and you push it, and you take it out, and then you see a bubble, a big a big drop of insulin comes back out of the injection hole and you're like, ah, and then you're then used to freeze me. I was like, I now know, I have no idea what to do now. And it takes time for you to realize like, okay, and I mean, how often does the insulin leak out? But when it happens? Are you ever freaked out? I'm sure you haven't done this. But sometimes you have it. Sometimes I see people like they'll push the they get they're pushing the plunger before the before they're actually in like something out of the thing. So there's different ways and you're like, Oh, well, how much did I lose? What do I do now? It all can be confusing. And and it gives you this sort of paralysis where you know, I can't move.

Jennifer Smith, CDE 12:03
It's actually kind of one of them is kind of with topic, but sort of off topic is. I never used insulin pens. I've never wanted to

Unknown Speaker 12:11
we've never I

Jennifer Smith, CDE 12:13
don't. And I don't like them. I don't I mean, they work really well for many people. So it's this is not a don't use them. But my experience was always that I always had this background like did I get everything? Because I'd see even holding it in under the skin for 10 second count after you fully injected all blah, blah, blah. When I had tried one when they first came out on the market, I'd pull it out, I'd still have this like drop hanging from the tip of the pen. I'm like, Well, how much insulin Did I just missed? You know, what, what was the purpose of this? Now I might be a half a unit short or a whole unit short. So I think I used it for a couple weeks. And I was like, nope, so sorry, Doctor, I like my files and my insulin syringes back, please. Okay, so

Scott Benner 12:55
now the other side of it. And I've received a number of messages about this over the years, but one that just sticks in my head is from a guy who said when you said it's not stalking, if you need it, it changed my life. And so I say it's not stalking if you need it. But right what I kind of mean by that is, like, first of all, you have to be like things have to be dialed in, like your basil has to be right, your insulin to carb ratio has to be a known quantity, you have to be, you know, good at giving yourself insulin, right. But once you do that, if you Pre-Bolus for a meal, and you it's 40 carbs, and you finish it. And then 25 minutes later you reach across the table and grab a roll out of the basket while you're talking. Well, Bolus for that role, like but but there are plenty of people who would that would then think No, that's stalking insulin.

Jennifer Smith, CDE 13:53
Yeah, that's entirely not stalking. Right?

Scott Benner 13:55
Right. If you need it, it's not stalking. It's bolusing. It's you know, and so, there's, um, there's just something you have to wrap your head around there. And it seems like it's simple, but in the moment, it's not because because you could see, you could Bolus for your meal, right? And 45 minutes later, your blood sugar might be 75. And you're like, Okay, well, I'm gonna have another role, it's hard for people to then go I have to Bolus for this role because my blood sugar 75 maybe it'll be okay. And that's where you have to trust that what you know is going to happen is going to happen, which is that role is going to go in and it's gonna have its own timeline, its own life, and so will the insulin that you put in with it.

Jennifer Smith, CDE 14:35
And I think that's an important point, obviously, is that if the insulin is needed, you also should be knowledgeable enough to understand why it's needed. And along with that comes things like sensitivity, you know, your sensitivity, you know that you're not just blindly taking four units right now that this much typically brings you down by this much and if you do take extra Insulin, you should see this type of a change, if you're not seeing it, you know, taking some more, but again, not these little like pulse pulse pulse pulse.

Scott Benner 15:10
I think in the end I, I would want people to understand that the difference between just wildly throwing insulin at something hoping and purposefully using it in ways that you know, are needed. Those are two different ideas, but they both to an untrained eye or to somebody who's just trying to keep you from making a mistake, which is law. It's it's a laudable thing, but those two things can look the same. And they're not, those two things have nothing to do with each other.

Jennifer Smith, CDE 15:41
Right? So they're both stacking, right? But one is a, I'm stacking insulin, but I know how it should impact me. The other one is, I think, sort of along the same lines as like Rachel is saying, it's like, God, darn it, I

Unknown Speaker 15:58
pop it in and hope for the best.

Scott Benner 16:01
Here. Well, it's um, I think I see people it happens to people too, with new infusion sets with pumps too, because they put their pump on and they don't get, you just don't get the right reaction right away when pumps first on and then the creeping blood sugar and then the Bolus that doesn't work. And now it all feels slippery slope p but I don't I mean, when when we change ardens pump, I just put it in insulin right away. I just Bolus something depending on her situation. Right anywhere from I usually do anywhere from an hour's worth of basil to, you know, a correction with that, like, I just like to get something moving. And

Jennifer Smith, CDE 16:38
Yep, I usually say that same thing for a new site. kind of know what your basil is, at that time of the day. You know, if it's at point six, eight o'clock in the morning, it's but it's 1.2 at you know, eight o'clock at night. Clearly you're gonna Bolus a little bit different. Ours is always Bolus about an hour's worth of basil with the new site change.

Scott Benner 16:58
I mean, I'd say it all the time. I just like to have a little insulin on my side when I know something's coming. And we'll get we'll move on to another topic in a second. But Arden's You know, we've been messing with different birth control packs, trying to find her right dose. The first two months, I'm gonna have to do a whole episode about the first two months was hellish. And then this third month, this pack seems to be right for her. And it's it's going better. But aside from her blood sugars being incredibly difficult to get on top of her appetite was bizarre. It like at times, it was like she was pregnant. Like, you know, she's like, you know, can I get grapes and rice and like, you're like, wait, what, you know, she's mixing these weird things. And there were times where she'd say, I'm hungry. But I don't want to eat. But I know I'm going to eat and in that in that situation. I'm like, well, just Pre-Bolus 15 carbs, then why? And I don't know, like, I gotta get something moving here. I can't just have her because once she says, Oh, I know what I want. I don't want to slow that. Well, I don't want to slow the process down because it took her 20 minutes to figure out what she wanted. Like if I say okay, let's just Pre-Bolus she'll go Forget it. And that and that'll be the end of it, you know, right. So I just like having some insulin on my side.

Jennifer Smith, CDE 18:10
Well, and that's kind of a good strategy. And I also use that a lot for kids and teens, especially for like, their lunches at school, that they often don't know what they're going to choose and they get there and then there has been no Pre-Bolus time. And the worry is that always comes up is well if they Pre-Bolus and then they don't end up eating that amount. I'm like, just Pre-Bolus for the minimum that you know, your kid is going to eat 10 grams, 15 grams to me, if your kid constantly eats 100 grams at lunch. A 15 gram Bolus, I guarantee is just a juice box in case they decide not to eat, they're gonna

Scott Benner 18:43
be okay. That's exactly how I talk about pre bossing little kids just get some on your side and there's an amount that you know, you know, they're gonna eat, there's an amount you know, every kid's gonna eat. Okay. My friend Jennifer Smith has been living with Type One Diabetes for well over 30 years. She has first hand knowledge of the day to day events that affect diabetes and its management. And as you've heard time and again on this show, she really is a wealth of knowledge about type one. Jen, he holds a bachelor's degree in human nutrition and biology from the University of Wisconsin. She's a registered and licensed dietitian, a certified diabetes educator, and a certified trainer on most makes and models of insulin pumps and continuous glucose monitors. She's also the person who here with me on the diabetes pro tip episodes, and in all of the defining diabetes episodes, Jenny is just absolutely terrific. And if you'd like to meet up with her in a professional way, Jenny does coaching. You can find her at integrated diabetes.com Don't forget to add your name to the T one D exchange at T one d exchange.org. forward slash juice box every time you complete their survey. It benefits everyone living with Type One Diabetes and it helps out the show T one d exchange.org forward slash juice box. I'd like to also thank Dexcom Omnipod chivo Kibo pen touched by type one and the Contour Next One blood glucose meter for being long time advertisers on the Juicebox Podcast you can check out everyone that supports the show with their ads at Juicebox Podcast comm or right there in the shownotes of your podcast player. And when you support the sponsors, you're supporting the podcast and helping to keep it free.

If you're interested in hearing more of the defining diabetes episodes and can't find them in your podcast player, you can go to diabetes pro tip.com and scroll to the bottom where you'll find all the defining diabetes episodes. You'll also find all of the diabetes pro tip episodes in that same place, diabetes pro tip.com and for all of your other Juicebox Podcast needs Juicebox Podcast COMM And of course you can find us on Instagram at Juicebox Podcast on Facebook at bold with insulin or in that private Facebook group Juicebox Podcast Type One Diabetes

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#426 Defining Diabetes: Growth Hormone

Scott and Jenny Smith define diabetes terms

In this Defining Diabetes episode, Scott and Jenny explain Growth Hormone.

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

+ Click for EPISODE TRANSCRIPT

---

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 426 of the Juicebox Podcast. Today's show is it the finding diabetes episode with Jenny Smith, and I'm excited to bring it to you. And it's going to begin right after this. g Volk hypo pan has no visible needle, and it's the first premixed auto injector of glucagon for very low blood sugar in adults and kids with diabetes ages two and above. Not only is chivo hypo pen simple to administer, but it's simple to learn more about, all you have to do is go to G Volk glucagon.com, forward slash juicebox g vo shouldn't be used in patients with insulinoma or pheochromocytoma. Visit g Vogue glucagon.com slash risk. Are you looking to help with Type One Diabetes Research? If you are, you can do it right from your home. Right there on your phone or your laptop? Just go to T one d exchange.org. forward slash juicebox. Answer the questions they ask which I've answered for Arden and are very kind of benign. To be perfectly honest, you need to be from the United States and have type one diabetes or be from the United States and care for someone who does. They're just looking for every day input about your type one diabetes life, then they use that data. To make great advancements for people with type one diabetes. I've mentioned them all before. And I can mention them again at the end of the show. But your effort, your tiny little few minute effort could go a long way towards helping everyone living with Type One Diabetes, T one d exchange.org, forward slash juicebox. And if it's been a minute, since you thought about your blood sugar meter, if you really never even considered it in the beginning, when you got it like I wonder if this is a good one or not. That happens to a lot of us, a lot of people just get handed a meter by a doctor not realizing there are many meters available. And that they vary in their accuracy, ease of use and ease to carry. My daughter uses the Contour Next One blood glucose meter and it checks all of those boxes, easy to carry, easy to use, and incredibly accurate. The Contour Next One blood glucose meter also has test strips that are special. In so much as that, you know, I don't know, this has got to have happened to you right you make a blood drop, you touch it with a test trip and it's not enough blood and then you have to throw the test strip away. You don't have to do that with the Contour. Next One, you get to go back in there's a second chance and it doesn't impact the accuracy of the test. It's a money saver, and it's a time saver and honestly it just makes things less aggravating. Contour Next One, that's the meter you should be looking into and you can at Contour Next one.com Ford slash juicebox. It's a very comprehensive website where you can find out about the Contour Next One meter but you can also look into their test trip saving programs and some of you may be eligible for a free meter. There's a lot going on at Contour Next one.com forward slash juicebox I'd ask you to go take a look. Thank you so much for supporting the sponsors are no more ads in this episode. Don't forget to check out the T one D exchange at T one D exchange org forward slash juicebox you definitely want to look into g vo glucagon Jeeva glucagon comm forward slash juicebox. And of course it just spoke about the meter that my daughter has been using forever. There are links in the show notes links at Juicebox Podcast comm when you support the sponsors, you support the show. Before we get started please don't forget 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.

Today's episode is part of the defining diabetes series, which lives here inside of the Juicebox Podcast. Today Jenny and I will be discussing growth hormone. My friend Jenny Smith has had Type One Diabetes since she was a child I think for over 31 years now. Jenny holds a bachelor's degree in human nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian and certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring. systems. In my mind, I believe Jenny can do anything.

So I want to just define growth hormone and then talk a little bit about how people might see it in their, in their blood sugar management.

Jennifer Smith, CDE 5:23
You probably have a lot of visual from eons of life with a very small child through teen years, I can

Scott Benner 5:32
picture the whole horrible journey in my head. It felt like, for a long time that I would get Arden's insulin, right. I'd get one night of sleep, and then it would change again. And then it would take me forever to figure out this was in the beginning, and then it would change again, and it would change and she'd get bigger and taller and Arden 16. Now, it's like, five, seven and a half. Like she's a fairly tall person. So she just kept growing like at one point, I was like, just stop here. Here's fine, you know. And it is interesting to watch girls mature too, because she got she would get tall. Then she ate curvier than she could tall again. But with my son who doesn't have diabetes, he would get tall, his legs would get heavy. And then he'd get taller again. We knew he was gonna get hard, because his calves would get like oddly too big for Yeah, for his body. And then boom, he'd get taller. Again, it was very interesting. But but so growth hormone, also known as human growth hormone, is the peptide hormone that stimulates growth, cell reproduction, cell regeneration in humans and other animals, blah, blah, blah. It's really important, and you want your kids to grow, obviously. But every time they grow, why does it happen overnight? Like why do why do people like you? Don't? I mean, like, it's like,

Jennifer Smith, CDE 7:05
yeah, I mean, that's a good question, I would expect. I mean, there's a lot of, there's a lot of processes that your body sort of goes through overnight. Because it's, it's a time period of day that your body has time to pay attention to itself. I that sounds kind of weird, but like you're sleeping, right? You're not running or you're not like, you know, doing math equations, or

Unknown Speaker 7:31
now's a good time.

Jennifer Smith, CDE 7:33
It's also a time period. It's the big reason that a lot of people see a weirdness in blood sugar, if they're eating late at night, and then they go to bed on that, right. Because really, your digestive system sort of slows down, relaxes, it's not really supposed to be digesting so late at night. So the same thing with growth and repair. It's a time period of the 24 hour day that your body has a chance to recoup, regenerate repair. And growth happens in that time period. I swear sometimes when my boys wake up in the morning, I'm like, you grew over looks bigger. Yeah, look bigger this morning than you did last night.

Scott Benner 8:08
Well, not to get too far off the subject. But did you just explain to me why I can't eat too late at night? Or I'll have heartburn? Because my body really is that that's simple.

Jennifer Smith, CDE 8:18
Yeah, it also I mean, to go along with it, too, is relative to heartburn is you know, during the daytime, when we're upright, we have the benefit of gravity working on our digestive system. It's pulling everything through along with the natural like movement and the muscles and everything that move things through the digestive system, gravity is helping Well, when you lay down, you're now flat, right? You have no advantage of gravity at all. And your digestive system slows down overnight. It's not really meant to be digesting like that. So not only for people like you without diabetes, but definitely people with diabetes. I'm curious, you know, I eat this at nine o'clock or 930 10 o'clock at night. And I don't see any problems with blood sugar until like three o'clock in the morning. And it wasn't high fat. I would have expected to affect like, you know, faster, given the fact that it wasn't high fat, and whatnot, but

Scott Benner 9:12
it's a much slower digestion.

Jennifer Smith, CDE 9:14
It's slower digestion.

Scott Benner 9:16
This is why these conversations are good. We figure things out while we're doing this. But so the growth hormone your kids are growing really not

Jennifer Smith, CDE 9:23
relative to growth hormone.

Scott Benner 9:24
I don't know. We found it. It seems relative to me. You know, your body needs those hormones to grow. No different than maybe a woman who's getting your period these hormones come in, they impact your blood sugar and can impact them really, right. Like, there are times there have been times in Arden's life where her basil rate has been double overnight than it is now as she's older. And if it is not, it is gonna happen to everybody. So in the end, and it's I mean, you know, the

Jennifer Smith, CDE 9:55
growth hormone is essentially it's, it's just it's a stress hormone. Really Okay, like, like your adrenaline or your epinephrine, like cortisol, all of these hormones growth hormone included? Are there kind of blood sugar? raisers?

Scott Benner 10:13
Yeah. Right. So when you're when you're kids, so when your kids growing, that's what I, you know, some people say these kind of not trite but overly simplified things about diabetes like, Oh, you know, every time you get it, right, I mean, I told the story, every time you get it, right, it's gonna change. But that's not really what's happening. It's that sometimes your kids growing and then then they're not, then they are again, and this seems to happen overnight. And you're going to have periods of blood sugars that are going up. And it will seem like maybe it's happening for no reason. But it's very likely because your kids growing so

Jennifer Smith, CDE 10:50
right. And it typically, as you've, as you probably saw, too, it's that growth happens over like, oftentimes a couple of days. And then it appears to just be done. Yeah, right. And then it might be a cyclic, like, I've got a couple of families who followed it enough that they're like, every couple of weeks, we get the same pattern. And we know that we need this much more insulin, so we dump it in, we ended up having much more beautiful evenings, sometimes we end up kind of kind of coming to a happy medium between the high insulin need of the growth hormone kicking in, and where they were before, they sort of sit between that they never go back down completely to where they were before they grew. But they're not staying as high as they needed during that growth, hormone impact. So

Scott Benner 11:35
these people are watching. So specifically, they're actually seeing the growth hormone impact. And they're seeing that there's a gentle rise and insulin need as the muscles getting bigger to begin with. Which Yeah, I always just break down to like, growth or body weight, or, you know, if they're bigger, they need more, although I talked to somebody yesterday, and they were freaking me out. They're like my daughter's 130 pounds and her Basal rates, point three, five, and I'm going over my head and like none of that makes sense. None of that makes sense. None that makes sense. And I was like, Wait, how long is she had diabetes? She was four months? I'm like, ah, got it. Okay. You're still getting some insulin from your, from your pancreas. I got it. Okay, so it's interesting

Jennifer Smith, CDE 12:11
that that's a funny one too. I've gotten a quite a number of littler kids lately to work with that. like talking to the parents, it's very evident when I when I look at their, with their at their insulin usage, is they have a very, very low basil, comparative to their insulin needs around mealtimes. And anytime you've got that like this kind of goes back to insulin deficit a little bit anytime there's a deficit in basil. But when you take or have no meal, that basil is working beautifully at like point 05. And sometimes they don't even need that. But when they add a meal, and they need this like whopping three unit Bolus, or they're ending up at 300, blood sugar, that's a good indication that you're still in honeymoon. Yeah, because basil and Bolus, I mean, the old saying is kind of a 5050. We know that it's a little bit up down from person to person. But if you're at such a strange difference where your basil is giving you 10 12% of your total daily insulin and the rest is coming from Bolus, you're definitely still in honeymoon, something still happening. Yeah,

Scott Benner 13:21
that makes sense. Also, like, as you get older, I do want to understand this eventually. Here's not the place to talk about but when you get sick, why do sometimes your insulin needs go down when you get sick? even notice that like there's certain illnesses that goes up with with certain illnesses it goes down with I don't know the difference? Just Yeah,

Jennifer Smith, CDE 13:40
I mean, for the most part, a simple answer is oftentimes, if it's an infection, usually your insulin needs I would say 95%, maybe even more your insulin needs will go up, right? And infection is a significant stress on the body, especially in infection with like a fever, or that really has you like down You can't go to school or you can't go to work or whatnot. Opposite is usually the stomach bug illnesses that require the the lower insulin, okay? Mostly because one, you're not taking in as much so metabolically, you need a bit less. Also, you may not necessarily be keeping things down, whichever way they're kind of coming out. That talks to go back to kind of the digestive system. Whenever you're taking things in that you can in a stomach bug, your body's not absorbing as much out of them. And so your insulin needs go down because you're just not processing

Scott Benner 14:39
them. Listen in the same vein, and I haven't said this in a while on the podcast and I know you have to go but I'm okay one day Arden's gonna listen back to this and be like so tell me again how you discussed constipation. But when, before we before we knew Arden had hypothyroidism, she got really constipated. And the more constipated she got, the higher Her blood sugar we get. And then once she went to the bathroom, boom, or blood sugar came back down again. It's always like, wow, is her body just continuing to leach out of even out of waste? That's fascinating, isn't it? All right.

Unknown Speaker 15:14
I feel a little bit gross today. It's

Scott Benner 15:16
completely gross, but it happens. And this pocket is about what happens. So you gotta you gotta know what we, we can't come on here and talk about the same boring stuff. Everybody else wants to talk about No. Fun. It's just a number. Okay, thanks. big help. appreciate all your insight.

Jennifer Smith, CDE 15:40
He did bring up a really I really I want to look further into why growth is more at night. I mean, that's an interesting question that I guess I've never really thought about other than just knowing that growth hormone comes from the pituitary in the brain and a wonder if it has something to do more with when the pituitary gland is supposed to be active, which maybe that is at night. Okay. I don't know. But that's I'd have to look it up. It's a good question.

Scott Benner 16:08
A huge thank you to one of today's sponsors, GE Vogue glucagon. Find out more about chivo Kibo pen at G Vogue glucagon.com Ford slash juicebox. you spell that GVOKEGL Uc, ag o n.com. forward slash juicebox. To learn more about the Contour Next One blood glucose meter, please go to Contour Next one.com forward slash juicebox. And I told you I was going to tell you a little something about the T one D exchange and I will in just a second.

If you'd like to learn more about what Jenny does it integrated diabetes go to integrated diabetes.com. The podcast has a private Facebook group that you can find. You know on Facebook, it's called Juicebox Podcast and then there's a colon and then it's type one diabetes. There's also a public page called bold with insulin. I'm on Instagram to just hit 10,000 followers there that was kind of cool cuz I'm not very good at Instagram. What a salesman I am. Hey, would you like to see an Instagram page? That's probably not good. Go to Instagram. Okay, back to the T one D exchange. The T one D exchange is looking for T one adults or T one caregivers who are us residents to participate in a quick survey that can be completed in just a few minutes from your phone or computer. After you finish the questions. They are very simple. I did them in about seven minutes. You will be contacted annually to update your information. And to be asked further questions. This is 100% anonymous, completely HIPAA compliant and it does not require you to ever see a doctor or go to a remote site. Now every time someone completes the process using the link T one D exchange forward slash Juicebox Podcast benefits. So if you've been looking for a way to help type one research, the podcast or both, nothing could be easier or more beneficial. After you get to T one D exchange using my link, click on join our registry now and after that simply complete the survey. Past participants like you have helped to bring increased coverage for test strips, Medicare coverage for CGM, and changes in the ADA guidelines for pediatric a one c goals and it's exciting to imagine what your participation will lead to. Thanks so much for listening. I'll talk to you soon

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#423 Defining Diabetes: Insulin Deficit

Scott and Jenny Smith define diabetes terms

In this Defining Diabetes episode, Scott and Jenny explain Insulin Deficit.

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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 0:06
Hello, everyone, and welcome to Episode 423 of the Juicebox Podcast. On today's episode of defining diabetes, Jenny Smith and I are going to define insulin deficit. Today's episode is part of the defining diabetes series, which lives here inside of the Juicebox Podcast. It's where Jenny Smith and I take terms from your life with type one diabetes, and explain them in ways that we hope make them useful, and understandable. Myself friend, Jenny Smith has had Type One Diabetes since she was a child, I think for over 31 years now. Jenny holds a bachelor's degree in human nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian and certified diabetes educator and a certified trainer on most makes and models of insulin pumps, and continuous glucose monitoring systems. And she used to be one of Santa's elves. Please remember, as you listen 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 are becoming bold with insulin. Now the music will build to a crescendo and we will begin.

This is going to be probably a pretty simple one. And it might not take a lot of talking. But I do want to I do want to give it its own space. Define insulin deficit? How do you think of it? If I say those words,

Jennifer Smith, CDE 1:42
I think it could be defined in a couple of different settings. And insulin deficit is easy to decide to eat whatever you're going to eat, you just don't take insulin for it. So there's a deficit of insulin nearly right. There could also be an insulin deficit. And this one, I think, is harder to determine how much insulin you need to correct and right, the situation of insulin loss is when you have someone using a pump, and the pump site has failed. But you don't quite know that that's what's happened. You're like doing all these extra things, your bolusing extra you're trying to like fix the high blood sugar. And finally, you realize, Oh, my pump site is all wet, or I smell insulin or Oh, look at that my pump site was like kinked instead of you know, when I took it out, that's a harder deficit to repair. Because you're not quite sure. How long is the deficit been going on? How much of the Bolus two hours ago actually went in? Did any of it go in the my blood sugar is here. So that one's I think, a little harder to take care of. But a deficit I mean, it's you're just you're missing insulin Bri has to do with like figuring out where you didn't get insulin.

Unknown Speaker 2:57
That's the reason we're

Scott Benner 2:58
in the situation scenario when your pump site goes bad. I sort of just looked back on as the Dexcom. So it's easier, but I sort of look back at where I start seeing that drift up and up. And if I think to myself, well, that was two hours ago, and she's 225 right now. I just act like none of that insulin that I thought I gave her exists. And I go pretty hard at it and and just try to start over again. I am such a big fan of like, crush it. Stop it start over again. Because I think it's time saving. Yeah, you know, and I and I don't like the idea of I don't know, I know, this is probably completely backwards from what most people get told. But if you have a 300 blood sugar, and it takes you six hours to bring it down. I don't know. That just seems

Jennifer Smith, CDE 3:45
that's a long time of feeling like crud. Yeah,

Scott Benner 3:47
yeah, that doesn't seem right to me. And I don't make a habit of dropping Arden's blood sugar like a stone. I'm not I'm not saying that. And I don't think that's good, either. I'm just saying that if I see that drift up, and it's been an hour, well, then I think all right, an hour ago, she stopped having enough insulin. But the truth is, though, is that I have the comfort in my head to know that her insulin is being used correctly, or it's been set up correctly, so that at any sort of a drift up. I don't think of as an anomaly, I think of it as something went wrong in the process. But that's because I have the confidence to know that the process is going to go the way it's going to go. It's tougher for people who are who are still getting things right or chasing things around. That's a horror that I have trouble putting into words like what does it feel like when something's happening inside of your body and you don't know what it is? Correct. And how do you make the next step? And I do see how people get to while Just wait.

Unknown Speaker 4:50
Right? You know,

Unknown Speaker 4:50
right. So,

Jennifer Smith, CDE 4:52
I mean, that's a really valid point to bring up is, if you're going to be as you coined the wonderful term, if you're going to be with insulin, know how your body responds to it, you can start to learn that, because you have things for art. And so well set that you can say, she wouldn't be drifting like this, I know that there's something not right here, I can add this much more insulin, I can attack it, I can avoid being 300. And if you do it with the pump and the pump site, she just keeps going up. Well, you're going to change that out, you're going to stop it again before and you might like me, I usually just do an injection. I'm not going to wait around for a pump site to start absorbing. Well, I give an injection and I take care of it. Yes. Who, like you said who wants to sit at 300 for six hours,

Scott Benner 5:37
right? You have some sort of a deficit fix. The issue is you can come in inject a correction I always like do like a Temp Basal increase to to kind of get the site moving. And then you're on your way again, I don't think we've experienced a site change high blood sugar in a very long time, because I don't even bat an eye. Now last night we changed Arden's pod and her blood sugar was like 85. And I Bolus the half a unit just because we changed the sight. And and didn't think anything of it. But but but to dig in farther for insulin deficit, like you can have a deficit at a meal, right? Like you could need four units us three, three units, that'd be a deficit of your meal Bolus. I see people whose basil rates are sometimes really steady. Like their their lines are steady, but they're higher, like oh, look how steady I am. But I'm always 140 That to me is a basil deficit. You don't have enough basil, unless you meant for your blood sugar to be at 148. And then even with corrections, you know, like we talked about earlier with, you know, with your with your ISF for your correction factor, you if you You're too late there, but when you're missing in all of those places, these deficits have different impacts, right, like so your basil depth, your basil deficit keeps your raised higher. If your meal deficit, if you have a meal deficit, then you're going to shoot up after you eat. And if you have a correction deficit, you're going to stay up longer, once you're up there and, and all of those things are really just to say that you have to use the right amount of insulin at the right time. And if your blood sugar is high, you probably don't have enough insulin. But a lot of people have deficits. I don't know if this is the right place to talk about this or not. But in the last month or so, since I talked to you last. I've helped to people with control IQ. And I did it blindly. Meaning that I have never seen the settings on control IQ. I don't know what the menu looks like, I have no idea. But I followed their Dexcom. And I said I'm going to talk to you, in my words. And we'll translate them to what you see there. And I was able to get two people's graphs level lower. Yeah. So it was all I almost just did it for fun, which I think says something weird about me. I was like, I wonder if I could do this. And I started with the one I said to the wrong one. I'm like, I have no idea what I'm doing. I'm like, I'm happy to like be a sounding board for you. But just remember that everything I say is going to be a gas, I have no idea. But in the end, it didn't matter. It was all the same. You know what I mean? Like it just you need more insulin here lessons on here. You don't Pre-Bolus you have to Pre-Bolus it was all the same stuff. Right?

Jennifer Smith, CDE 8:25
I think something too. And you bring in like good point about like, Where did the deficit kind of start and you know, with your initial if you're sitting nice and stable, but at a blood sugar 140 or even 150 or whatever, and you're flat and stable at it. What I always recommend to people is, was it flattened stable at a lower number and then you ate and then you got to the 140 or 150. And it never came down after that. Yeah, because that's the not necessarily relative to the basil. That's the Bolus problem. Right? Right. So sometimes it takes like, you have to take a couple steps back to look at where does it look like the deficit kind of got going? Because somebody might think in the scenario of Oh, it's 140, but it's flattened. I'd rather it be at you know, 102 and flat. I'm going to dump more insulin in here. Well, what if you start at 102 then and that basil hike that you popped in? isn't quite right, it's too much but you didn't realize you needed the insulin before that. So

Scott Benner 9:25
yeah, I will probably this will just end up being a different kind of an episode than I thought but I'm so where I go when I see somebody grant for the first I listen, you show me a 24 hour graph. I can fix your blood sugar in about four hours. Like that's how it is right so but the first thing I look at, if I see a graph that's kind of up and down my first question is always are you feeding insulin or stopping highs? Right? If you're feeding insulin I it makes me leap to your base was too strong. If you're always stopping highs, and everything's else faded away from where I where I want it to be. And I'm thinking about 85. When I'm looking at it, then I think, okay, where we'll start is, we're going to pick one basil rate, yep, I'm going to bring everything down, try to get it flat. And then we'll identify spots on the graph where maybe you need less or more overnight or etc, that kind of a thing for basil. And then once I've got that, then we figure out the Pre-Bolus time, you know, and yeah, and I'm, like, Look, you have to Pre-Bolus it's just not going to work. Otherwise, after you've got the Pre-Bolus time, then we work on understanding like the glycemic loads of different foods, and then you're kind of done. Like, I don't I listen, we're stretching this podcast out.

Unknown Speaker 10:43
It doesn't need to be rocket science,

Scott Benner 10:45
get your basil right. Pre-Bolus your meals, understand the impacts of foods, go live your life with diabetes. Right? Right. Like it kind of is like that. But it's fascinating to have that conversation. And you know, just as well having a conversation with a person and watching them have all their different aha moments. And, and they see all the things that they thought they were seeing that weren't right. And you're right, they can they never seem to be able to step back far enough away to see the whole, the whole picture, you know, right. It's really interesting. Okay, do you do it? Similarly, you do it, you do it like

Jennifer Smith, CDE 11:18
I do? Well, we do, actually. I mean, you're you do it kind of, really in the same scenario that we essentially we look for, we look for the lows, we always want to get rid of lows to begin with. Because if you're constantly feeding extra insulin, you're creating a lot more of the roller up and down, because you're constantly adding, and then you might be correcting, and then it's dumping you off, and then you're feeding that incorrect. It's just this never ending cycle. So we avoid the lowest first, even if it means adjusting things to a little bit higher to begin with, to get rid of the lows, and then we can bring that down. Once it's more stable, you can easily bring that down once you're not adding in all this extra food that you didn't really need.

Scott Benner 12:02
Do you find that it's harder to talk people into believing that their Basal is too low? If they're experiencing lows? Yes, like, like when you say to somebody, Hey, your Basal needs to be higher, they're like, No, I'm low all the time. Like if you're low all the time, because your base was too low, or over bolusing for food and you're crashing for the foods out of your system, and then they're gone, then their minds are like, Oh, you know, like, No, no, we're gonna make the basil higher, so that stable times are lower so that meals aren't as impactful on your system, you'll see and it that's a hard thing to talk people into believing it is it that's that's always interesting.

Jennifer Smith, CDE 12:40
It kind of it kind of goes right along with like, it's not really insulin deficit, but it you know, in a way, it's sort of robbing Peter to pay Paul, insulin in one place for insulin and another one place is wrong. And the other one, you're compensating and feeding with more insulin because the other place doesn't have enough of it. So if you get it smoothed out, yeah, then you got this nice, like, you know, but because

Scott Benner 13:06
we need to librium when you do that, when you have it unbalanced like that. To me, the biggest problem it causes is extra Bolus that's still available after food is digested constantly Yeah. And then you're crashing, and then you're feeding the you feed that insulin, and then you fly back up again, then you're correct and crash and then and it's just, it's fascinating to watch people. It makes me better at it to watch to watch it go wrong for people. Because the more that I can look at it, and just say like, Oh, just do this, this and this. It's it's great practice for me every time like, like my wife has said to me one time, she's like, the podcast reaches so many people at this point. She's like, Why are you like, you're giving a lot of time talking to like, one person at a time. Like, no, I'm learning. Like, they're getting help. That's what they get. I'm like, but I'm getting better at it. Like, right, like, by doing you learn? Yeah. So it's Yeah, it is really interesting.

Jennifer Smith, CDE 14:02
Yeah, I think it's, um, it's the way that and that's why I always bring up people's graphs when I'm talking them through adjustment, and why do I see the things the way that I am seeing them, because going forward, I want you to have that tool. I mean, as much as I love all the people that I work with, I want you to be able to have these tools in your own toolbox and go on your merry way. And

Scott Benner 14:24
Jenny can't sit in the matrix and just with a thing plugged into her telling you all how to take care of your ledger for the rest of your life. So it's funny. What I do notice, too, that some people are just in general. So like, I don't, I can never tell if it's they're scared or they're so sure that the things that they figured out are right. But I end up saying to people a lot of times privately, listen, I appreciate what you're thinking here is like but you're just wrong. And you got to let it go. You know, because you just you're fighting and you're wrong. Like I just try this once and see what happens. Yeah. I think

Jennifer Smith, CDE 15:00
it's many of the people that I see that more so in are those that have some pretty significant like hypo anxiety, they're very, very, very worried about having a low and many for good reason they've had a very significant problematic event happen, or, you know, EMTs coming to their house or,

Scott Benner 15:26
you know, be that's a good reason to be scared treated

Jennifer Smith, CDE 15:27
with it, right. I mean, there are a lot of reasons to be scared. But I think I see that a lot more with that group of people with diabetes. Well, I'm talking

Scott Benner 15:39
about that. And I mean this with love, but the Type A lunatics that are just trying to control like everything. And I'm like, Yeah, like you're trying to control six things you don't understand, which is, you know, who's particularly. And I mean, this again, would love particularly bad at this, nurses. I'm not a nurse, nurses and nurses who have kids with diabetes, are particularly thrown by diabetes. It's really interesting. Like, like, I listened had it happen once, twice, three times, I'd say, okay, maybe I'll make it up. I'm on my 30 100th nurse who all react exactly the same way. Like, I think that they're so accustomed to this, the order that they follow at the hospital, not really realizing that that hospital orders just really in place as somebody doesn't drop dead or get too low. It's not really about managing diabetes day to day. But yeah, they're they're the hardest to break free. But once they break free, boom, then they've got it like because then they can use that order that they that they're accustomed to in the right way. It's interesting. It really is interesting how different people react differently. If you'd like to learn more about what Jenny does it integrated diabetes, go to integrated diabetes.com.

The podcast has a private Facebook group that you can find, you know, on Facebook, it's called Juicebox Podcast, and then there's a colon and then it's type one diabetes. There's also a public page called bold with insulin. I'm on Instagram to just hit 10,000 followers there. It was kind of cool because I'm not very good at Instagram.

What a salesman I am. Hey, would you like to see an Instagram page? That's probably not good. Go to Instagram. Juicebox Podcast is sponsored by the Dexcom g six continuous glucose monitor and you can learn more@dexcom.com forward slash juicebox. We're also sponsored by the Contour Next One blood glucose meter. Check it out at Contour Next one.com forward slash juicebox. Want to get a free no obligation demo of the Omni pod tubeless insulin pumps sent right to your home. You can do that at my Omni pod.com forward slash juice box. Learn more about g vo Kibo pen at G Vogue glucagon.com forward slash juice box support my favorite type one diabetes organization at touched by type one.org and follow them on Instagram, and Facebook. And if you'd like to support type one diabetes research that makes a real difference. Check out T one d exchange.org. forward slash juice box. Let me do a little bit of talking for the podcast itself here at the end. As the year winds to a close there's one more episode left. But if you want those diabetes pro tip episodes, go to diabetes pro tip comm or head back to Episode 210. Your podcast player that's where it starts. Diabetes pro tip newly diagnosed we're starting over Don't miss the after dark series. Any of the episodes that are titled after dark and then something else. They're incredibly interesting and topics that people don't talk about very often. More recently, we have type ones who've experienced heroin addiction, believe me it depression, bipolar disorder, divorce. They talk about having sex with diabetes, smoking weed drinking, look for those episodes in your podcast player there after dark. And then you know other words. If you're interested in algorithm pumping, I have a whole series on it. Episode 227 is where it starts with diabetes concierge from there 250 to 304. And then the great three parter Fox in the loop house episodes 312 313 and 420 with Kenny Fox. We even have an episode about the mini med 670 G. Jenny and I talked about that Episode 326 and the blog looks pretty great too. You should check it out at Juicebox Podcast comm or anything else? Oh, no, I don't want to tell you about that yet. How about this juicebox Doc's dot com Have a great endocrinologist or diabetes practitioner or need one juicebox docs.com. Alright, that's it. One more episode left in 2020. It's kind of a relaxed conversation between Jenny and I, I started the year with Jenny. I wanted to end it with her

without them, without the talking overtop of the add music, you can see how incredibly repetitive it is. Isn't that weird?

But if you just talk over top of it, it's kind of handy. Learn more at my omnipod.com forward slash juicebox. See, then it really comes in, then it really does the job. promise that now you want to just chill with me. We'll do the end here. Change this here a little bit. I can tell something's gonna happen. I'll be back soon with another episode. Thanks so much for listening, for sharing the show for leaving great reviews. Wherever you listen. And if you're listening online, find yourself a nice podcast app and subscribe to Juicebox Podcast is available everywhere you get your audio

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