#219 Diabetes Pro Tip: Insulin Pumping

Scott and Jenny Smith, CDE share insights on type 1 diabetes care.….

I am thrilled to welcome Jenny Smith, CDE back to the show. Jenny will be joining us for an extended series of conversations that focus solely on the management ideas that we discuss on the podcast.

Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com.

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, everyone, and welcome to the sixth installment of my diabetes pro tip series with CDE Jenny Smith. Today, Jenny and I will be talking about insulin pumping. But if you're not using a pump still listen, lots of good information. As a matter of fact, listen in order, you want to start at the beginning and work your way through this series is designed to tell a story. This series is a narrative about how I manage my daughter's type one diabetes. The ideas you're hearing in these episodes, coupled with my favorite technology, is how we've kept my daughter's a one c between five two and six two with absolutely no diet restrictions for over five years. And while we're talking about that, this episode of The Juicebox Podcast is sponsored by Omni pod Dexcom dancing for diabetes, and real good foods. To get a free no obligation pod experience kit from Omni pod go to my omnipod.com forward slash juice box. Want to check out the Dexcom g six dexcom.com forward slash juice box. Go to real good foods that calm and when you place your order, use the offer code juice box and save 20% on your entire order. And never forget to go to dancing for diabetes.com just to see good people doing good things for people living with type one that's dancing the number four diabetes.com

Welcome back to the diabetes pro tip series with CDE Jenny Smith, I'm glad you're here. In this episode, Jenny and I talk all about insulin pumping and the ideas that surround the practice. Please don't forget that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And always consult a physician before becoming bold with insulin or making any changes to your medical plan. And double Don't forget that if you're interested in hiring Jenny privately, you can do that at integrated diabetes comm You can find links for Jenny at Juicebox podcast.com, or in the show notes of your podcast app.

We are back talking about insulin pumps today. Awesome. And the idea of pumping in general not any specific pump, although we might go over the ones that are available at the moment. So we discussed in the MDI episode that it's tough to get an insulin pump right away, you'd have to be have great insurance, you'd have to be able to get over the What do we want to call them roadblocks that some endo offices put up to you getting? Right getting an insulin pump. But but congratulations, if you've gotten that far, and you're thinking about getting an insulin pump. Why do you think? Well, do you think Let me ask you, do you think pumping has advantages over MDI? And if so, what are they?

Jennifer Smith, CDE 2:55
Yeah, I mean, a broad a broad statement. Yes, there are advantages. I think there are pros and cons to everything. But there are a lot of pros. I think one of the biggest ones is precision in dosing. I mean, you know, from the standpoint of injections, we can dose accurately, I quote accurately, to the half a unit with an injection, right? I mean, I've even got a couple of friends who still do MDI don't like pumping and, and they've sort of figured out how to get that quarter unit in an injection. But is that accurate? No, it's not like the pumps accuracy, you know, pumps can pumpkin, pumpkin get down to the point 05 or the point 025 of a unit. That's, that's precise. That's minuscule, you know, and for the broad spectrum of people that need insulin in different doses, the very, very little to the adult who is very, very sensitive for whatever reason, that can be important. So,

Scott Benner 4:07
okay, and I agree, I think that when, especially when they're younger, I've used mo I've had moments with Arden where it's a point one or a point to Bolus that can really move somebody and the, you know, the obviously, the lower your body weight, the more that kind of precision makes incredible differences. I guess the con to that can be if you are so small, it's possible that it might be difficult to set your basal rates up because if your basal needs are that little in the beginning, you can do that. I've seen people do all kinds of crazy stuff like set a basal rate on for one hour off for the neck, back and forth. And that's that there's a way to get through that. I think if you have a smaller child and you want to pump, there's a way to accomplish it. There is

Jennifer Smith, CDE 4:55
absolutely so precision definitely and then you know i The icebergs that kind of pop up in your day. And you know, you I know your strategy and a lot of people strategy is kind of the navigation of blood sugar, right? And utilizing the smart tools on an insulin pump smart being things like the extended bolus and the temporary bazel feature. You cannot do that with an injection. You just can't. And that is that's another huge pro to a pump.

Scott Benner 5:29
Yeah, I, I can't say I agree anymore. I'm in full agreement. I didn't understand it all about pumping. When Arden was injecting, right? There were just a lot of words I didn't understand people would talk about bolusing and all that. What's that carb ratio? I have no idea. I know a little bit for me, Jackie. But it was so much more specific talking about pumping. I had its own language. And I've mentioned before that as we were in Arden's pump class at at her children's hospital. And I recognized that insulin was going to be used, like fast acting insulin was going to be used as basal insulin. Yep. And that I could turn it off and turn it back on and increase it and decrease it. I'm telling you angels,

Jennifer Smith, CDE 6:11
like a light bulb light bulbs are going off,

Scott Benner 6:13
like everything happened. I was like, okay, immediately. Yes, please. I genuinely think that before you have a pump, and for a lot of people after you have it, people just believe the pump is a way to avoid injecting. And I want to I want to, as we do the overview about in some pumping today, I want to show them that it's just so much more than that. So it is

Jennifer Smith, CDE 6:36
absolutely and I think another piece to definitely clear up. Even for anybody who might be listening to these that doesn't necessarily interact or is a caregiver for somebody that with diabetes, but they've come across it because they just want information. A pump is not the magic, do it all. You don't plug it in, and it takes care of everything that is is not the case. And for those who might be dying, newly diagnosed in our hearing Oh pump is like the magic thing. It does all these ones. It does what you tell it to do. And it does it based on the parameters you set within the pump. There's it's it's personal input is what makes the pump as beneficial as it can be. So you can then see that if you don't know what you're doing.

It could be not that's the best thing.

Scott Benner 7:31
Sometimes you hear people say I've had this pump for a month. And I'm thinking of going back because I think they had doing what I need. Yeah. And I think they had that expectation like look, I bought the pump I put it on Why did my UNC not go down? How come my spikes aren't going away? Why is my body and in some cases, people's blood sugars get worse in the in the in the beginning because they don't get their bazel setup correctly, right. Or, or I think for some people, your insulin needs change, sometimes greater or lesser, when you go from injecting the pumping

Jennifer Smith, CDE 8:03
because of the precision, especially of that bazel, sometimes with the imprecision of an injected basal insulin, and the fact that it isn't based on your physiologic need and the change through the course of the day, that basal insulin could be off via injection at a time when you need less insulin. And so things look like they're happening around a bolus when it really isn't the bolus is problem. It's the bazel. So getting that bazel set is huge. It's like the foundation of a house and the opposite as well to not instead of the boluses problem. You can't You can't give the Bolus credit. Sometimes Sometimes you have a lower stable blood sugar that you think you made this great Bolus off Oh,

Scott Benner 8:48
but but your 11 year or your lantis, you have too much of it, or it's just it's working stronger at that point or something like that. So when you switch to a pump, and you go to these more precise basal rates, using a fast acting insulin in the background, then if you don't have that correct at that number, you don't you no longer have that sort of like I don't know what to call it like when you inject basal insulin, it's just sort of a Is it a catch all? Is it a is it it's a blanket of insulin that you made?

Jennifer Smith, CDE 9:18
Yeah, that's a good way to think about it. It's kind of a blanket of insulin, but it's not a blanket that's always warm and cozy at the right places through the course of the day. I mean, I can my example is before I started pumping, I was using Lantus was my basal insulin, and I took it in the evening. If I did not have a snack, when I went to bed after taking it, I could have bet a million dollars that I didn't have that I would have a low blood sugar between two and 3am. And that's because

Scott Benner 9:49
your new basal insulin starts coming online and it works.

Jennifer Smith, CDE 9:52
And it worked the way that it did. I needed less insulin at that time, but lantis didn't know that Atlantis was like, Hey, you put me in here. I'm gonna get a tour of this, I'm going to do my thing that I was supposed to be doing right. So I needed at that dose for the rest of the day. But I didn't need that dose for that action time of the morning.

Scott Benner 10:11
So that's our first kind of lesson here with pumping, when you get an insulin pump, your basal rates need to be dialed in. And there's two things about that. The first thing is, and this, of course, is not true for everybody. But I do meet a lot of people whose doctors under welcome them with basal insulin, when they put them on a pump I because they don't want to cause a low, they don't necessarily tell you that going out of the office or you don't expect it. And so you get hot, you get home, you're high all the time. And it doesn't ever occur to people that it's bazel. So I get on a pump, get the bazel. Right, I think the next thing is

Jennifer Smith, CDE 10:48
one one comment about that as adjustment factor. And you mentioned it before insulin use may change going on a pump, we usually find give or take, we usually find that when you start on a pump, your bazel injected insulin dose in the pump will need to be about 10, sometimes 20% less than what you were injecting in your basal dose. So let's say your basal insulin is giving you 20 units a day via Lantus or levemir, to you know, to jail or whatever it might be 10% less than that is two units less. So we would actually dose your bazel in the pump on 18 units across that 24 hours versus 20 units. Because it's it seems to be that the body responds better to that one type of insulin or rapid and coming in at one precise point in the body all the time. Rather than being injected like all over

Scott Benner 11:49
really be either then you can you can get your pump set up with baselines and find yourself high all the time and realize your basis not enough or, or too low or where you have to come in. So that is why doctors start that way. Because I guess more over the likelihood is you'll need less. But for the people who that's not true for it's the situation I described. Right? So what we're really saying is, you're not going to know until you know, but but figure it out, get it in there and figure it out. I also want to know what you think about multiple bazel rates in the beginning, because in my mind, I think you set one up, and then you start adjusting off of that one.

Jennifer Smith, CDE 12:26
Right? Agreed? Absolutely. Even when I started pumping, you know, as an adult once there were finally pumps, like Omni pod. And that wasn't about tubing. I wanted that pod. But when I started doing that, you know, I actually did I started on one solid basal rate. And I was already an educator. So I knew about pumps, I just, you know. But yeah, you have to test you have to evaluate and see what does that one solid diesel? Where do I need it to be less? Where do I need it to be more for how long?

Scott Benner 13:02
Yep. And we're going to talk about the adjustments in our own little piece of this. So okay, so let's move on now to to the idea of bolusing. So I want everyone to understand that the doctor, your doctor is going your pump trainer, whoever you talk to is going to do their best based off of what they know about you to set up an insulin to carb ratio in the pump. But it is incredibly important to know that that is a number that is not completely made up. But it is a guess on some level. And so if you're putting insulin in for a bolus, and you just you say to yourself, man, I counted these carbs 100% correctly. And it's telling me three units. But I used to eat this food on injections, and I had to inject four units or two units or it was different in some way. I just think it's incredibly important to remember that your doctor just did the best they could putting that in there. And this becomes where sort of the next step of how people get confused starting pumping. Because things don't go the way they expect. And they never diagnose the idea that it's the it's the insulin and I mean, this series is obviously it's all about timing and amount, right, you're using the right amount at the right time. Their minds. I think Siri just heard me say something. Sorry. Sorry. It wasn't. It says, Hey, Siri, I have it's obviously it's all about timing. Shut up Siri. Sorry. My point is, is that you're our brains somehow focus on the idea of the pump specifically and not and we forget about the insulin. So I got on a pump and something didn't go the way I wanted. There's something wrong with the pump, that the leap you make. It's the it's it's very likely the insulin, so you can't jump over the obvious answers to get to the other ones. Then Then We run into the problem that people don't want to make insulin adjustments in their pumps in the beginning. So for all of you listening who are about to start pumping or a noodle pumping, and you're seeing something in your heart, you know, isn't right. I would implore you not to sit around for three months waiting for your next endo appointment. Right? Okay. So if you're not, if your blood sugar's high, you probably have not enough insulin, it's possible that you know, you haven't timed it, right? But there's safe ways to make small adjustments to your insulin on your own. Right. And absolutely. And so, would you talk to me about how you would How would you if someone called you and said, Hey, I don't know what to do. And you you looked at their graph and said, I think your basal insulin needs to be turned up or turned down? What percentage do you tell them to to move at? Like a kid in a candy shop, I just spent an hour using the Omni pod dash PDM. You may be listening to this now thinking it's not out yet, but but it will be very soon. And if it's already out, well, then, you know, welcome to time travel. While I was in that room, I got to use the new dash touchscreen, all color Bluetooth really fantastic. I also got to see the display and view apps that on the pod will be unveiling, Sophia, the caregiver of someone using it on the pod when they bolus you'll be able to see it on your app. You'll also be able to receive alerts on your app as a caregiver. And I know you're excited about that, there has never been a better time to use the tubeless insulin pump that Arden has been using for 11 years. The Omni pod. The best part, of course, is that Omni pod will offer you a free pod experience kit, they're going to send you a free demo of the pod. There's no obligation, it doesn't cost you anything, it comes right to your house, and you get to wear the pod to see if you like it. You don't have to just trust the guy on the podcast, you can see for yourself. So if you're switching to a pump or switching from a pump, in my opinion, there is no better choice than the Omni pod. You want to find out if I'm telling the truth. Go to my Omni pod.com Ford slash juice box and get yourself a pod experience get there's absolutely no obligation. It's 100% free. And if you can't remember that link, it's also available at Juicebox podcast.com. Or right there in the show notes of your podcast player. My Omni pod comm forward slash juicebox insulin pumping is absolutely terrific. And insulin pumping tubeless Lee with Omni pod is whatever terrific times a million is what percentage do you tell them to to move at

Jennifer Smith, CDE 17:44
it depends on what the overall picture looks like, you know, if there are small, if there are small, less aggressive looking changes to their blood sugars, but it's in a bazel only time period. And you can tell that obviously something is wrong, we recommend making adjustments if there's more than a 25 to 30 point shift up or down from a set blood sugar. So let's say if you're testing the overnight, you go to bed at this rock solid, you know one or two blood sugar, but by you know and that's 9pm. But by 1am, your blood sugar's at 201. That shouldn't happen on basal insulin, that's there's something incorrect there. So you know, with a shift like that, we would bump bazel probably by like a point one in that time period to offset the incoming flux of incoming need for extra insulin. Usually, if it's a smaller incremental change to blood sugar, you know, you're going from a blood sugar of 102 to 152, you probably don't need that much of a change. And so maybe more of like the point 05 in a rate, smaller increments to the point zero to five, which most of the pumps on the market can do. Not all of them, but some of them. So that may be something that you play with, especially if you feel like you're pretty sensitive to small changes in dosing, then you may want to start smaller and make an adjustment up or down. Right.

Scott Benner 19:14
And so again, it's a good place to point out that the numbers not important because we can't tell from one person to another. And I'll give you an amazing anecdote about that I was with a group of people this past weekend, there was a college age kid there who in my best guess was 610 and must have weighed 230 pounds. And his bazel rate was lower than my daughter's who is five, six and weighs 125 pounds. My daughter is also growing and you know gets a period and things like that. So you can't, you can't reach out into the public into back to your doctor and say Just tell me how much to turn it off. You know, like you have to pick an increment. That's not that's not crazy. It's not dangerous. Obviously. You're not Going to take 8.5 bazel and make it a one, you know, try point six. You know, like if you're if you're a little high trade point six, and then if you do it for a few hours and nothing's going on. I mean, try point seven like and you know, you might get to a point where you Oh, now I'm a little too low. And then again, I'll dial it back point six, five and, and make that decision on your own like, think it

Jennifer Smith, CDE 20:25
and certainly communicate with your provider. If you want some assistance thing, hey, you know, even calling your endo office, most often you get connected with a nurse, the nurse is then going to relay your message to the endo, you might get a call back, hopefully 24 hours, maybe 48, or, you know, whatever it might be, but at least you're acknowledging, hey, I'm seeing this issue. I'm making my adjustments because I'm the one living with diabetes 24 seven, I'm just telling you, so that if you've got any additional feedback,

Scott Benner 20:53
great to hear, yeah. But you can't, you definitely can't do what happens to some people, you just freeze because I want you to really consider what we've been talking about what you've been listening to going back to your doctor four times a year, and saying, hey, look at 90 days worth of my blood sugar's and adjust this and make it correct. It's just they're not guessing. But they're just doing their best and their best is limited because they're not with you. And so I know you're that it's probably happened to you before you sit and you stare at these blood sugars. And you think, well, this isn't what I was told. But just remember, you're getting this machine, and it needs to be dialed in. You just have to get it right, you got to get it running, right so that you can start enjoying the benefits which are significant. Once you get it going. And I will say that I was one of those people who got a pump for my daughter when she was four years old. Oh my god, over 10 years ago, wow. Yeah. And I slapped it on her. And then I stepped back and I looked at her blood sugar. And I looked at her. And I'm like, okay, just start going down. You know? Everybody get back this, this this, my gosh, back then this 8.9 a one see it's gonna be magically lower. Well, it did go down a little bit. but not a lot. I only went down a little bit because I guess I was able to bumper insulin a little more. That's where we started, right? Well, I guess a little more because back then if you missed on a bolus, doing it again met injecting again. And no one never wanted to do that. So you just waited and hoped and cross your fingers, right. But now I could give a little more in a little more. But in honesty, just adding an insulin pump without understanding it did not bring Arden's a one seat down that,

Jennifer Smith, CDE 22:36
that. I think it's kind of like, I mean, the adjustment is kind of like getting wheels aligned on a car, right? I mean, if you have, if you want to ride this straight line, you have to do these incremental adjustments so that you're not consistently like veering off there.

Scott Benner 22:54
Gotta rotate your tires, again, to get your your ball bearings all straightened down everything that was just the extent of my knowledge of cars, as we've heard, but you want you know, their engine, I joke a little bit I understand. So people who really understand cars, there's toe and camber, there's these these tiny adjustments that get made to your front wheels that keep your car moving straight. And it's the same situation. Those again, just like bumping and nudging blood sugars, these are tiny adjustments to get you where you want to be. And the difference between being 190 all day long. And 90 all day long, could just be point one, a half a unit of a change, depending on your size and your weight, your needs. The tiniest amount. And just imagine that, you know, we talked about all the time if you if you don't have enough basal insulin going when you Bolus, a lot of your Bolus is just replacing the Basal you don't

Jennifer Smith, CDE 23:48
have. And so that when the Bolus isn't there,

Scott Benner 23:51
you're wondering, Well, why I didn't even eat at this point today. And what's happening here, right? Why is this happening now? And so so you need to get these things straightened out. Now, I guess moving on to the idea of bolusing Yeah, before when you had your shots, you were counting your carbs, doing your thing, stick it in your pan or your needle and pushing it in there and just hoping you know, hoping for the best right? You are now opening yourself up to an entire world of Pre-Bolus saying and and doing it with

Unknown Speaker 24:22
different and what Pre-Bolus

Scott Benner 24:25
boluses all the things you're pumped, you know, well, first of all Pre-Bolus things not a setting. It's just the idea of putting in your insulin and giving it a headstart over the food that you're about to eat right. But an extended bolus. So we're talking right now it's 11am. And 40 minutes ago, Arden texted me and said lunch is soonish. I want you to really hear that. She didn't say she didn't say in 10 minutes. He didn't say 20 minutes from now she said soonish and I know based off of how this year is going at school, we're going to Pre-Bolus here And I thought about what was in her meal. There's not anything incredibly like simple sugary, that's gonna spike her right away. And she was 106 when we did this. So she'd been a little resistant towards the end of her period this week. We did a Temp Basal increase a 40% for an hour and a half. And so that takes Arden's bazel rate from 1.4 to whatever 40% more of that is for an hour and a half. And then I did a 11 and a half unit Bolus. We did 20% of it up front and the balance over an hour. So 20, whatever 20% of 11 and a half in 11 and a half units is goes in when she pushes the button. The balance of that goes in incrementally over the next 60 minutes coming online and getting active along the way. And now it's 40 minutes later and Arden's blood sugar is stable and 90. And she probably started eating 20 minutes ago or so. Mm hmm. I'm expecting the food to begin to impact her right now. Yeah, right. And so we got we got momentum on our side for the insulin, we've got our going down. You know, we've got that tug of war set up we've we've given you know, we were letting the insulin cheat. And we're going well, now, I'll tell you right now, if 20 minutes from now she starts curling back up. I might you know, if there's any temp, if there's any extended bolus left, I might cancel it and put it all in at once a extended bolus is over, I'm going to go through I might have missed a little bit. There's all kinds of different adjustments you can make to change the timing and the amount of the insulin. I want you though to talk about first about extended boluses. And I want you to talk about the way I know I can't, which is technically and smartly. Yeah.

Jennifer Smith, CDE 26:52
I think you give very good description, I think the biggest thing to understand to begin with when with an extended bolus is that all pumps can do them. They all term them or call them something a little bit different. And it really just kind of boils down to how you're telling the pump to give this this dose for a meal. Whether you want it all up front, meaning like you'd give an injection, you get this whole normal amount of insulin deposited under the skin all at one time. That's normal. And extended allows your pump to drip drip, drip drip, almost like your bazel is dripping all day. But in a time period you've defined whether it's 30 minutes, an hour, three hours, you told the pump, I want to deliver 11 units over the course of some now and some in an hour time period. That's what we kind of refer to as a dual wave bolus to dual being you get some normal up front, meaning a bump right now like an injection. And then the rest of the the meal like you said 2080, right 20% now is the normal 80% over an hour. So your pump is now saying Okay, I'm going to drip drip drip drip drip this 80% in and by the end of an hour, that whole extra 80% will have been dripped in. But it's action time then is pushed out because you didn't deliver it all right now that last pulse of insulin at end of our one still has now an active insulin time for whatever you have set in your pump, three hours, four hours, five hours out from that last active pulse. So I think that's the important thing to know about extended boluses some people first start to think of them as Okay, well, I'm going to get some insulin, but then three hours from now it's going to give me the rest of my insulin. That's not how extended work. They always give some and extend some drip drip. Or you might want to say for this meal, I'm eating a big ol plate of broccoli and a chicken breast. There's carb in that broccoli that you do have to count and cover. Is that broccoli gonna hit you like white rice. No way. It certainly isn't. So a meal like that. You may say okay with these really low glycemic carbs. I'm going to extend the full bowl is something we call a square bolus. You take that meal that's suggested as a bolus, and you drip drip drip the whole amount of it out over your designated time period. And there are different reasons for all of those. Yes,

Scott Benner 29:33
and you got to figure them out. And you can I was with a person eating low carb this past weekend. And we sat down at a restaurant. She had a meal that you would expect had almost no carbs in it but a ton of protein. She said she ate she sat and ate it. We got in the car drove away it's now 20 minutes or more past when the food was and she grabbed her PDM from around the clock. give herself insulin, because she does know she needs insulin for that protein. And but she didn't need it. If she would have bolus and sat down or Pre-Bolus sat down, she would have gotten incredibly low. Yeah. And she, it was amazing to see somebody figure that out. I was, I'm going to add what I learned about that, to me, like how the protein needs more later.

Jennifer Smith, CDE 30:19
Absolutely. It takes into the immune takes into the fact that we know these things from a set of rules. But I mean, the classic your diabetes may vary. Your diabetes bolusing strategy will vary. Well, it really yeah. Not Not me, it will vary. I mean, I my breakfast every morning, I've got a friend who eats the same exact breakfast after talking to me, she was like, Wow, that sounds awesome. I like it. I want to give it a try. Blah, blah, blah. And so now she loves it. Her bowl of strategy for it is similar, but not 100% of what I do. It's different because physiologically, she's different. Yeah.

Scott Benner 31:01
And and so if you've ever heard me speak live somewhere, there'll be a moment where someone in the audience asks the, you know, the question, how much how long, you know, and I go, I don't know, figure it out.

Jennifer Smith, CDE 31:13
Starting places, there are some starting sure things. It's like kind of like, you know, the How much do you adjust the bays? A lot? Oh, point point. Oh, 5.1. It's a starting place, right? Sure. Give it a try. If it doesn't work, Okay, next time you adjust different, right,

Scott Benner 31:30
and I'm more aggressive, like when I adjust basal rates, I adjust them like 30% of the time, because I'd rather cause a low and then back down from the low to find a level spot than to

Jennifer Smith, CDE 31:40
go high for several days

Scott Benner 31:43
in the high, right. Because also because I feel like you're getting a more accurate depiction of what's happening. If you're using more insulin, when you're using less insulin, then there could be resistance going on. And maybe

Jennifer Smith, CDE 31:54
you know me and the feel to them that you have to correct and so you never really get a true picture of what does the basal adjustment really just do because now I'm high and I want to correct and I'm not going to leave it high. So I don't understand what the bazel I know, I just know it's not enough,

Scott Benner 32:08
you'll get a look into my parenting style that way too. Whenever my children asked me something, I respond immediately with no. And then we work backwards from now. And so I sort of do the same thing on the inside, I slam the insulin, and then I work backwards from there to find a level spot. I wanted to say about insulin action time, it's another idea of settings near pump, right? So there's an amount of time that they you know, insulin should work in your body, like how long from when you put it into when it stops working. And you'll see people say all different kinds of numbers, you know, for hours, you know, it's different for me here and there. Same insulin, you know, they're using one kind of insulin. Some personal say, Well, my action time is four hours, my x times three hours. Arden uses a pager and her insulin action time and her pump is set at two hours. And so I have found that when you Bolus art and that Bolus stops having any effect on her in by two hours. Wow. Most of the time. Some of the time now. I don't know how to tell you the difference, but most of the time it's Yes. Last night it was now last night I couldn't get Arden's blood sugar to budge off of one ad. It didn't matter what I did. She had incredibly Carbo rific afternoon. Like I said, she still has her period. And you know she's going along. Now there's a moment where I'm like pushing and pushing and pushing and I'm finally that guy. This is enough like this insulin is going to start working eventually. And it did later at night after a hot shower. Her blood sugar started coming down and we had to catch it. It was hours and hours later. That doesn't make Arden's insulin action time six hours, right, right. That's a specific situation. Most times insulin I put in now doesn't cause her to get low Two hours later. Now keep in mind, insulin on board is calculated by the insulin action time set up in your pocket. Am I right about that? Correct. Can you explain that for us, please?

Jennifer Smith, CDE 34:07
Yes. So insulin on board specifically uses your active insulin time that you have set in your pump. So for Arden, two hours if she were to get a bolus now for you know, at at 11:07am. Two hours from now, at 1:07pm. The pump would no longer identify active insulin on board from this Bolus, which means that if she chose to Bolus at 115 it's only going to factor in blood sugar and the carbs she tells it she's eating to give a bolus suggestion. However, within active insulin time, let's see, you know, an hour from now somebody's birthday comes up and they bring a big old big old tree to school and she's like, Hey, Dad, I'm totally

Scott Benner 34:58
I'm gonna need another 30 carbs over On top of what we just bought for an hour, right,

Jennifer Smith, CDE 35:02
exactly, but that was an hour ago. So your pump still assumes, hey, there's still insulin on board from this bolus that she gave an hour ago, there's this much active insulin left. Important thing about iob is that you have to feed the pump information in order for it to consider iob information being blood sugar, and carbs. If carbs are a piece in the picture here, right? Because if you do not feed the pump, a blood sugar, it doesn't know the effect of the insulin onboard that's still left. And to calculate the next bolus correctly, it sees the insulin on board, but it may not be able to adjust because it doesn't have a pinpoint of glucose value to now say, okay, she was an hour ago at 82. Now she's at 179. That insulin on board that's left is coming into the picture, but the pump also sees a higher blood sugar. So it's gonna say, okay, she's high. She wants to eat this much more. This is how I'm going to calculate the bolus despite there being active insulin left but

Scott Benner 36:16
in a situation where like, for instance, now Arden's blood sugar's 111. Okay. And I'm seeing a curve up on her CGM. But her pump right now if you test it right now say she didn't have a CGM she tested right now for that, you know, surprise treat an hour later. And, and it says, Oh, your blood sugar's 111. You have all this insulin on board from the meal, go ahead and eat that you don't need insulin for this you don't need, you don't need as much insulin for that. That would be stalking. Okay, and that's a word that doctors are going to throw at you. And they're going to mean for it to scare you. And, and maybe maybe it should, in the beginning, I'm not 100% sure, but what they're going to tell you is you can't stack insulin, because eventually it's going to, it's going to catch up to you. And it's going to make you low. I say to that, yes. If you don't need the insulin, if you do need the insulin, it's not stalking, it's rolling, knowing the difference is the is the trick, I guess. To go back to, I'm going to layman's terms a little bit more about insulin on board and action time if I can. So if you decide that your insulin action time is three hours, and by you, I mean, the doctor sits down says this is what it is for most of my kids this age, so I'm going to set it for three hours for you. But your insulin action time is actually less or more, then your pump is going to make decisions based off of that number. It doesn't make it right, I want to be clear at the pump doesn't have a magic sensor that's in you somewhere that knows that it's telling you the right thing it's making, it's making a static decision from a static number. That's not necessarily correct, it's probably a good guess. It probably won't hurt, you know, it's gonna err you on the side of caution a lot. It's going to keep you from being you know, from getting well.

Jennifer Smith, CDE 38:07
And I think that's a good it's a it's a very good point to bring up. Because what we've actually found, especially in the community of people who are doing the Do It Yourself looping types of pumps, which is a whole nother broad topic, but I bring it up in this mainly because what we've found is that the action time of rapid acting insulin is actually beyond what most people have it set in that their insulin pump. And the reason that we have it set for less time in an insulin pump, is because we inherently do not want to run high blood sugars. And so if we give the pump and active insulin time of three hours, when really that bolus is probably lasting about four hours for us. What it means is that at three hours and one minute after this bolus was delivered, if your blood sugar is still high, your pump now no longer sees any active insulin and it can bolus you more aggressively for the blood sugar that you now want to drive down. Right. Whereas if you had it set for four hours, at three hours in one minute, you were like I'm high I want a bolus to get this blood sugar down. Your pumps gonna be like, let's be a little conservative here because you still have this like quarter of that last bolus still working.

Scott Benner 39:31
We are now six episodes deep into the diabetes pro tip series. We're halfway through talking about insulin pumping. And next month, the episode about how to use a CGM like a ninja is going to come out. It's time guys. Let me be bold and say I think if you don't have a dexcom at this point, if you want one, you have to take the leap. You have to go to dexcom.com forward slash juice box and get started right now. But if you need to be reminded again, why I'm happy to do that for you. Good Dexcom g six continuous glucose monitor is not only going to show you what your blood sugar is, it's not only going to keep you from having to check with a meter, it is going to show you the direction and speed that your blood sugar is moving. how fast you falling? How fast are you rising at what pace? is this happening? Should I put more insulin and should I not? The data from the Dexcom g six is going to help you make that decision. All of the things you're hearing in the Juicebox Podcast. And even more specifically in this diabetes pro tip series. If you'd like to put those things into practice, if you'd like to grab diabetes by the you know what, and just bring it snack and say I've had enough of this, I want to eat Chinese food, I want to have a pizza, I don't want my agency to be 12. Because of that, I don't want to spike the 400 I just want to eat. I think you can do that with the Dexcom. Now my results are mine and yours may vary. But I got a good feeling dexcom.com forward slash juice box or links in your show notes or Juicebox podcast.com. I mean, even if you don't want the Chinese food, wouldn't you just like to sleep overnight with some comfort.

If you have an omni pod, your pump is going to be completely self contained, it will adhere to your body, the insulin will be in there and all the smarts and everything and you'll use a wireless controller to tell it hey, I want you to change my bazel or put in a bullish or something like that. All other pumps have tubing and an infusion set, right. So you'll have an infusion set that'll put your cannulation tubing will run to the pump, and that pump will have its insulin in it, you'll need to keep that with you. It'll be clipped somewhere,

Jennifer Smith, CDE 41:50
right. And that's a good point to make to about the difference on the pod. The PDM does not have to be on your person for the pod to continue delivering. That's a big question that a lot of people have, well, I don't want to carry around this extra thing all the time. You don't have to once the pod has been told what to do. It does it

Scott Benner 42:09
as soon as it beeps and it recognizes the signal you're done. Actually you can walk away from if your insulin starts in like say you're putting into reverence delivering, right? As soon as it starts to walk away. You could you could run to, you could run across the state and your pdmp in your house and the insulin will keep delivering Yeah. It's also important to talk about there about pumping in general is that to bathe or swim on a tube pump, you're going to have to disconnect to more than that for most right. So even in you know more aggressive like sports, for instance, like you there's a lot of people who disconnect to go play soccer or you know, football or something like that. With Omni pod, you'll always be wearing it. I think to me, that's a huge point that made me want to do it. Because you always hear people say like, Oh, I went to the beach and I got high, I get high at the beach. And I always think back to someone who was on the show. I think it was a just a few episodes ago, where he said if you put a pencil in your back pocket, and then rob a bank, pencils don't cause bank robbery. And, and so the batch doesn't make your blood sugar high, taking your insulin pump off major blood sugar high. Right, right, like that kind of an idea. So just understand that there's different ways to manage with different pumps, I'm not telling you which pump they get.

Jennifer Smith, CDE 43:30
And that's a lifestyle look, right. And that's the biggest thing when I work with people. They're always like, what what do you think is the best? There isn't a best, there's the best for me, there's the best for you, you need to take a look at you know the pros and the cons of all of the pumps. What are the what's the pump that has the most Pros for your life, to navigate your lifestyle your needs, you know, an athlete, I've got a lot of athletes who really prefer Omni pod. Because of the tubeless piece I've worked with a lot of triathletes, who really they need I mean from going from a swim into a bike into a run, they need something that's a seamless management, then they're not having to clip in and pop in and reload and you know everything. So there? I think it takes a lot of examination of your lifestyle. Yeah,

Scott Benner 44:17
no, absolutely. There's no, I would I would jokingly say that, you know, I'm sure you think that I think you should get an omni pod. And probably if you ask me my personal opinion, I would say yes, right, not just because they advertise on the show, but because artists use one for 11 years. And it has been nothing but absolutely fantastic for us. But I completely agree with Jenna, you should decide what works best for you. You really have to do that. Not everyone's going to see the same pros and cons as everyone else.

Jennifer Smith, CDE 44:47
And all of the pumps despite delivery and mechanism of driving insulin. They all do have some features that are different and may apply better to your lifestyle than another They're brand. Absolutely.

Scott Benner 45:01
So. So again, figure it out for yourself, do your due diligence. I think the greatest thing about the Omni pod might be is that they offer a demo, they'll send you one to your house and let you try it like that, where it the other companies are at a loss, they can't really do that, because

Jennifer Smith, CDE 45:16
of the problems is set up very big and extensive.

Let me just send you Oh, and I'll send it back. Yeah,

Scott Benner 45:22
please, please give it back. And a couple of other ideas. And he's it right, so what I was getting to whether you're using it on the pod, or you're using another one, there's going to be some adhesive of some sort, you know, a simple preparation, like we talked about back in the MDI episode, I think I don't over prep, skin, right? clean skin.

Jennifer Smith, CDE 45:44
Right, without lotion or anything on it, you're good to put it on. You could see.

Scott Benner 45:51
You know, if you have soreness with a pump, right, it shouldn't hurt. No, right. So it should not. So be careful. Like, if you start if you have soreness that you know, I mean, after it first goes on, obviously, you know, it's not fun to have a hole poked in you. And that's going to be done by any one of these pumps. But an hour later, whatever it is, if it's hurts, or it's hard to bend your arm, sometimes the candle can hit a nerve,

Unknown Speaker 46:14
or a muscle muscle like looking up again. All of

Scott Benner 46:18
these companies will if you call them up and say, Look, I had to put it in an infusion set, and it hurts so bad. I took it out. Can you send me another one? Generally speaking, they're their customer service is good, they will?

Jennifer Smith, CDE 46:30
Correct. And that's really important because it can affect absorption at the site. If you've got a site that isn't it that's hurt, or, you know, maybe getting infected or for some reason there's irritation under the site. If that site is bothering you, there, that's not good. Remove it, pop in a new one do something.

Scott Benner 46:47
Yeah, don't sit in pain. Yeah. And that I think that's important. tubing is something I don't completely understand I how much tubing Do I need is it just as much to get me to where I want to store my pump?

Jennifer Smith, CDE 47:04
Correct in that depends, you know, tubing comes in many, many different lengths for the tube pumps being of which there are only two on the on the market, either tandem or Medtronic are the tube pumps that are available now, at least here in the States. So the tubing length depends on exactly where you're going to move that pump to and pop it in. If it's in a pocket, you may need short tubing 18 inches, if you're going as some some of the guys that work with, you know where the shirt stays around their lower leg to keep their shirts tucked in, well, they end up just clipping their pump down their leg, and then they can easily lift up their pant leg to Bolus during the day. So if that's the case, you probably want 40 plus inches, tubing. how tall you are, you know, if you're Shaq, you probably need like

inches but yes,

Scott Benner 47:57
and and the two pumps also you when you go to put them on, they have to be primed, which means that you have to fill all of that tubing with insulin. Before you can put it on the pod self Prime's. So you when you there's no tubing, there's no tubing, there's a tiny little candle that that obviously goes under your skin stays there. Yep. So again, there you go. There's pros and cons with all of them. You know, I hear people say that so on the pod has a failsafe, right? If it gets around too much electrostatic electricity, and it and it affects the internals of it, it will shut down and ask you to do to change it. Yep. I've had it happen in 11 years, six or seven times, you know, it's happened. And people go, Well, that doesn't happen with a tube pump. And I'll say Well, yeah, and my daughter is also never walked past the drawer in the kitchen and gotten her tubing caught on and yanked out her infusion set. Oh, that's the tube pump version of that, to me, like they all have something if you're looking for something right? If you're looking for perfection. They don't ask a machine to do anything on it. Absolutely.

Jennifer Smith, CDE 49:03
And I think you know, one even that might be going towards the the tube pump potential need would be if, for some reason, the angle of the kanuma is a concern or an issue for you. That is one I would say potential drawback of Omnipod is that there's only one canula it comes on every pod it's exactly the same canula and it goes in exactly the same angle for every single person, which may not again, your diabetes will vary because your body physiology may be very different. So you may need to choose the pump. Despite not wanting tubing, you may need to choose a pump. That's too because you need a different type of canula or what's called infusion set. You may need something to go in at an 80 degree angle versus an angled you know, you may need a steel canula versus a plastic kanila for various body reasons. So there are a lot of considerations

Scott Benner 50:00
Yeah, absolutely. But don't take, don't you keep this in mind, no matter what pump you're thinking about. I know this is gonna sound a little dirty. But it's, it ends up being true. Companies have salespeople, salespeople influence doctors, doctors get stuck prescribing things right over and over, you walk into an office and say I want it on the pot. And the guy goes, No, no, you want one of these? Trust me, you don't need to trust him. You know, you can say that you appreciate your input. But I'd really like to try the on the pot or vice versa, I don't want it on the pot, I really would like to try that. You can you can, you can speak up for yourself, please, please do that. Absolutely do that. So at the very end of this, I want to talk about about something that can't, it doesn't happen with injections that could happen with a pump, right. So as long as you inject your insulin with your injections, you remember to put in your Atlantis, you'll never marry your trustee. But whatever it is, and you you know, remember to put in your insulin for your food or your high blood sugars, you're watching the needle go in your arm, you're pushing the button, you pull it away, you know the insulins in there. With any insulin pump, the possibility could exist that your canula could get bent, that your tubing could get kinked that the pump could, I don't know, the batteries could die like like, you know, on the pod doesn't have batteries. And there's the but the other ones, there's mechanical, you leave the house and totally forget that your reservoir only had five units. And for the rest of the day, you actually needed 20 units. And now you have no influence area and you're in trouble. Right? Right. So these are things that could happen when you try I we have a radius in my mind, if I'm more than 30 minutes away from my house for any extended period of time. I bring insulin and another pump with us. The other day, we drove an hour and a half to something stayed there all day had all this extra diabetes supplies with us didn't need one of them. You know, most of the time you don't need it. But when it happens, it happens. Now, in 11 years, I'm happy to tell this story in 11 years, we've had one insulin delivery problem with Omni pod. And it wasn't the pump. It was us. We changed the pump by sight. And it you know, it was at a pool. Right? So we put it on and I she got back in the water. And I think the adhesive didn't have time to adhere and it loosened up a little bit and it pulled her canyelles out. Oh yeah, of course of a day right along July day of swimming. We got home her blood sugar was still fine now. Was it still fine because the candle was still in it hadn't worked its way out yet because she was so active during the day. She didn't need as much as I don't know. But what I can tell you is, is that overnight Arden's blood sugar started to skyrocket. And I kept bolusing. And it took me a while to figure out that my boluses weren't doing anything. That's not going to happen to you injecting. Right? So is it is it I actually saw a person say the other day, I'm scared to get a pump because of that. And I think if that's why you're scared, I think you're worrying about things you don't need to worry about. But you do need to be aware of them. Correct, right? Your tube tube kinks, something happens. You're not getting insulin delivery, you're also don't have any slow acting insulin. And so when you lose your pump, you lose your slow and your fast acting you can go from everything's right on to DK a. Pretty fast, quick.

Jennifer Smith, CDE 53:30
Exactly, absolutely. And that's, it's a really good piece, you know, to discuss because it's one of the primary things when I work with starting somebody on a pump that we discuss, right in the pump training, is the risk for decay or the risk for a pump malfunction. And how do you how do you navigate that without having such tremendously high blood sugars that then take forever to bring down because you're at such a deficit of insulin right? I mean, our recommendations really are with a pump, an odd high blood sugar or now with the use of a CGM blood sugars that are like you said, just all of a sudden skyrocketing, and there should be no reason for that skyrocket like you didn't go eat the whole Dairy Queen cake and just not bolus for it right. There is something wrong, you bolus from the pump. If that initial bolus doesn't start to make a dent in that glucose within the next 30 to 60 minutes, you change everything out you change the site, the tubing, the reservoir, the pod, whatever you might even change the insulin you know especially if it's been a D at the beach and your insulin hasn't been kept change the insulin out really important I

Scott Benner 54:41
bail on a pump site. As soon as as soon as I know too. I will sometimes if I if I get a stuck number, but it's not too high. Sometimes I'll inject a little bit. And if you inject instead you go oh my god, it started moving right away. Maybe I'm gonna get off this pump site like a little banner. And that's, you know, to just go over a couple of like ideas, you can't keep reusing the same site over and over again, they eventually become less effective. For reasons we talked about in other episodes, you have to understand that when you when you put in an insulin pump, you've you've needle has poked a hole in you, and left behind a piece of plastic in most cases, right? This plastic is a foreign body. You're right, it's an irritant. I remember discussing with Aaron Kowalski from the jdrf, one time that he thinks one of the most ignored technologies for people with diabetes that we don't spend enough r&d time on is cannulated materials, and how to make them less irritating to the body. Because when your body thinks it's injured, it sends white blood cells to the place it believes there's an injury. And I don't know anything technical, but in my mind's eye, in my mind's eye that draws cartoons of what I think the world looks like, and how I understand things. There's little white blood cells, sort of like the beginning of Jurassic Park, when they show that cartoon to explain that I know DNA, in my mind, I see little white blood cells coming and attaching themselves around that Canyon and making my insulin not flow correctly. I know none of that's probably technically correct. But I do know that when a when a place gets irritated like that, that insulin becomes less effective. And there are times you have to bail on a site sooner than you want to.

Jennifer Smith, CDE 56:26
It could be and it's also a good just around site change itself to be very aware that the potential for that new site to be less absorptive, from really what you're talking about, there is inflammation. Anytime you introduce something underneath the skin, you ask your body to become irritated. And inflammation is what follows. So an absorption at that site is significantly decreased. Everybody's a little bit different. Some people it's for about an hour, some people it could last as long as four, six hours, that inflammatory response. It's also a guess, for those who are using a continuous glucose monitor, you know, that two hour thinking window? Yeah, a big reason for that to our sinking window. Besides that sensor needing to get wet, you've put something to sit underneath your skin, your body's got to get used to that and you don't want glucose values coming in, from a site that's probably injured. Right? So same with a pump, you really have to pay attention. What do your site changes look like? How does your glucose level change around site change time? And is this normal? Is this a normal flux in glucose? Or is my gosh, my blood sugar's never 300 after I change the site, right there in lies the difference of change it out or figure out how to navigate the site change, so you don't have a high blood sugar. And I think it's incredibly important to know that while this may sound scary, that you'll figure it out very quickly.

Scott Benner 57:54
It's not something that's going to dog you for your entire existence. There's little is the word peccadilloes, there's small things about everything that you have to you have to figure out along the way. And the only way just like we talked about within, the only way to figure it out is to do it. Let it go the way you didn't expect, you know, suss out what happened and and fix it next time. I think

Jennifer Smith, CDE 58:16
just the fact in you know, this episode, especially talking about these little pieces. It's really, really important because these are pieces that are often not talked about from an endo education standpoint. They're not they're missed. They're things that you figured out along the way. And you've talked to other people, and you're like, Ah, I'm not the crazy, man. This is what's happening. Right? Me, me, too. I mean, I, I could have sat and asked my endo about it. But there's things that in interjecting and working with other people and my own self experience. I'm like, I'm not crazy. This is what happens. And I'm not the only one great

Scott Benner 58:57
example, that when RM is younger, and we changed her pump, she'd get high. And people say, Oh, that's a thing. That's a pod chain tide only happens with Omni pod, and blah, blah, blah. And I'm like, you have to Bolus mark with Bolus with the old pod before you change the new pod because the new pod won't work and everything. None of that was the truth. You want to know the truth. Arden was incredibly nervous to get her insulin pump change when she was little, and the adrenaline would hit her and shoot her blood sugar up. And one day, Arden stop being nervous about having your insulin pump changed. And that all stopped. There was no match. So people had had imagined this entire story around this and I started buying into it at first I was like, oh, obviously the pump doesn't work right away and and all this and by the way, it doesn't it that's not an unnecessarily incorrect statement. There like you just said new inflammation. There's an injury, you do sometimes need more insulin. upfront and I don't disagree with that. But the leap she got wasn't the pump changing. adrenaline's adrenaline. And I still, like we talked about earlier, a new pump. As soon as I put on a new pump, I double the bazel for an hour, like, right, just to get it going. But, but I started thinking down that it's again, this cause and effect, it's the pencil in your pocket, right? Like, I changed the pump in her blood sugar went up, obviously, the pumps not delivering insulin anymore. Make sense? didn't end up being correct. Right? Right. So just you'll figure it out.

Jennifer Smith, CDE 1:00:32
My experience was coming from a tube pump to Omnipod. So I had experience with site change from a tube standpoint on the Omnipod. And I'm glad that I had that. Because I do experience that site change inflammation. And I had experienced it on a tube pump with the canula. And so I knew it was likely going to still happen on Omni pod. So, you know, again, your experience is going to be different from somebody else's.

Scott Benner 1:00:59
It's 100%. Right? Ah, good. Oh, did we didn't miss anything? Do we do okay? I think I like what you said at the end. I appreciate it. Because I wanted this to be a real real conversation. Not some like shiny. Oh, you'll get a pump and you'll love it. And it's gonna end by the way you will love it. It's in we won't. I don't know who you are. You know, I can tell you it's been an amazing experience for us, I believe wholeheartedly that the Omni pod is one half of the reason that we are able to keep Arden's agency where it is

Jennifer Smith, CDE 1:01:30
where it is. Absolutely. And I see the population of people that come off of a pump is small. But there are people who I've got a good friend who pumped for years and was like, man, she had a major issue with her pump. And she was like, No, I'm, I want to make sure I know I'm getting my influence. She's been on bolusing. She's gone through pregnancies with bolusing via MDI, it works for her. But again, that's her choice. And most people will stay on their pump. Listen, here's

Scott Benner 1:02:00
the here's the key, be happy, be healthy. That's all I care about. It doesn't matter to me what you do, just no differently than the way I talked about using insulin. I talk about pumps and glucose monitors the exact same way. I want you to know how it works. I want you to know what to do when you try it. And once you try it, if you don't want to do it, whatever, man, I don't care. You know, like I'm not telling you what to do. I'm here telling you, you shouldn't make decisions based off of bad information. When you have good information, make good decisions, do whatever you want. If you're enjoying the Juicebox Podcast, there's a couple of things you could do. In return, let's say you could leave a rating and a review on iTunes that helps the show be more searchable so more people can find it. You can support the sponsors and I'm talking about on the pod decks, calm dancing for diabetes, and real good foods. These are the people who bring you the podcast for free. Right, right support it. The last thing you can do is tell a friend, if something you've heard on this podcast has been valuable to you. help someone else to find it. podcasts are not intuitive to everybody, you may have to send them a link, you may have to show them how to put a podcast player on their phone. I'm not sure what that will entail. But I know one thing when you share the podcast, it grows. When it grows. The sponsors are happy. And when the sponsors are happy, the podcast continues. I hope you're enjoying the diabetes pro tip series. That's going to be it for March. Jenny and I are having a fantastic time making these. I have to tell you I think maybe we might even you know keep going after this series is over.

Did you think I was gone? I'm still here. At this point, you have to be asking yourself why am I not pushing stop? It's the Curiosity right? Like you think maybe something else is gonna happen. But I'm telling you right now nothing else is gonna happen. Could you hear me breathing? I was holding my breath right there.

Thank you for listening to the Juicebox Podcast. I'll see you next week.

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#218 Diabetes Pro Tip: Temp Basal

Scott and Jenny Smith, CDE share insights on type 1 diabetes care.….

I am thrilled to welcome Jenny Smith, CDE back to the show. Jenny will be joining us for an extended series of conversations that focus solely on the management ideas that we discuss on the podcast.

Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com.

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

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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 and welcome to the fifth installment of my series diabetes pro tip. Today, in this short but very important episode, Jenny Smith and I are going to talk all about how to manipulate your basal insulin.

Jennifer Smith has a bachelor's degree in human nutrition and biology from the University of Wisconsin. She's a registered and licensed dietitian and certified diabetes educator and a certified trainer and most makes and models of insulin pumps and continuous glucose monitoring systems. I first met Jenny when I had her on the podcast back in Episode 37, an episode called Jenny Smith diabetes guru had her back in Episode 105. And she and I talked all about a one C's really breaking down what they meant, what was important about them and what wasn't. One day, I just had this idea to bring Jenny back on to talk about all the concepts that we talked about here on the podcast, but real granularly just, you know, really break down ideas in a way that I thought you guys could absorb and remember and share and revisit. And that's what this series has been. Hopefully you've been enjoying it. This is the fifth installment of the diabetes pro tip series with Jenny Smith CDE. And please remember that nothing you hear on the Juicebox Podcast

should be considered advice, medical or otherwise. And to always consult a physician before making changes your medical plan for becoming bold with insulin, temporary basal rates, do a number of different amazing things

Jennifer Smith, CDE 1:45
laugh and laugh compared to what your doctor told you. Yes,

Scott Benner 1:49
and and so here's how I always think about it about basal rates in general, it is bizarre for us to think that we can set up a static basal rate that will always work at 2pm for the rest of this week, or this month or our lives, right. It's just an odd statement. I don't have diabetes, my blood sugar varies based on what's happening in my body or what I eat. And I bet you even though I have no medical training whatsoever that my body is more aggressive with the amount of background insulin that I get the amount of force it pushes on my blood sugar at different times.

Jennifer Smith, CDE 2:24
Because it's got natural compensation. Yes. And I think that that that piece about about measles is also really, really, really important for women. Right?

Scott Benner 2:33
Okay. Yes, because of their periods. Or, by the way now I've been told not to say, Lady time by people that maybe I should say, period. So then I went back to period to make that person happy. Then I got a beautiful note from somebody the other day, you said I think lady time is delightful. And I'm like, I can't win. But that's not the point. So so so here's a couple of ideas. We get Chinese food coming into the house, right or not so or something that's high carb that breaks down slowly in your system. Oh, my Pre-Bolus for Chinese food is this Temp Basal increase 95% for two hours, boom, I start right there. Then I get a healthy Pre-Bolus in you know, and I start the I want to decline when when Arden starts eating her food. Chinese is a good example. Because it's not it's simple sugars and complex carbs at the same time, right. So the coating on the meat might have a lot of sugar in it like the sauces will hit you quickly. But that rice could sit in your system forever and take hours and hours and hours to to break down and to go away. So I think of it as carpet bombing insulin, I want to I want to cover the entirety of the timeline that this food is going to have impact on art and with an increased basal insulin. It I would also use an increased basal insulin, when Arden's hormones are affecting her. Yeah, we just got done doing that this week, there was a day and a half or Arden ran a Temp Basal increase of 80% for two days straight. Yep, get a straight. Yep. If your basal is not right, your bonuses aren't going to work, right? Because you're just replacing bazel with your bonuses. So even again, you count your carbs 100%, right. But if your basal insulin is set at, let's say a unit, but it should be at two units, then when you make a bolus for a three unit snack, the first unit of it is only covering the bazel you don't have plus you haven't had enough bazel leading up to that. So you're probably insulin resistant and having a higher blood sugar to begin with. None of this works without base when people come to me and say, Oh my God, look at my rollercoaster. I'm 60 I'm 400 Um, but the first thing I say is okay, let's get your basals right. If your bases aren't right, the rest of it doesn't work. Right

Jennifer Smith, CDE 4:54
and temporary visas then are not going to work either because they're working off as a setting. That's not that's not right. To begin with,

Scott Benner 5:00
yep. Inevitably, while I'm talking about basis with people, they say, Well, what about my insulin to carb ratio, and I went, that's not even worth thinking about your basis, right. So now you can think about basal insulin as basal insulin used, you know, in the normal course of your day to keep your body function low when you don't have any food, and but if you really start to think about them around food, that's when they become incredibly powerful. Why. And so, there's also a time where, like I alluded to before, you can bump in nudge with bezels. Right, so not only can you create a hard bazel, that helps you with carb, heavy meals, but you can look at a blood sugar that's at, you haven't had insulin for hours, and then suddenly, it just a 75. And it sits there for a little bit. And instead of feeding that 75, you can Temp Basal back. So Temp Basal is unlike the, you know, when I think about the tug of war with with Pre-Bolus. Basal is I think of this way, I imagine if you and I put our hands out, stood up and put our hands together our palm the palm, and we pushed equal amounts on each other. That's it, you don't fall back, I don't fall back. That's a perfect bazel rate. Right now, there might be a situation where my my blood sugar starting to fall. So I need the body function to push a little more. So I, I take a little power away from the bazel, which allows me to push up. Same thing if I'm at a 90 that's going to a 95. And it's creeping up. But a bolus is definitely even a tiny bolus is going to make me later I might just do a Temp Basal increase to stop that kind of creeping. Yeah, this all occurred to me when I interviewed someone about artificial pancreas, and they told me that most of the adjustments that an artificial pancreas makes is through basal insulin. Yeah, not through boluses

Jennifer Smith, CDE 6:57
100%. If you're doing anything within the looping community to do it yourself, insulin pumps, either open APS or looper, Android APS are whatever that is. That's the gist of the algorithm. It is most of most of the incremental adjustments based on the trend in glucose are being done by positive and negative what's called temping, you get a bit of a bump up, you get a bit of a bump down, he had a bit of bump bump up, and it's all being based on your current bazel setting. Right? Right. But the incremental ups and downs are what keep you stable.

Scott Benner 7:34
This past week, I visited the army pod headquarters in Massachusetts, where they've just moved their production facility. It's about to go live. And I got to tour the floor, where you're on the pods are going to be made from now on, right here in America, right in Massachusetts. I want you to know that what I witnessed in Massachusetts on that assembly line, it didn't just renew my excitement about Omni pod, it shot me over the moon, the accomplishment of bringing a production like that into one facility, putting it under your roof that showed me a real commitment to the people living with Type One Diabetes. Right? This isn't being made overseas somewhere or you know, a bunch of different factories. It's all right there at the Omnipod headquarters, and its state of the art and it's absolutely stunning. This is a company who is behind you for the long haul. I believe that before but I believe it even more now. Here's what you want to do. Go to my omnipod.com Ford slash juice box or click on the links in your show notes or Juicebox Podcast comm when you get there request a free experience kit. That's right up pack. A pod experience kit on the pod is going to send you a pod that is an exact replica of the one you'll get when you start using the product for real, but this one's non functioning, and so it's safe to wear for you to try

Unknown Speaker 8:55
out.

Scott Benner 8:56
You'll be able to find out if you like it where you want to wear it. And you'll notice how after you've had it on for a little while you don't even remember that it's there. Miami pod.com forward slash juice boxes links show notes or Juicebox podcast.com. The Dexcom g six continuous glucose monitor gives you a complete picture of your glucose showing you where it's going and how fast it's getting there. There can be nothing more important. The dexcom g six also eliminates finger sticks for calibration, diabetes treatment decisions, and diabetes management. It also has an automatic inserter. Like it just you know you stick it on and you push the button and the next thing you know you're wearing it. Now you can use the dexcom receiver to get the information from your transmitter. But for those of you who enjoy using your cell phone, it works great with iPhone and Android as well. The last little thing about Dexcom isn't so little How about the share and follow features also for Android and iPhone. Your loved ones can follow your blood sugar anywhere in the world and if you're the pain Or a caregiver of someone with Type One Diabetes, you can be watching their blood sugar as well. You want to know what Arden's blood sugar is right now. It's 82 just glanced up and saw it just like that. Now my results are mine and yours may vary, but my daughter's a one C has been between 5.2 and 6.2. for over five solid years, the decisions we make about how to give my daughter insulin and when to give it to her, come directly from the data that comes from the dexcom g six. And I don't know if you know this or not, but my daughter does not have one dietary restriction. Those numbers are accomplished through waffles, just as well as through salads, through burgers, just as well as through zucchini, it doesn't matter, anything that impacts my daughter's blood sugar, that impact is shown to me by the Dexcom g sex, and then I make good decisions. You want to make some good decisions, go to dexcom.com forward slash juice box and get started today. That's the best decision you're ever gonna make. So when I talk about bumping and nudging, which is going to come up in the future a little more, it's the idea that if you don't use too much insulin, it can't cause a wide swing. Correct, right. So bumping a 120 diagonal up back to 90 takes a smaller amount of insulin than ignoring your blood sugar till it gets the 180. Now you're putting in a bunch of insulin and becomes Miss time and you get low later. So using these little bumps, just make sense that you can accomplish that with Temp Basal. Again, remember, Temp Basal is don't start working right away. You can't save yourself have a 65 one arrow down with the Temp Basal. No, that's, that's juice time. Right, right. But, but but a 70 that's drifting low and has no impact from insulin really could be saved with it couldn't be saved. Maybe it won't be but you try and figure out for yourself, maybe that'll end up being a 90 that's drifting low that you'll eventually use Temp Basal for. But they are, they are such an important tool. And if you're not using them, you're missing out. I I'll say it here, I'll say it again, an insulin pump is not just a way to get less injections. It's also a way to be able to give yourself micro bonuses to be able to manipulate your basal insulin to be able to manipulate your boluses to spread them out. These tools are vital. So please tell me and I know you and I are short on time here. But tell me how you talk about Temp Basal with people like where do you Where do you really focus in on on education about it.

Jennifer Smith, CDE 12:33
So I we I and I usually really, really focus in on all of the scenarios that are likely to come up where temporary bazel is really an important piece of management, that that bumping and nudging that you talk about, you know, unfortunately, most people are only taught about exercise and the benefit of temporary bazel. And they're usually told, well just, you know, just set it for zero percent or turn your bazel off during that time. Well, that's 100% incorrect to begin with. But exercise is one of many reasons that you may want to change your bazel for a, you know, a duration of time, illness, a woman's menstrual cycle, or that woman's time of the month or whatever you're going to call it, that time, you're going to definitely need temporary bazel you're going to need it for sedentary days, I can go to a conference where I'm literally sitting for eight hours. And while I might be walking between conference rooms, the sitting and sedentary, I need a 25% increase in my basil. In order to not run high that whole day. I've figured that out right? I figured out what I need to do to take a five mile run versus a 12 mile run temporary bazel changes. I figured out what to do for different kinds of illness a stomach bug may require a decrease. an illness like a sinus infection or a bronchial infection may require an increase. Even even temporary bazel around food like you mentioned before with the Chinese high fat food, yes. 100% requires knowledge of using temporary bazel because I know we'll talk about extended boluses and things a little bit too but temporary bazel for high fat man that can affect you eight to 12 hours after you're done eating it and it keeps you high and you may go to bed with an awesome looking blood sugar thingy that I made. I nailed that I really got it. What do you get an alarm at two o'clock in the morning where you're 300 and you're like what happened?

Scott Benner 14:37
And those are the examples By the way, when you can't say to yourself, oh, well that's just diabetes. It's not just diabetes, that it's you didn't use the insulin right? And so every time you think diabetes is just this, this, you know, magic fairy that runs around messing with you. It's something happened like you might not know what it is in that moment. But some thing happened. And you can figure out what those somethings are and stop them. And there's a great example high fat, you might need a Temp Basal increase that goes on for hours and hours later,

Jennifer Smith, CDE 15:11
high fat 50% at least 50% increase for at least six to eight hours after the meal. Right?

Scott Benner 15:18
Right. It's just it's, I know, it's a little mind numbing to think that, but that's a lot to think about. But I want to, I think now's a great place to say this. As much as we're breaking things down and really stretching them out. So you can see the tiniest little aspects of these ideas. For people who understand them, I will speak for myself, I do not think about diabetes that frequently during the day, this stuff just kind of happens. I know that sounds crazy. But I look at a plate and I go, Okay, here's what this means. And if and if I miss I readjust. But But I don't spend a lot of time, of course aside of this podcast, but I don't we don't say the word diabetes in our house very frequently, I guess is what I'm saying. We're not always fighting and, and you know, scary lows, and oh my gosh, she's been high for three hours. Like that doesn't happen around here. Right. And you can live that life too, by understanding how insulin works. Isn't Jenny terrific. You know who else is pretty great on the pod and Dexcom. Go to my omnipod.com forward slash juice box to get your pod experience kit today. That's right, a free no obligation demo of the Omni pod is yours to have by going to my omnipod.com forward slash juice box. You want to make these great adjustments, you're probably going to need a CGM. I recommend the G six by Dexcom. Go to dexcom.com forward slash juice box to find out more. These links are also available in the show notes of your podcast player, or at Juicebox podcast.com. I put three episodes out this week, this one Pre-Bolus thing. And the next one insulin pumping. Don't forget, get all three. This diabetes pro tip series was designed to be listened to in order. So if you're finding this one, go back, work your way through them. They build a narrative around type one diabetes. Coming up next month, using your glucose monitor, bumping and nudging and more. You can hire Jenny at integrated diabetes.com. Instead of me talking to her you could be talking to her. You could get Jenny on the phone or by Skype through FaceTime. She talks to her clients in many different ways. Bring up the things that you're struggling with and Jenny will help you go to integrated diabetes.com. To find out more about that. If you're interested in seeing me speak live and you're in the Orlando area, I'm going to be at the touched by type one event put on by dancing for diabetes. Just go to dancing for diabetes.com go to the Events tab click on touch by type one. When you do you can register to attend. This event happens on May 18 2019. It runs from 8am to 5pm. And there are a lot of great speakers not just me. If it's after May 18. Please still go to dancing for diabetes.com. They're a sponsor of the show. They do amazing work with people living with type one diabetes, and I would love for you to find out more about them. They're also on Facebook and Instagram.

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#217 Diabetes Pro Tip: Pre Bolus

Scott and Jenny Smith, CDE share insights on type 1 diabetes care.….

I am thrilled to welcome Jenny Smith, CDE back to the show. Jenny will be joining us for an extended series of conversations that focus solely on the management ideas that we discuss on the podcast.

Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com.

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

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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 and welcome to the fourth installment of my series entitled diabetes pro tip. In this episode, we talked about something so important it gets its own episode, and what could be that important Pre-Bolus thing. Today I'll be joined again by Jennifer Smith. Jennifer has been living with Type One Diabetes since she was a child. She also holds a bachelor's degree in human nutrition and biology from the University of Wisconsin. Jenny is 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. And I love the way she thinks about type one diabetes. If you'd like to get one on one coaching with Jenny, you can go to integrated diabetes.com. To find out more. Before we get started, I'd like to thank the sponsors of the Juicebox Podcast. Today we're going to be talking about Dexcom on the pod and dancing for diabetes, you can find out more about the sponsors and about Jenny, in the shownotes of your podcast app or at Juicebox podcast.com.

Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And always consult a physician before becoming bold with insulin or making any changes to your health care plan. Now let's talk about the most important of important things, making sure your insulin is well timed with your meals.

In the episode about insulin, I told you that that my nurse practitioner CDA told us that fear of insulin was the biggest sticking point for people making good decisions with their diabetes, right. And after I got past my fear of insulin, the next hurdle I had to get past was Pre-Bolus. And I am now years and years later at a time where I will tell you that if you do not Pre-Bolus a meal, the likelihood of success is near zero. And if you have success without Pre-Bolus, saying.

All that means is that you gave yourself too much insulin prior to that. And it's just catching up now. And so this is it. We're going to talk about Pre-Bolus. And we're going to talk about how about insulin action, right the action of the insulin and how to balance it against the impact of the carbs or your body function. So tell me, let's go over the part that people aren't going to find comforting at first, right, which is, the amount of time it takes insulin to begin working in a person varies person to person and insulin to insulin. Is that pretty fair to say?

Jennifer Smith, CDE 2:58
It's pretty fair to say yes. And insulin to insulin. I would definitely say most of the rapids on the market should be fairly similar. The rapid acting influence on the market and their time of action should be fairly similar now. person to person. Yeah, that may vary situation to situation as well, creation to situation, it may vary. But again, that's the learning part of it.

Scott Benner 3:27
Okay, so person, the person could end up meaning just your body chemistry could mean where your infusion set is, right, you know, or your injections, right? Absolutely, yeah, you're a person who gets stuck on, I always injected my belly in the same place, that spot might not be as reactive to the insulin as if you would just try a new spot. If I went to a new spot, it might work quicker than it has been in your old spot. Right? If you're wearing an infusion set, it could and we alluded to it before you could get better action from your insulin on day one than you do on day three or better on day two, then, you know, two hours after you've put it on, there's a lot of different variables. But we're speaking generally here to you, you'll apply them to your variables later. Now, if you've heard this podcast before, you'll know that I have alluded to how insulin works in a number of different ways. So I'm gonna give my kind of cartoony description of it, and then we're gonna let Jenny talk about it for real,

Jennifer Smith, CDE 4:24
or 2d might be better as

Scott Benner 4:25
we'll see. So here's how I pictured my head a couple of different ways. The first way is I think of a tug of war. And I imagine a rope with a with a flag hanging in the middle of it. And on one side of this tug of war rope is insulin. And on the other side is your carbs and your body function. It could be adrenaline, it could be fear, it could be anxiety, whatever it helps to drive your blood sugar up. That stuff's on one side of the rope. The insolence on the other side. Unlike a tug of war in a school yard, our goal is not for one side to win. Our goal is for them both to pull and pull and pull until they get it exhausted, they both go, I can't do this anymore, and they drop the rope and our flag still in the center. That flag represents the blood sugar. You start at when the impact of the carbs begins in my mind. So I'll explain a little more. If you let them both start pulling at the same time, the carbs are generally speaking going to gain power and momentum before the insulin begins to work. So now your rope is going towards a high blood sugar and you're starting to head up. Now suddenly, you're 50 points higher. And what if you started with 150 blood sugar, now you're at 200. And now these carbs have momentum, they have speed, they're pulling your blood sugar up. Now, all of a sudden, 15 2030 minutes later, the insolence like, Oh, no, wait, I have a job to do. I remember and it kind of comes online. But now it's pulling, it can overpower the the momentum that the carbs have created. Plus, you now have another hundred points of blood sugar to contend with. And all you have is the insulin that you counted your carbs for. So even if you counted your carbs perfectly, and realize that this meal is five units, once the momentum of the carbs is rocketing your blood sugar up, once you have a number that is higher than you started with those five units, are not even going to begin to cover what's happening, let alone the food that you've put in. But if you put the insulin in first, and let the insulin come online slowly and begin to pull down and create the momentum in the other way, then you flip the script. And now the carbs are fighting. So instead of having a fight at 180, blood sugar, you're having a fight at an 80 blood sugar. And instead of your blood sugar falling at 80, it's being the attempt is that it's now trying to be pulled up by the carbs. And that's how when you see people with a stable graph, that's how they're doing it. And so for me, in a perfect situation, for me, my daughter's blood sugar is diagonal down when I give her most foods. Mm hmm. There's differences, you know, food to food, situation to situation, but in a perfect world. To me, that's it, you want your insulin working, your blood sugar trending down, creating some momentum down, when you allow the carbs to begin to pull up. Now, you explain that in a technical way that sounds

Jennifer Smith, CDE 7:28
and in most in most settings, yes, that's 100% I mean, insulin, our rapid, I've always thought that rapid is such a misnomer, honestly, rapid indicates like now rapid is like, you know, click, click, click lights with design, it's working. And it's, you know, still education is take your insulin and start to eat. I mean, even from most endo offices, it's take your insulin and start to eat, it's going to be working very, very quickly. That's not the case. And anybody who has been taking insulin long enough, and you've seen the spikes, and you've seen the issue is despite counting your carbs as precisely and weighing them and everything, and you're still seeing these issues. It's the mismatch of insulin timing, it is so rapid take anywhere between about 15 to 30 minutes to really get that active peak, not peak, but that active phase where then when you start putting your carbs in. They will match as you said that carb digestion will start to match with the insulin, you'll get a nice gentle curve up. And it should then start to curve back down. There is a lot of there's a lot of education that also focuses on, as you mentioned, watching for that curve down, watching for the curve down to start so that you know the insulin is already moving thing. Yep.

Scott Benner 9:04
Yeah. And to give you some context, the person I spoke about in a previous episode, who was having trouble, told me but what am I gonna do, I'm gonna be scared. I said, Well try it a little bit this time, and then a little more next time and a little more next time and go forward. And, and so I always tell this story somewhere. And I think here's the right place to tell it prior to glucose sensing technology being a thing that anyone knew about, but prior to, you know, Dexcom, I was again in the office and the CD says to me, hey, you're going to get one of those Dexcom things and I thought, I don't know what that is, you know, and she starts telling me it's it's a continuous glucose monitor. And I'm like, I again, don't know. And then she tells me this simple story. There's a 17 year old boy in our practice, who loves candy, certain kinds of candy and he can't figure out how to bowl with it. So he gets a dexcom whatever the first one was, I don't even remember anymore. His whole goal was to eat this candy without a spike. So it goes out to the store. And he buys like little grab bags of these candies and a number of them enough for a week and every day starts on this experiment first day, just like you said, eats, gives himself as his insulin, just like he'd been told his whole life, blood sugar goes up to 20, something like that sits there forever. Eventually, he has to give himself more insulin to bring it back down again. Next day, he tries a little sooner, give himself a few minutes, 510 minutes gets a little less of a rise. So the next day, he goes even sooner. And then before you know it, it's a little sooner, a little more, and he starts adjusting it back and forth a little more, a little sooner, a little later, until one day, he eats the candy. And his blood sugar never moves. And she tells me that story. And I thought immediately Wow, that means it's possible. Yeah, that was the first time I thought I was like, if that kid can do it with candy. I can do it with anything. Like anything, right? And so yes, give me that CGM. Please. And I got it. And I and I started, you know, dispense with my fear. And I started learning about it. There were hiccups along the way, right? I've given her insulin, and she's gotten lower than I meant to for two when she's eating. But you know, once twice, I'll go back to this over and over again, when something goes wrong. It's not a mistake. It's a learning experience. It's data for next time, right? Right. So I put the insulin in, and she goes down to 70 and sits at 70. While she's eating. It's beautiful. You know, like, there she goes that and then and then then a spike. Even if I really messed up on the amount of insulin I used a spike takes you to 120. Right, right, right. It's not right. It's just, it's all about that timing and amount. And I repeated over and over again, that you all the things you and I are going to speak about all the things that people hear about on this podcast, if you want to know how to use your insulin, at its core, the very first step is timing and amount. If you get used the right amount at the wrong time, you can use the wrong amount at the right time, that it's too much if the right amount of insulin at the right time, you have to balance the action of the insulin against the impact of the carbs. If you do that, I don't want to say it's easy, because that's insulting to people. But let me just say I don't think about diabetes that much anymore. It's easier, it's much easier if you do that. It is easier. Absolutely. And it's a lot more.

Jennifer Smith, CDE 12:26
It gives you a lot more visual than to understand. Because it's not so much of an unknown well, gosh, I counted the carbs, I took the right amount of insulin and this is always happening to me. Why. And if you can start to put those pieces together, it's not a y anymore. It's like turning the light bulb on. Here's how I explain what Jenny just said.

Scott Benner 12:53
The dexcom g six continuous glucose monitor gives you a complete picture of your glucose showing you where it's going and how fast it's getting there. There can be nothing more important. The dexcom g six also eliminates finger sticks for calibration, diabetes treatment decisions, and diabetes management. It also has an automatic inserter. Like it just you know, you stick it on and you push the button and the next thing you know you're wearing it. Now you can use the dexcom receiver to get the information from your transmitter. But for those of you who enjoy using your cell phone, it works great with iPhone and Android as well. The last little thing about Dexcom isn't so little. How about the share and follow features also for Android and iPhone, your loved ones can follow your blood sugar anywhere in the world. And if you're the parent or a caregiver of someone with Type One Diabetes, you can be watching their blood sugar as well. You want to know what Arden's blood sugar is right now. It's 82 just glanced up and saw it just like that. Now my results are mine and yours may vary. But my daughter's a one C has been between 5.2 and 6.2. for over five solid years. The decisions we make about how to give my daughter insulin and when to give it to her come directly from the data that comes from the dexcom g six. And I don't know if you know this or not, but my daughter does not have one dietary restriction. Those numbers are accomplished through waffles, just as well as through salads, through burgers, just as well as through zucchini. It doesn't matter anything that impacts my daughter's blood sugar. That impact is shown to me by the dexcom g sex and then I make good decisions. You want to make some good decisions, go to dexcom.com forward slash juice box and get started today. That's the best decision you're ever gonna make. This is a short episode and I don't want you to have to have to add breaks. So hang on for me for one more second. Let's talk about Omnipod. This past week I visited the AMI pod headquarters in Massachusetts where they've just moved their production facility. It's about to go live and I got to tour the floor where you're on the pod You're going to be made from now on, right here in America, right in Massachusetts, I want you to know that what I witnessed in Massachusetts on that assembly line, it didn't just renew my excitement about on the pod, it shot me over the moon, the accomplishment of bringing a production like that into one facility, putting it under your roof, that showed me a real commitment to the people living with Type One Diabetes. Right? This isn't being made overseas somewhere or you know, a bunch of different factories. It's all right there at the Omnipod headquarters, and it's state of the art is absolutely stunning. This is a company who is behind you for the long haul. I believe that before but I believe it even more. Now, here's what you want to do, go to my omnipod.com Ford slash juicebox. Or click on the links in your show notes or Juicebox podcast.com. When you get there request a free experience kit. That's right, a pack a pod experience kit on the pod is gonna send you a pod that is an exact replica of the one you'll get when you start using the product for real, but this one's non functioning. And so it's safe to wear for you to try out, you'll be able to find out if you like it, where you want to wear it. And you'll notice how after you've had it on for a little while you don't even remember that it's there. Miami pod.com forward slash juice boxes links show notes at Juicebox podcast.com.

Last thing, don't forget dancing for diabetes that's dancing the number four diabetes.com. It's the little organization that does a ton of good for a lot of people living with type one, they're on Facebook and Instagram, and it dancing the number four diabetes.com check them out. Here's how I explain what Jenny just said. I think of it as this equation that it's a mathematical equation that doesn't have any math in it. I did this. That happened. So next time, I'll do more or less sooner, you know, a little less a little more, that kind of thing. And I always just I always just keep looking at it like that. I did this. And that happened. It's the idea of being in a fistfight. And you want to hit first because now you have caused an effect. Right? And if you and so now, you know, I've done something. And that's what happened next. Now I can make a good decision about what what I do next, instead of waiting for diabetes to do something to you. And then you're just covering up your face hoping not to get knocked out. Right? Like because you don't know what's happening. You don't know why it's happening, you have no context for what's going on. But when you make the first move, you can be sure that what happens next was impacted by what you did, I put insulin in 10 minutes before you ate 10 minutes before I ate. And my blood sugar went to 150. So the next time I'm going to try 15 minutes. And if it goes to 130 I might try 20 minutes. And you know, if I get low, then later I might say okay, I might need a little more a little less. Now here's where people always say, Well, how much Scott How long? You know, give me the time, give me the amount? That answer for me is always going to be I don't know, figure it out for yourself. Okay, you have to

Jennifer Smith, CDE 18:13
this is the starting place.

Scott Benner 18:15
Yes. This is

Jennifer Smith, CDE 18:15
where to start. This is how to start. You have to do your own. I mean, diabetes as a science experiment, it's a daily, I feel like every day you're almost given like this new petri dish. And you're told, keep the dots growing purple today. Okay, let's work on keeping the dots growing proponents of something green pops in. And then these like little horny pink things pop on, you're like, Ah, you know, but it is it's like, it's a science experiment that for the most part, when you figure out what does work, the timing around the most typical foods that you eat and whatnot, it takes a lot less thinking out of the equation.

Scott Benner 18:55
Yeah. And while this isn't about Pre-Bolus, and we'll come up later. But it's important for me to say because I think this is impactful when you really stop and think about your, your habits around food. They're pretty similar. Right? Right. So you know, you're not I always say like this, like, if you're a person who gets a pizza on a Friday night and has two slices. You don't suddenly next Friday have seven slices. You don't go from being a two slice person to a seven slice person, right? Like Yeah, and so, so you can start making these decisions about how much insulin and when. And you can make them based on historical knowledge about what's going yeah,

Jennifer Smith, CDE 19:33
I usually tell people as the Pre-Bolus piece you've got most people have about 20 to 25 foods that are the most common for you to eat regularly. Yeah, that's at least 80% of your control there at least. So if you can nail the Bolus timing around those and figure it out, for the most part, you know, variations in setting will happen. Whatever Ever Yeah, but for the most part, if you've figured that out, you're also much more likely to be able to figure out food that isn't your norm, because of the similarities to what you've chosen. And what you're usually eating,

Scott Benner 20:18
because you can stay flexible, I call it 60 fluid, right? So here's, here's where I'll tell people this, don't get mad. I don't count carbs. I actually think about it a little backwards from maybe how most of you think about it. I don't look at the food and say, you know, weigh it or measured and say, Okay, well, that's 25 carbs. And my pump says that, I get one unit for every 10. So that's two and a half units. In honesty, there is no accurate insulin to carb ratio set up in Arden's pump. We don't even I don't even pay attention to that. I look at a plate and I say to myself, that's seven units. I think that if she's gonna sit down and gorge herself on nachos and cheese, the last time that happened, it took 10 units. I think of it as insulin, not as carbs. And of course, that takes a little practice, right? It does, it does. And it is a little contingent on you having a CGM, I'm not gonna lie about that, right, because I start with a healthy Pre-Bolus. And healthy would mean in amount and time. And then I watch her CGM, and I don't really watch it, I have her tolerances set tightly enough that if she leaves that range, I find out about it. So as an example, if I were to give Arden something incredibly carb heavy, I might use a Temp Basal increase, and a Pre-Bolus to try to spread out the action of the insulin across this timeline where there's going to be these carbs, right? If I make a bolus, and 30 minutes after I do it, she's 121 30 diagonal up. I look at that line. And it tells me something based on my previous knowledge, it's that I say to myself, ooh, this I missed, like, this isn't enough insulin, and I will give her more I will bump it and nudge it back. It's not a ton more, it's enough to stop the arrows.

Jennifer Smith, CDE 22:16
Right? And the arrows are very important to bring up in this in this as well. Because if you are using a CGM does arrows do indicate a rate of change? And again, that's not something that most people realize. They don't understand that and not understand.

Scott Benner 22:33
Don't tell us that

Jennifer Smith, CDE 22:34
it's that they've not been told they've not been told, hey, these arrows tell you that you're increasing by 30 to 60 points in the next 30 minutes. Okay. If that's the case, and I know what my kind of correction factor is, or whatever, I can say, Okay, I'm going to need this much more insulin, because if I don't correct my rising 130 blood sugar in the next 30 minutes, I could be 30 to 60 points higher. I could be as high as 190. I don't want to be 190 I've obviously miscalculated someplace, I can throw in a bit more insulin to counter that expected and stabilize it. Yes.

Scott Benner 23:11
Yeah. It very much. Yeah, it very much is remembering to, like I guess the way I usually say it is that you have to trust that what you know is going to happen is going to happen. Right? Yeah. You see, and and i think that the least important aspect of what the Dexcom does is the number. It's the direction and the speed, direction and hundred percent.

Jennifer Smith, CDE 23:40
I wish more please say that, again, is the direction it's the trend, it is not

Scott Benner 23:46
just the number, the numbers nice, like don't get me wrong, it's a starting point. But you know, if you're 60 and stable, and you haven't had insulin for three hours, you have had food for three hours, well, maybe you could get away with like a Temp Basal decrease of 100% for a half an hour, maybe you'll rise to 90, right. But if you're 60 and you're falling well, then you don't have enough time because as we've now discussed over and over again, insulin doesn't begin working right away. Also temp basals are insulin. It's funny how people think of bolusing and bazel is different. But once you're on a pump, it's the same thing. You can't just turn your bazel off and it starts happening right away,

Jennifer Smith, CDE 24:26
takes about 60 minutes for circulating insulin level to be different.

Scott Benner 24:29
And I always write and I always try to think of it a little bit as like Arden's Pre-Bolus time like if Arden's Pre-Bolus time is 20 minutes, well then setting a Temp Basal is not really going to start working for at least 20 minutes plus, it's a fraction of the bazel rate if if you're getting a unit an hour, and I say to it, okay, let's double it. Let's double it to two units an hour. That impact of that doesn't begin for 20 minutes or so plus, it's not the whole unit extra. It's the it's the fraction of it. So right when we talk about bazel We'll get to that. But so Pre-Bolus thing is really just the idea of balancing, again, the action of the insulin against the impact of the carbs, giving yourself a chance, not letting the carbs wash you away. Because here's what happens when the carbs wash you away. Count your carbs exactly right, you put your insulin in, you spike up the 200. When that happens, that insulin was only for the food. It wasn't for the 200 blood sugar, and it wasn't for the momentum of the rise. And so when I see that, like, I guess an easier way to say this, when when I don't have time for Pre-Bolus and Pre-Bolus. And to me is never about the number, you can Pre-Bolus a 65 blood sugar, you know, you can Pre-Bolus at 90 blood sugar, because still no matter what, if you're stable at 65, the insulin you put in is not going to start working until it starts working. So you have and so don't get me wrong. If I see a 65 blood sugar and I and Arden needs 10 units for what she's eating. I don't put all 10 units in at a 65 I might do an extended bolus which we'll talk about an extended boluses. But I get some insulin moving, I make sure the insulin is on the winning side of this tug of war to start. But in a situation where I can't Pre-Bolus let's say I know the meal is five units, hundred percent certain it's five units. But for whatever reason life, let's call it I can't Pre-Bolus and ardens. You know, I'm going to start eating right now. I'll give her seven units. Mm hmm. Because I Bolus for the food, the five units for the food I knew. And I pre buy. And I'm Pre-Bolus seeing the rise, I know is coming. And the and the number I know is coming. So I'm already treating a high blood sugar that hasn't happened yet. Because I know it's going to happen. Because I didn't Pre-Bolus

Jennifer Smith, CDE 26:54
right. JOHN Walsh goes into detail about what you're doing in a little bit of a different way. He calls it super Bolus,

Scott Benner 27:01
I call it over bolusing.

Jennifer Smith, CDE 27:02
Yeah. And he calls it super Bolus in the way that you take that five units, let's say in your example, and let's say your bazel behind that meal for the next two hours is one unit an hour, you actually take your bazel running for the next two hours, and you add it into the Bolus for the meal and you take it all up front. And then to decrease the chance of being too low later. Because of so much upfront action and the blood sugar staying normal, you actually set a temporary basal decrease, he recommends starting with 100% because you've loaded that onto the front to avoid a low but on the back end. Some people find though that attempt B is 100% off is too much. They only need a 50% they still call the spike and prevent it. But in the back end, they're not having a low then. So similar kind of concept.

Scott Benner 27:58
Yeah, I consider that trading Bolus for Basal. So so you know, say 120 diagnol, up 3040 minutes after a meal and I go, Oh, geez, I gotta stop that arrow. How much do I Bolus to stop the arrow? I usually Bolus an hour's worth of a baby of basal insulin. That way, if the arrow stops, and I stay steady, and she doesn't go down, I say okay, well, obviously, I was just wrong on the initial amount. But in those situations where you push the button, you know the unit and a half goes in, and five seconds later the error goes from 120. to diagnose the flat you go, Oh, I didn't need that. Right Temp Basal off a half hour. All I've done is trade the Basal for the Bolus. Absolutely. Here's a good place to say this. And we'll say this in each of these little vignettes. Never suspend your bazel it's always temporary basals. When you suspend you're shutting your pump off when you shut your pump off. It does not.

Jennifer Smith, CDE 28:52
You have to remember to turn it back on. Yes,

Scott Benner 28:54
yep. It's always temporary, because you can set at Temp Basal for a half an hour, an hour, two hours, but at the end of that time, it was that it'll go back on and start delivering your Basal it's always temporary Basal is not not don't suspend your pump. Okay, so I think do you think we covered Pre-Bolus? there?

Jennifer Smith, CDE 29:11
I think that's pretty good. Good. Yeah, that's awesome.

Scott Benner 29:16
Don't forget that you can work with Jenny yourself. If you want just go to integrated diabetes.com to find out how. Let's also take a moment to thank our sponsors Dexcom on the pod and dancing for diabetes. There are links in the show notes of your podcast player app, or Juicebox podcast.com. But you can always go to dexcom.com forward slash juicebox. My omnipod.com forward slash juicebox or dancing the number four diabetes.com. I hope you're enjoying the pro tip series. This was Episode Four where we talked about Pre-Bolus. And don't forget that episode one is for those starting over or just being diagnosed. Episode Two was all about multiple daily injections. Episode Three. We talked all about insulin. today of course Pre-Bolus Singh. In the next episode, Temp Basal rates huge and important and then after that insulin pumping, they're designed to be listened to an order, trust me, listen to them in order. I have just a little bit of music left here. So let me thank everyone for the great reviews and ratings on iTunes. very much appreciated.

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