#227 Diabetes Concierge
Katie DiSimone knows Loop……
Katie DiSimone is on the podcast to explain what the heck looping is and how it can change your life with type 1 diabetes.
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Scott Benner 0:00
Hello and welcome to Episode 227 of the Juicebox Podcast. Today's episode is sponsored by the dexcom g six continuous glucose monitor, by real good foods, and of course dancing for diabetes, you can go to dexcom.com forward slash juicebox dancing the number four diabetes.com or real good foods.com To find out more about the sponsors. Now when you go to real good foods calm and you place an order, use the offer code juice box to save 20% on your entire purchase.
As you well know nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And you should always consult a physician before becoming bold with insulin or making any changes to your health care plan. Today's guest is Katy de Simone. And you're going to want to hold on to something because I think what I'm about to say next is going to take you by surprise. But one of our listeners Gina brow beat me browbeat me online into trying the loop now that it's available for the Omni pod. And so I got Katie on the show because she is about the loop beiste person. That doesn't sound right. She's really entrenched in the world of looping. She's not loopy, she's actually delightful. Anyway, Katie came on. She explained to me everything about looping and I had a bit of an epiphany that I thought it might actually help me help you. So I said, All right, let me try it. So sit back and relax and listen to the conversation that I had with Katie, that made me think. Alright, I'll give this a shot.
Katie DiSimone 1:56
My name is Katie DiSimone . And I work for Tidepool now. And I'm also part of the DIY loop group. So I have a little bit of dual hats in that respect. And so sometimes I try and clarify which hat I have on.
Scott Benner 2:13
Which one are we wearing today? Both one?
Katie DiSimone 2:16
I am imagining probably mostly the DIY Katie hat. Because loop has had a very exciting announcement this week that it now integrates with the Omni pod.
Scott Benner 2:27
Okay, so if you have to change hats, just make an announcement before it happens.
Unknown Speaker 2:31
Yep, we'll do.
Scott Benner 2:33
Katie, I'm gonna give you a tiny bit of background on me and what I think is probably the feeling of more people than should be. And and then we'll move from there. So my daughter is going to be 15. This summer, she has been using it on the pod since she was four. And because I think greatly, because of the things we talked about here on this podcast, her agency has been between five two and six two for over five years. She doesn't have any diet restrictions whatsoever. And we just kind of, you know, figured it out a little bit. But I also want to stay, I want to ride the wave, you know, on the crest of the wave, I don't want it to crash down and then just be you know, going back out to see what I'm like, what's the loop? So I'm excited. I said before that the documentation scares the heck out of me. But I got cajoled harshly by somebody online. And they're like, try it. Just try it. Just try it. And then she finally said to me look by the Reilly link and if you don't like it, I'll buy it from you. So Gina, this episode is for you. And for everyone else. I think we need to just first kind of as simply as possible, let what loop means makes sense to people. Can you do that?
Katie DiSimone 3:51
Yes. Basically, loop does what most of the general population I call them muggles, the people who aren't living with T one D. What most of the Mughal population thinks happens for T one D. That's what loop does is that they see if you explain to a muggle that you have a continuous glucose monitor that provides you information about your blood sugar every five minutes, and you tell them that you dose insulin off your insulin pump based on your blood sugars. They assume that those two systems talk to each other. And that's, as we all know, pretty much not the case on any commercial product these days with the exception of very recent developments, relatively speaking of the 670 and Basal iq, which does half of that equation, it responds to low blood sugars. So what looping does is that it takes that and closes the loop. In other words, your insulin dosing you will actually be based on CGM data without having any Your brain involved in that or your fingers involved in making pump button pushes. So in the simplest form, that's what it's doing is that if at any given time, you would have looked at your CGM data and known that you had eaten and thought, maybe I should give a little bit more, or I should suspend. Or I should decrease my insulin. That's what loop is doing for you. Okay, now we're loop itself with a capital L. As opposed to a little case L of sort of the general concept of looping. What loop app itself does is that it puts all of that into a really simple, wonderful interface of an iPhone app. In all the traditional ways you love Apple products for their ease of use that you can just look at it and it makes sense for what you're looking at. That's what loop is. It's an iPhone app that sits on your app, where you can easily enter all of the information about the food, you're eating the boluses, you want to give, where you're headed, what your settings are, it's basically all moved off of a device that you have to fetch out from underneath your sweater under your dress. It's all now on your iPhone, where you interact with most of your day anyway. And for my kid, the iPhone is almost an extension of her hand, because she's 16. She is on Spotify and Instagram and all of those other kinds of things. And so bolusing from her phone is a really natural place to put her diabetes management. for adult users, most of them are really psyched on the watch for bolusing and entering carbs. It's super discreet. You can do it at a professional meeting, and nobody's going to ask you, are you being rude or somehow ignoring things you can take care of it all on the watch.
Scott Benner 6:53
So most of you know that I'm speaking at these dancing for diabetes touched by type one event on May 10. in Orlando, Florida. If you're in the area and you'd like to come, I don't think it's too late. Check out dancing for diabetes calm, but if you can't make it, dancing for diabetes is like I don't know, auction me off or something. All you have to do is go to dancing for diabetes.com hit that donate tab, make a suggested donation of $10. And when you do that, your name will be like in a hat. I'm going to pull from that hat while I'm down there on the 18th number plot three names two of those names. I'm going to have a 45 minute phone call with you. And one lucky name. One hour phone call and a 30 minute follow up and if you don't want to use the phone, we could FaceTime we could Skype I could be off the window smoke signals. I don't care. Ellison if you don't want to talk to me on the phone, I appreciate that but don't embarrass me Okay, you hear what I'm saying? You guys got to get on there and do this so I don't look like a schmuck expected numbers out of this. The whole like Scott phone call thing Imagine if three of you do this. I'm going to look like an idiot. Alright, so don't do it for me Don't do it for the cute kids dancing for diabetes out you know do it for me do it for me so that I don't look like an idiot to have your name including this opportunity to go to dancing for diabetes.com click on the donate today button between now and may 17 2019 make a suggested donation of $10 and be sure to mention juicebox in the notes. If you don't have internet access or flat out just don't want to make a donation but you still want to submit your name you can do it by mail. I mean God bless if you're gonna do that that's like a stamp and envelope but I don't know what you're even writing there. juicebox nothing and it's got to get there by this I mean do it if you want I'm just saying a lot of work. I hope to see you on the 18th but if I don't I hope we can talk
in its very basic form. All the things that we all sit around thinking are always simplified for us right like I think much like most people like artificial pancreas will come one day and what that means is my glucose monitor will talk to my insulin pump it will make decisions for me and I won't have to think about it. And that really is this it's this in real life. It's it's your right now it's Dexcom right you you loop works with Dexcom CGM
Katie DiSimone 9:10
correct loop works with all the Dexcom CGM Solanas, the g4 has share capability. It also works if you're on one of the older Medtronic pumps it works with the older Medtronic CGM systems. Gotcha.
Scott Benner 9:24
And this is quite literally something that was done. I don't know what the word is. Is it a consortium of people like how do you think of it when you Is it a a cabal? Are you guys which is like what is? What is it exactly like how did this How did this begin?
Katie DiSimone 9:40
The story started long before I ever got here. And it's a web of people in the most simplistic of forms, and it'd be too hard to name everybody who's been involved. But basically people across the nation were frustrated with where the state of diabetes gear Was that it wasn't collecting information for the patient that it was residing in silos separate from each other and not being integrated. And so people started taking actions smart people who had the capabilities of, and I use the term hacking, because that's what comes to mind for most people. But not hacking in a nefarious way. Hacking, as in, I know, my information is in here, I just want to see it, I want to use it to better basically all these people across the country, we're all working on separate parts, that all ended up through the wonders of internet, finding each other, and they all moved closer together, right? So people who are working on understanding that Dexcom and making that more available before share was around, met with the people who were decoding the pumps and people who are doing algorithms, and they all started to form together till eventually, these closed loop components were all close together, okay. Where my involvement came in, was my daughter was on Omni pad for about a year and a half after diagnosis, and was doing great with it. And then she started high school. And when she started high school, she told me, Mom, I want to wear tubes pump. I said, Well, why do you want to wear two buttons? This is the opposite of where most kids go. She said, I'm on my diabetes to be more visible. Oh, okay. And it's an odd thing to request at high school time, but I'll go with it. And I said, Well, I've been stocking the internet. And I saw that these really smart people over here who are working on this open APS system will get on an older pump. And I'm going to have to get an older two pumps. So if I can find that maybe I can get two birds with one stone and automate some insulin delivery, and that might make our lives easier. And so that's what that's how I ended up here was that my daughter wanted it to pump I knew I was gonna have to buy a used one mine as well. But the problem at the time was that the used pump system, this open ups system at the time was really bulky, and would require a lot more than a teenager was willing to give it time and attention to at the time, it's gotten better. So I was looking for small open APS systems. And I was searching the internet frantically going, somebody must have worked to miniaturize this. And that's when I came across the loop, which is a different system than open APS, but conceptually still the same automated insulin delivery based off your CGM readings. So when I saw that it fits on a phone, and it's a really small, sleek form factor, I thought, yeah, I could do that. And when I got there and found where the project was, didn't have a whole lot of information about how to build it. So I spent a lot of time with Google, and putting myself out into uncomfortable spaces of trying to figure out how to build an app onto a phone when I've previously never done that. And with some help of some very nice people on the internet, who answered my questions, and Google, I got it built. And I was so excited. And it worked so well for us that my involvement that I committed to as a kind of pay it forward movement, is that I would write the documentation so that other people could come after me and be successful with it.
Scott Benner 13:25
So you're the translator you
Unknown Speaker 13:27
Yes,
Scott Benner 13:28
you took complicated, technical, almost geeky and weird and turned it into something my brain can absorb? Yep. Is that what's at the loop kit? dot GitHub dot whatever dot loop force? Yeah, even. Is that
Katie DiSimone 13:44
even? Even that I wanted to simplify? So it's, it's loop docs.org lpds.org.
Scott Benner 13:53
Okay, I'm gonna write that with the OC s dot o RG.
Katie DiSimone 13:58
And be intact. It's really, you know, honestly, I totally get it like when you when you come into something technical. From the first start, as soon as you tell somebody, you're going to build an app onto your iPhone, half the audience leaves the rim and goes, I can't do that. And what I promise you is that you absolutely can it is really, really not as as hard as it seems. It's super, super difficult.
Scott Benner 14:24
My understanding here would be that this is not, I mean, you know, this is not a medical device company, right? That's giving you this basically an algorithm that's going to tell your CGM gonna tell your pump what to do with the information from the CGM. So no one can take responsibility for this. If you do this, it's it's on you right now. It's it's do it yourself in the most most meaningful way you are doing it yourself. No one is helping you if something goes wrong, it's all on you. It's a decision you're making on your own. And it says that very much right. I'm just seeing now is the first time I'm looking at At loop, Doc's dot org says you take full responsibility for building and running this system and you do so at your own risk. So if you want to get involved in this right now, Katie is going to tell us now about how to get it set up. Because and I know everyone who listens is going to be thrown off by this. I'm going to try it. And that trust me, Katie, you have no idea. Everybody's just like, no, Scott said he was scared and he can't do it. And trust me, I am scared, and I can't do it. But I think that by having Katie on the podcast, I now have a Sherpa that I can bug. I'm going to figure out how to do this. And then I'm going to report back to you guys how I did it. And that I'm going to report back to you if I like it, and whether or not we're going to stay with or not. Because Katie, while I believe that this is incredibly important for the large majority of people with type one diabetes, I think they're going to have results that they've just never seen before. We already have really good results. So if this improves my life, then I'm all for it. By the way, like I'm not I have no, I have no ego about this, I don't need to be making decisions about Temp Basal increases in Temp Basal decreases, like, you know, throughout the day, I don't care if I would like it to just work. And so I'm super excited to try it.
Katie DiSimone 16:14
Oh, that's that is, you know, you, you just said something that kind of triggered in me a funny part that it took me a long time, we've been looping for two and a half years, roughly. And I've had an evolution and how I appreciate the system when we got on it. And we were fairly low carb only because it was the only way we slept at night, we just you know, we were going through an evolution we were only a year and a half in. It's a teenager, she's changing, we're changing, it was very, very hard. So we got on loop. And it was at the time, we were mostly focused on E one C on blood sugar control and all of that kind of mindset. And then she became a team and she wanted more independence. And I wanted more independence. I didn't want to keep talking to her about diabetes. This was silly. That's just we had a life to live. And what looping has done is, is made me realize just how much potential damage I was headed into with navigating that very complex transition, an independent type one team. And loop gave me back the ability to understand how to let her live her life and how capable she was and how she could do this. And that. The other part it relieved from me as part of the reason I was doing so much help on it was I felt like if I shifted that responsibility that she was asking for even though she was asking for it, I still felt a huge, enormous guilt that I was somehow saddling her with now this enormous responsibility. And seeing loupe work for her literally like a like a, like a nanny like a personal assistant that carries the umbrellas of the rich and famous stars. And you know, the movie festivals kind of thing. Like, who can afford that. That's how Luke has done for us is that it's this umbrella carrying personal assistant for her. That makes that shift over so much easier.
Scott Benner 18:23
Yeah, insulin concierge. Yes.
Katie DiSimone 18:26
That's a great, that's a great term for it. And so from
Scott Benner 18:29
Katie, patent pending,
Katie DiSimone 18:31
I think you should that's your new, that's a new hashtag, you should you should do that. Because it really it redefined how our relationship was and it took a lot of diabetes conversations off the table, which I'm so grateful for. And it wasn't at the expense of good. anyone see results or all of that kind of stuff. It was less effort, less Lowe's, great agencies, and less commerce conversations. It was women and all the way around. Yeah. So we have.
Scott Benner 19:00
So here's where my excitement lies as I sit here and just look at this image that you guys have up on the screen of the loop app on an iPhone. So I'm not even though there are a couple of people who like to say that I have a lot of ego and I I'm brash about like how well we're doing. What I'm saying here is, I've gotten this figured out, my daughter doesn't go over about 151 70 more than about twice a day, she doesn't get dangerously low more than maybe about once a year. You know, we don't get under 70 very often she's mostly between 70 and 120 give a lot of stability. But it's come through these things that I'm now realizing as I'm staring at the algorithm there are these things that the algorithm understands mathematically that I understand in English I don't know if that makes sense or not. And and and so I'm super excited to see the feedback from the app as far as like active insulin, insulin delivery and glucose level. Because I actually think that this app can take me farther in my understanding than I am and I really thought I was about at my peak. Honestly, I didn't think there was much more I could understand about this. But seeing this information, I think I can mine a lot out of it. And, and, and really go on to be able to describe to people who don't have this app, my ideas but in better detail, and maybe more easily detail to understand I'm, I'm getting excited. So this is good. Okay, so let's go through a couple of things.
I needed Dexcom I have that. I need Omni pod because it works with Omni pod. Now I have that and then I need something called a Reilly link and as soon as you say that in the past my brain would go Okay, I'm out Forget it. Right but but but let's let's make it let's take away Riley link. And I don't know did you see spider man into the spider verse by any chance? Yeah tastic movie you really have to make time in that one of the spider man. Men spider man's one of the guys calls something electronic a goober. He says there's always something like this in every one of my problems. I just call them all goobers. So let's call the Reilly link a goober. Okay and so. So the pump has to get information from the CGM and your phone needs to talk to everything. The problem is, how does a phone talk to an insulin pump? It talks to the goober so that's it the goober is the bridge the Riley link is the bridge Don't be scared by it. It's a thing that makes a connection in the future. They'll be there'll be some the I guess the Bluetooth pods right when for dash comes out and then you guys will come out with something where that's right in the app and then the Riley link will be gone at some point, right?
Katie DiSimone 22:02
Yeah, so I DIY Katie says the rail link is necessary because the pump speaks one language and your CGM and phones speak a different language. Gotcha. Your your phone and your CGM are speaking Bluetooth there. They're over there speaking that one language your pump is speaking with radio. And so those two languages need a translator. And that's what the rilink does is it bridges or translates between those two different languages. So what title Katie's hat is saying is that the next phase of looping will be when you don't need that translator. And that the pump is speaking Bluetooth. And the phone is speaking Bluetooth and your CGM is speaking Bluetooth you don't need a translator anymore. And so the phone will be able to directly communicate with both devices. And so tide pool loops development is focused on insulin pumps that have an eye pump designation and Bluetooth capabilities built in.
Scott Benner 23:06
And can I ask tidepool Katie, a question real quick. On the pods all for this right? Like I've spoken to them, they're super excited to have a relationship with tide pool.
Katie DiSimone 23:16
They are incredibly supportive. And kudos to them for recognizing a community need and stepping up and partnering with tide pool to do that I I am as a parent of a team Wendy actively involved in the DIY community incredibly heartened by the commitment they've made with tide pool to bring that forward. Yeah, because at
Scott Benner 23:40
some point, the people understand, you know, let's say that we don't I obviously Katie's not gonna tell me timelines and because you need to be able to hit timelines and their company and all that stuff. But let's just make up a day and say that a year from now, tide pool is going to have this setup so you don't need your grouper and it's just going to talk to the Bluetooth pots right? On the pod might not be ready with their horizon system by then. But you can use you'll be able to use basically tide pools algorithm with loop to do that. If one day or when one day excuse me on the pod comes out with their horizon, you get to decide you get to use their algorithm, then try the loop algorithm and say, Well, listen, I this one works better for me. I'm gonna use this one on the pod completely okay with that, for those of you who are more newly diagnosed and have not been around diabetes for a decade or more, like I have that's unheard of, for a company to just be like, Hey, you know what, if this works better from you, and it's not from us, we don't care just we want you to be happy. That's insane. Like no one says that. Everybody always wants you tied down and locked into their thing. But this is the beginning of a whole new world. super exciting. You should be genuinely jacked up that on the podcast on this because this is just I think the beginning of a lot of good stuff.
Katie DiSimone 24:58
It's a monumental Shift, it really can't be oversold or overstated. How big of a shift this is towards understanding the needs of the community and saying, I believe that the marketplace can absorb this
Scott Benner 25:17
and decide for themselves.
Katie DiSimone 25:19
Exactly. And there's so many people that aren't on pumps. And I think there is a huge portion of people that aren't on pumps not just for access issues, but also for choice issues is that there's not a product that offers them a lot of choice, you're locked into one. And for Omni pod to say, Hey, listen, we support our product, we support this new tide pool, whatever the system is, like you say, they're into the interoperability and you can choose, and it's amazing, it really, it's, it's visionary, and I'm completely supportive of that kind of vision. I think tide pool has that vision to putting on a little bit of a toot their horn here, but really a nonprofit coming in and saying we're gonna take on this, this huge task, it really is a lot of work. Is, is amazing, and we have jdrf support for tide pool and Helmsley family trust is sponsoring a djabe observational study for loop users in the US, that's going to provide a lot of insight into how the system's working for people. So I really look forward to kind of getting this project down the road and showing what it can do for a lot more people who, perhaps like you mentioned at the start, look at building an app on their phone and say, that's just not for me. Yeah.
Scott Benner 26:45
Okay, so we're gonna get to the building part in a little bit. But I want to understand the using part first, I want to talk about the fun part before I talk about the heart. Okay, so, Katie, you don't know me. But when my daughter gets a plate of food, I look at it. I think that's 12 units. And I'm gonna break it down into an extended bolus. I'm gonna do 30%. Now I'm gonna do the rest over half an hour, we're gonna do a Temp Basal increase of 75% for an hour and a half. And that's that. And then if I'm right, great. And if I'm wrong, I adjust. I don't count carbs. I don't know my daughter's insulin to carb ratio. I don't actually believe she has one. I don't believe any of us have one. I don't think there's a static insulin to carb ratio. I don't think there's a static basal rate. I think all of that is some old timey bs way before this stuff was available to us before this technology. I think that was just the best people could do. And so how different is it going to be for me now when that plate of food comes out? Do I still get the guests at how much insulin is or do I now have to count the carbs? Or what's the real like how does it work in a real life situation plate comes out. What do I do? Are you looking for delicious low carb snacks and meals? Well, if you are, look no further than real good foods. You ready? You want to hear what they have newest offerings breakfast sandwiches that come in sausage and bacon. Of course they have the chicken crust pizzas and personal supreme personal pepperoni and personal three cheese. cauliflower crust pizza lovers do not miss vegetable pizza, pepperoni pizza, Margarita, pizza and cheese pizza. All of these come in delightful variety packs as well as one at a time. Have you had an enchilada for lunch lately? How about a pork enchilada chicken enchilada beef cheese or go crazy and get the mixed case. Real good foods also has real good poppers bacon and cheddar, jalapeno and white cheddar artichoke and cheese and pepperoni and mozzarella. Maybe you want the chicken crust pizza, but you don't want the personal size, go to the seven inch. Again cheese supreme and pepperoni. And if you go to their website, they got a pro tips area. Now it's not like our diabetes pro tips. These are pro tips about how to cook the real good foods to perfection. Because real good foods wants you to have a real good experience. Now what could make your experience better? Better than having what I've just described you sent right to your home is having sent to your home and paying 20% less. You'll see other coupon codes out there for real good foods for 10% But please, I told you a good foods for the Juicebox Podcast listeners 20% I demanded it and so it will happen real good foods comm use the offer code juice box. You can also find a link to real good foods in the show notes of your podcast player at Juicebox podcast.com.
Katie DiSimone 29:42
Yeah, so for you it will be an adjustment because I'm conceptually the same statements that you just made all still apply. The difference is instead of knowing your insulin dosing You're going to be refocusing on carb entries, because you will have to use a carb ratio Still, the whole premise of loop is that it makes a prediction of your blood sugar over the next six hours, and it says, This is due to these factors. And one of those factors is your carb entry that you put into it, you say, I'm going to eat 12 grams, this is what, based on my carb ratio, and my insulin sensitivity and how much I have on board, this is where it's going to go. So the carb ratio is still an important part of making that prediction line. That said, it's, it's not an insurmountable shift, because I actually was much like you prior to going into looping is that I knew these things needed extended bezels. And these things needed or extended bullets, excuse me, or maybe these ones get an extra hit of insulin in two hours. Those kinds of things all translate, and instead now instead of saying I need two units here, you get a carb ratio, and you say, Okay, if that previous thing needed two units, and my carb ratio is one to 10, you just do it now as a carb entry instead of an insulin entry. And so will it will be a shift,
Scott Benner 31:20
okay. And on the image I'm looking at right here, there's like pictures of like, I see a taco, I see pizza and I see candy, do I tell it 15 grams, and it's this kind of food?
Katie DiSimone 31:29
Yeah, see, that's the really cool part loop is the only system that does this. So for people who know after, after you eat a pizza, that first time, you know, if you gave everything that you need all up front, you'd be low, and you'd be incredibly high later. So what loop does, it's got this really amazing ability to extend your carb absorption and say, this is going to be a really long, slow burner, I'm going to be fighting the impact of this meal for six hours, or four hours, you can tell it that and the way that as you described, you know your meals, you know that this meal impacts your daughter this way. And it might not be the same for everybody. But everybody kind of has a sense of this particular plate of food kind of does this. And you can tell loop that ahead of time, and it will watch for you. So for pizza, for example, let's say you have 100 grams of pizza. And you know that you need about 60 grams worth of that bullet up front. And maybe 40 grams of that later. And you think of it in terms of your Temp Basal that you send stuff. But you could say I need about two thirds of that upfront, and maybe a third of that whole insulin amount later. Loop actually has that built in. When you tell it Your food is going to take a long time to absorb. It knows that if it throws all of the insulin on board early, you're going to go low early. So it will withhold some of that base, some of that Bullis recommendation, because it's going to keep you from going low early. And by withholding it early. It also knows that you're going to need some later and it will automatically add that as high temp basals as soon as your danger of going low, has passed. So it basically functions as an extended bolus for you when you push that pizza button.
Scott Benner 33:23
Yeah, so I have to tell you that I had I'm so bad with names. But like two years ago, I had that that woman on the girl who like made her own AP, like, you're gonna know exactly who she is. Yes, Dana, Dana on. And I had Dana's husband on, they did him in two different episodes. I don't know why I did that back then. But I thought it was interesting. And what I took away from those episodes where I just asked that, so I asked like a silly question. I was like, so how often does it Bolus she was really most of it's handled by basal rates. And I thought to myself, like it was like, somebody clocked me in the head and the light went off. And I was like, that makes so much sense. And that's it. That conversation helped me, you know, supercharged, but I was already doing, I was like, oh, okay, I'm going to use more bazel. As I look at this, my next question is, does it learn? Does it learn?
Katie DiSimone 34:16
Yes, and no, it doesn't learn long term. So for example, it's not looking at your last day or week and say, Oh, you look like you're running a little sensitive. It doesn't do that. But it does do some near term looks at how it itself has been doing. It looks as its own predictions. So basically, it looks over the last hour. And it says how close was I and if it thinks that it was really far off, it will wait the next 30 minutes of data and say I've been off a little bit. I'm going to help you out a little bit more because something's going on in the near term. And we'll fix that. So in the short term, yes, it looks at its data. But it's very short term in the long term. So there's this one thing you're talking about, like learning systems within loop, there's a really incredible line within loop. That's called insulin counter action effects. It's a big name. But basically what it means is that loop has a screen that you can tap on. And at the end of the meal, it will say you told me this was a 50 gram meal. And actually, based on your blood sugar response, and how it handled it, it actually hit you more like 63 grams. And so you can actually learn a lot from loop. When you look at your food at the end of the meal, you can go, wow, you know what? I see what it's saying, based on my blood sugar's that meal treated me as if I was 80. So you know, nutritional labels aren't right. And sometimes you're at a restaurant and you're like, I'm still trying to learn this meal. How? How much do I give up front? How do I, how do I Bolus, this meal loop will provide that input that impactful statement towards you, or for you at the end of the meal and say, Hey, that meal treated you like this. So the next time you go back to have that meal, you'll be better informed.
Scott Benner 36:07
So this is like a blown up idea behind all carbs aren't created equal. Yes. And it's an extension of what I told you where I say I stay flexible, I put the incident and I see what happens. And then I stay flexible. So in for your knowledge. If I were to do a, you know, do the regular Pre-Bolus that we do you know, as far as time goes, and Arden starts eating and 30 minutes later, I see a diagonal up arrow, I do what I call stop the arrow, I stopped the arrow from from going up, I use little bits of insulin to make a stop. And then the next time I would say to myself and I preach it to people all the time. You look at a meal. And you think oh, that's five units. And then you later use a half a unit to correct it. Well, then next time, don't look at the same meal and go that's five units say to yourself, that's five and a half units.
Katie DiSimone 36:56
You can't see me I have my hands in the air go on. Yes, yes. Yes, exactly. It's dynamic thinking is probably the biggest tool you have in your tool about for successful. I'm
Scott Benner 37:08
kidding. I wish I knew what a moron I was that anything in life has struck me well, is, is absolutely a miracle. But that I figured this out, you have no idea that it was me doesn't make any sense. like it should. This is not something I should have figured out. And I don't know how i think i a lot of times give a lot of credit to writing on my blog for so long. and wanting to help people. And seeing that I had to find out what worked for me. And then I would wait months, I would never share anything right away. I'd like let me make sure this is really valuable before I tell somebody about it. And then I would tell them about it. And I kept building and before I knew what I realized they had like these, like 10 basic tenants of how to keep a blood sugar stable. And I was like, wow, this is like a system. Like it's a way like if I put it all together, it makes sense, you know? And still, I swear I really wish you knew me because that I figured anything out is just hilarious. No, it is it is absolutely huge to have a dynamic attitude. If I always put it as respond to the information you're seeing, not the information you thought. And so if you're seeing that a meal is actually cheating you like 10 grams more than what you thought you had to give more, take that into account the next time and if the people who are listening aren't thinking right now trust what you know is going to happen is going to happen, then you have not been listening closely enough. Okay, so you have to trust that what you know is gonna happen, it's gonna happen. You can't get high every morning at 8am and every morning at 745 think oh, I hope it doesn't happen today. It's gonna happen. Give yourself insulin now. Right? Like so. Oh, I'm not see. All right, okay, let's calm down, because they think we're coming up to the point where I'm gonna get upset and sad. So I see how it works, I see that my daughter will be able to, you know, count carbs and do things like that, that I also, by the way, believe holy, that people eat mostly the same thing over and over again. So it's not like you're counting carbs forever or trying to figure out how much insulin a meal is forever. Usually you eat about the same 20 or 30 or 40 things eventually you'll figure out figure them out on Dexcom you want a Dexcom you might not know you want it or maybe you do know you want it one way or the other. You'll want it dexcom.com forward slash juicebox. Here's what you're going to get when you have a Dexcom a GE six continuous glucose monitor, you are going to get information. And as they say information is what do they say about information? There's a saying about homozygous I know there's a saying about information all the time. Well, there's 486 sayings about information. It's not helpful. No, that's not it. Huh? Oh, that's kind of deep. Albert Einstein, but not the one I was thinking of like that one. God, turn DNA is like a computer now. Or maybe there's not a saying about information? Well, I'll tell you what, I'll make one up right now, when you get the information back from your Dexcom, you make better decisions about your insulin. That's all. There's nothing else to say. That information can come to you with the next comment a couple of ways. One way, share and follow available for iPhone and Android. You know, that means sharing follow, like there's an app share, and there's a app, you know, share app follow up. One you probably like the person you love, who has diabetes has to share up and then another one of you, like a person who cares enough to pay attention to their diabetes, that's the follow up. And then there you go, their diabetes does something that goes up, it goes down. It's trending in one way it's trending in the other. It's moving, it's dancing. As you can tell, I'm making this episode late at night. And I'm completely dopey. So just buy a Dexcom dexcom.com, forward slash juice box links in your show notes and Juicebox podcast.com, you will not regret making the jump to continuous glucose monitoring with Dexcom. So here I am. I'm Scott, I'm standing in front of my microphone, and I have ordered my Reilly link, which is on backorder. And by the way, if you know anybody who can help me with that, Katie, I would appreciate if you put in a good word. And it's going to come to me, my goober is going to show up in the mail. And there's other things I could probably be doing before it gets here. Is that true?
Katie DiSimone 41:30
Yes, you can do everything before it gets here. Except actually, you can build the app, you can get other things set up. If you're ready for it. If you're a nightscout user, you could get your nightscout set up, you can you can do everything you can except for turn on the router link and look,
Scott Benner 41:51
okay, and this is not going to get in the way, by the way of my Dexcom share, that's still gonna work fine. Everybody's gonna be able to see that stuff.
Katie DiSimone 41:59
Totally. It's still you still actually use your exact same Dexcom app, your Dexcom alarms are all still the same. Basically, what Luke does is it eavesdrops on your dex comms communications. And so it doesn't interfere with your Dexcom. Okay.
Scott Benner 42:14
All right. So, if you were me, what would you do first?
Katie DiSimone 42:20
If I were you, what I would do first is I'm kind of conceptualize what your game plan is. Number one, is, get your computer up to date. And also kind of let me take one step back on my Instagram account. I do have a loop advent calendar that I did just kind of on this topic, as I was trying to prepare the community with this is coming. And here's a really small, digestible day by day, advent calendar of day one, make sure your computer's up to date. Do you have Mojave Mac OS? I'm kind of explaining what starts to sound like technical stuff, just pay Make sure your computer is up to date. And it has some back Is that right? It does have to be a Mac, yes, it has to be a Mac running what they call Mojave
operating system, which is their latest one.
Scott Benner 43:12
Oh, I see your Instagram account. Look at you, you're delightful Look at this.
Katie DiSimone 43:18
So yeah, so you can run through each of those admins day by day and just sort of take it in tiny digestible chunks, and do each of those. And basically, you prep your computer and and this is the part that looks intimidating on the website. But it's actually not is that each of these are natural stopping points as I've tried to lay out the pages in the building the app section into natural stopping points. And so you prep your computer. Basically, you want to make sure your OS is up to date your operating system and that you download a free app from your app store that comes from Apple is called Xcode. And basically what Xcode is, is like you present that code for the application for the loop application. And it compiles it all and builds it into a nice little package, you plug your phone into your computer, and Xcode puts that app onto your phone. So you're literally downloading the loop code from us online. And you're using a free app on your computer and you press like four buttons, and the whole thing builds by itself. That's how easy it is.
Scott Benner 44:25
Fancy as now Yeah, I have already. Wow, Katie was saying that even though I swear to you, I didn't know she was gonna say it. I've already downloaded Xcode onto my computer. Haha, yes.
Katie DiSimone 44:38
That's step one is you get that on? It's actually a pretty big download. And believe it or not, that's the longest part of building a loop app is downloading.
Scott Benner 44:49
Okay, so
Katie DiSimone 44:50
then I have a cup of coffee and you're good.
Scott Benner 44:52
Okay. And I need a developer. I have to be like an apple developer, right? Yeah. Because Because for everyone listening, I know Am technically making my own iPhone app right now. And they're gonna give you obviously all, you know, Luke gives you all of the instructions and the you know, and the code and everything you need for it. But you have to do that because it remains your responsibility. And yes, right. And in the future, if I, once everything, you know, work in the way we want it to work, but tide pool and everybody's got their own Ks and their FDA clearances and everything like that, I'll just download this app from the App Store, I'm assuming or downloaded from tide pool.org or something like that. And it's gonna go right on my phone, I'm not going to need to be a developer have Xcode or anything like that. Is that right? Correct.
Katie DiSimone 45:35
The tide pools project is basically taking the fundamentals of the DIY loop system, and taking that through FDA approval. So the study is going to help solidify what needs to be done to make that app able to be distributed as a medical device under FDA approval through the app store. So yeah, that's where the that's where the two projects between DIY and type loop start to diverge is that concept of being able to download this on your app store on your iPhone, and what needs to be done to make sure that all the FDA clearances are done.
Scott Benner 46:14
So yeah. So to tide pool, Katie, eventually, this is just gonna be checkboxes and drop down boxes on an app.
Katie DiSimone 46:23
Yeah, what we envision is that you'll, as type Oh, Katie, I'll speak now is that you get to go to your endocrinologist, talk to them about your settings and your carb ratios and make sure that you have some reasonable settings, they prescribe title loop for you, you have your components, and you get to go to the app store with your prescription number and download it.
Scott Benner 46:47
Okay. All right. Let me think. I'm thinking, it's coming in my head, I'm figuring it out. So it's going to look, it's going to look like a lot, but Katie has as a person who's done this, not knowing what she was doing, and getting what would probably be the best expert advice that she could as she was going along, has turned it into the simplest step she could possibly have now, I'm gonna do this and I'm gonna, whenever my Reilly link comes, I'm gonna, I'm gonna be ready. I'm gonna be set up and I'm going to go, and I'm going to try it and see what happens. What is my expectation for a person who lives between 70 and 120? a, like, in my mind, I think my first excitement is going to be sleeping soundly overnight. Is that is that the simplest win that I get from loop the effects?
Katie DiSimone 47:43
Yes, for sure, sleeping through the night is unbelievable. I think I didn't know what I had started missing until I started sleeping again. Good example. Last night, my daughter was out to the movies with their friends and needed a ride home at 130. In the morning, it was a drive in double feature far away. And so I was up until 130 in the morning, I can't even tell you how tired I was. Because I've gotten used to getting a full night of sleep all the time. Now, it really was daunting to have to go back to the olden days of missing hours of sleep.
Scott Benner 48:19
You're making people cry right now you don't realize that but there's like thousands and thousands of people listening and they're like weeping in their cars. And while they're working out at the grocery store and stuff like that. So that's a Yeah, yeah,
Katie DiSimone 48:29
I'm a I'm a different person. When I sleep, I'm a nicer parent. I'm a better spouse. There's, there's like a lot that goes with sleep. Yeah.
Scott Benner 48:36
There's plenty of conversations in this podcast where I tell a story about I was so exhausted at one point, and I didn't know it. And then I went away for a week without my daughter. And about the third or fourth day into the trip. I thought to myself, Oh my god, this is me. Like I remember having thoughts like this. Yeah, you know, like and being clear headed, and that sort of a thing. So that's my, that's my excitement. Can I ask you something? Yeah, say I decide I like loop for sleeping. But I want to just stick with what I do for eating, can I do that?
Katie DiSimone 49:08
Hundred percent. You can turn on loop has one slider, it's super simple. It's called an open loop or closed loop. If you open your loop loop will let you just get the recommendations but not automatically put them in. So it will use your scheduled Basil's just like your normal pump therapy would it would just give you your bezels that you have programmed in and you can choose to deliver the insulin any way that you want to, you can enter the carbs and you can choose your particular bullet sport. So let's say during the day, you want to say you know what, I still am working out my carb ratios. I'm still figuring them out. I just kind of want to do at one meal on a convenient Saturday and see how my settings are but in the meantime during the week while she's at school, I just want to keep our old paradigm until we can get to for example right now. Thinking summer, you know, hey, summer, I'll be home, this will be easier. Absolutely. You can go to school, keep it an open loop, they can enter their carbs, provide whatever bullets number they want and loop won't be taking any extra action. And then when you come home at night, you can go ahead before you go to sleep at night, you can turn on the closed loop switch, just toggle it right over. And it'll be looping overnight then.
Scott Benner 50:25
And so being an open loop would show me what the algorithm is thinking because it would say to me, hey, right here, if I was you, I do a Temp Basal increase of
Katie DiSimone 50:34
Absolutely. Every five, every five minutes across the top, you'll see the recommendation update, and I'll save this is the new basal rate, I think you should set so you'll be able to see if it's greater than or less than where your existing settings are. And you'll see the prediction too, as well. You'll see the prediction go up and down. I think that's one of the first things that kind of freaks people out as they see that prediction. They're like, Oh, do I cheat a low now because it shows in six hours, I'm going to be low. That prediction line is always as if no other actions are taken. And that's the whole thing is that loop is going to take actions to prevent or change what is in the future. So if you see a low coming in six hours, you don't need to treat it right now. loops going to be treating it for the next six hours and staving that off.
Scott Benner 51:25
And so that ever happens. It's just like a time travel movie. In a time travel movie, sometimes they show you what's going to happen in the future. But then the people in the past make better decisions in the future never happens.
Katie DiSimone 51:38
Yes, that's exactly what loop is doing for you is insane. Oh,
Scott Benner 51:41
wow. And Katie, by the way, now you know why the podcast is popular because I can take incredibly complex things and turn them into moron talk that everybody can understand.
Katie DiSimone 51:52
I have tried to do that with loop building instruction. So I think you're I think you're my kind of people,
Scott Benner 51:57
like a seven year old in my mind. So okay, so I also just realized, I might be boring, and people are gonna laugh because I don't think I knew this about myself. I think I'm more of a diabetes geek than I thought I was. Because when you said you could open the loop, and then see what it was thinking. That to me takes me back to back before CGM when I used to test Arden and all these wacko times that my end would be like, why did you test 45 minutes after she ate? And I was like, Don't you want to know what's happening? And she was like, no. And I was like, No, I think we should know. Yeah, you know, like, I'm gonna keep testing. She'd always be like, I don't understand how you're a one sees or like this. But you're showing me all these weird blood sugars that don't make sense. I'm like, because I'm tracking what her blood sugar is doing so I can make better decisions. Yeah, I really think I really think that with six months with loop, I might have to have my head made larger, not for my ego, that one person that left the review, but for my knowledge of diabetes, because I really think this is going to just kick it into another stratosphere.
Katie DiSimone 52:56
It really it's a truth serum, it really tells you a lot about your settings, your understanding how you conceptualize and reacting to things. For example, a lot of people as they're getting used to this are impatient with insulin. They'll say I don't want to wait it out. And they'll rage bolus or or they think the rage bolusing they're actually not even bold enough with insulin, you know, name to say, Oh, I'm so scared of going out having the feedback from a loop constantly telling you, hey, here's what I would do. And here's Oh, by the way, your meal absorbed 20 grams more than you initially told me it would be and lasted. It also tells you the time and took two hours longer to digest than you expected. That kind of information is so powerful to relieving the diabetes burden because it's fine tuning your expectations. And when you change your expectations for going into it and say yeah, you know what, it's okay that this meal choose me as 65 I feel comfortable, something has helped me learn better.
Scott Benner 54:04
Okay, I'm so proud right now. And I don't know if you did that on purpose, or if that was by mistake. Either way. I'm proud. You said bold with insulin, which is really the whole tagline for this podcast. It's that's my hashtag. It came from here. If you don't know that, I'm just thrilled that those words are somehow in your brain, which means it's getting out in the to the shadow sphere. And if you did know that, I appreciate you listening.
Katie DiSimone 54:27
Well, I actually heard that from a podcast interview you had with T when Junebug because she's a good friend of mine for several years and I saw her use that phrase and I thought Yes, that rings true people
Scott Benner 54:43
are scared to dynamically think they'll see the same blood sugar rise the same blood sugar rise, the same blood sugar rise, and yet say but the label told me it should be 10 grams or my endo told me it should be this and stringing that along and, and being a more dynamic thinker and being bold with the insulin, taking the insulin you need for what you've seen over and over again, is really good dynamic thinking. Yeah, I appreciate that. I was just speaking with a mom last night. And I said to her, you have to I said, I know that, you know, I haven't given you any advice here, because I don't give advice. I just pass on my own stories. But I told her, I said, I can give you this one piece of advice. I said, I would stop thinking about all the things that people have told you to do, and told you not to do and just apply a little more common sense this, you know, like, like, stop overthinking it, your blood sugar's high, you need more insulin. That's kind of Yes, I'm down to like, if I see something online, people are like, look at this graph, and I go, and I type more insulin. And then I hit Enter, because I can't I can't explain it any more. We do it here enough. But sometimes I'm just like, how can you look at a 300 blood sugar and think I don't understand what's wrong, I know what to do. Of course, you know what's wrong, you didn't use enough insulin. And so
Katie DiSimone 56:03
it's not going to be it's not going to be the same and it's not going to be perfect, my daughter gets nervous around certain situations and her blood sugar spikes. And Luke doesn't know that's coming. Nobody gave it an announced warning, nobody gave me an announced warning, or my daughter. And so there's ways that you can help correct that faster as well, you can still override and give more insulin and give a correction. There's a lot of information built into loop to help you with that decision making process. If you choose to take that interactive step. If you're the type of person that just says you know what? I'm happy, I'm happy with a little wider range. And I just want less cognitive burden of interacting with it today. or long term, you can let Luke do that as well. It's it has all the information put in there that it will meet you at your comfort level and help you make the most of where you are
Scott Benner 56:59
gonna say something real quick. And I'm gonna ask you a question. What I'm going to say first is for everybody listening who has come to count on the podcast, I just want you to know that even if I do this and stay with it, I think it's only going to enhance my ability to talk to those of you who aren't doing this. So don't worry about that. I the thing I want to ask, Are you comfortable telling me what your daughter's a one C is on loop?
Katie DiSimone 57:20
Oh, yeah, totally. She started loop at 449, I think. And again, we were low carb, heavily intensively, lots of work, lots of communications, lots of texting, lots of lost sleep. So we are working hard. She is now at a five, six, what was our last 156? I think, and she is as high carb as they come has become a vegetarian. So we have no, no like low carb meals ever. And she is completely independently operating and bolusing and doing everything through loop. I have not told her how to split a bolus in, I'm gonna say a year. She is completely handling all of that just by loop recommendations and putting it into a loop. I hope I don't tear up, it is changed everything. I now have the space reclaimed for what used to be diabetes conversations I now hear about her friends at school. I hear about the things she wants to do I hear about going to the beach, and can I go on a date, and I hear the things that I'm supposed to be hearing and they're not laced with. Don't forget to bring diabetes into this conversation. Don't have to do that.
Scott Benner 58:46
Don't forget Did you I start too many sentences with Did you? Or you know, can you tell me or what does the say? There's, there's still and listen, I'm gonna be honest with you. We don't talk about diabetes around here very much. Because we really are. We just have a rhythm. Like I don't know another way to put it. But at the same time, it still happens. And if it could be less, that'd be amazing. And if it's less for me than I imagine it's going to be much less for a lot of other people. I have to say that this is this is the future that I always imagined. I always thought it was going to come more in like 2020 like, right, that was my kind of estimation. And I was always happy with that because I thought well, that's still a couple of years before Arsenal, go away to college, so I'm okay with that. But just the idea that it could happen sooner. It's got me
Katie DiSimone 59:40
It's amazing. I'll give you an example. When my daughter goes to summer camp, we always talk well do you bring lip Do you not bring loop and you know, I realized that sending her to camp with a non FDA device puts a little bit of burden and asked on those camp staffers and you know, so cognisance of maybe we don't lose when we go to camp and certain camps even don't allow it. But our particular camp is supportive. And, but it's always, it's always funny, she goes to camp because she doesn't want to feel different, right? She's got her, her crew, her tribe. And she doesn't feel different around them. But she does feel different. She's perceived this, if we talk about it in April or May, of going to camp using loop because she's worried none of her other friends will be using the loop. And so we have this conversation every summer for the last two summers about whether or not she's going to live there. And every summer, she goes into it telling me, well, I'll probably take it off while I'm there. I'm taking it now. But I'll probably turn it off, because I don't want to be different. And she never turns it off. And she comes back to the pickup station after two weeks away. And all of her friends are around her. And I'm telling you, it's like a little gaggle, there'll be five teenagers with her that I'll go. Katie, can you get us on loop to we want to use it to? And so, you know, I kind of take that, as my bellwether of how good the system is, or isn't, is if adults weren't involved, and parents weren't involved, what would the kid decide to do? Because I think that's a really important aspect is the informed decision making process involving the kid and letting the kid be a part of that? And so when she comes back from Camp, and there's five kids with are saying, um, can you help us? We want to do that, too, I think it's a good sign that the system is well designed and helpful, as opposed to an extra burden that just isn't useful. And
Scott Benner 1:01:34
it makes a lot of sense, can I pick your brain about something else as a, as a person who's obviously given a lot of their time and effort to the diabetes community? I think that overall, that shows the your concern for people who you know, who have type one and people who you don't know who have type one, and I feel similarly. I don't ever have this feel fear. But I know some people do that if you take away the idea of how to manage diabetes, that if the technology is not available, you'll be lost. And I don't talk about that here. Because I think it's silly to make somebody struggle and cry and be upset and exhausted just so they can understand how Bolus works. I don't think you need to do that I have dedicated this podcast to fast forwarding people through that whole process. But I'm now I'm projecting into the future, right? I talking privately and have been for weeks and months with a mom of a little girl who is so newly diagnosed that she's honeymooning to the point where she doesn't need insulin some days. And it's really going on for a long time. And I'm imagining her right now. And I'm thinking I could put this on her. And she would never know all of the tragedy that I've lived through and that so many other people have lived through, like figuring out diabetes. And is that a good thing? Obviously it is. It seems like it is at the onset. But what would happen if that technology like if her insurance changed, or something happened, it was just taken from her? Do you think that she'd be gobsmacked blindsided by what diabetes really is without the technology? Have you ever thought about that? Like, I'm just interested in your in your like off the top of your head thoughts?
Katie DiSimone 1:03:21
Oh, yeah, I think I think people would be if it disappeared from us. For us. Would it be impactful? Would we notice it? Absolutely. I'm giving you an example. We we switched to Omni pods because we were having problems with sites on NEOs and Medtronic. So one day during a particularly painful yet again, canula failure kink kind of issue day. And she had to turn off loop. We were just perfect storm CGM fails, Meo failed, we were playing blind and she had to give herself a shot for the first time in two and a half years almost. And I was away from home. She was home alone. And I said, Can you do it? And she's like, Yeah, Yeah, I think so. And she did. And it was daunting and all of that. But that said, You do what you got to do. And I don't believe in keeping the covers on the couches, and not using the things that are great in life just because something might fail later.
Scott Benner 1:04:36
I don't, I don't like it when there's fear mongering around advancement. And and I think it happens a lot. I think when Dexcom first came out, there were people running around going you're not going to understand your diabetes. And I think there are people that tell people, you know, you have to have a do shots for a year before we give you a pump. I think all of that and I'll bleep this out later. I think all of that is okay. I think that you need to understand how it Insulin works in your body, and then you're good. And it seems to me that this algorithm is going to understand how insulin works on my body. Now, should I still understand it? I should, but I, but what I'm foreseeing in the future is, is that you're going to go on this. And right on the screen, you're going to see what's happening. And you will learn how insulin works in your body without ever having to fumble around with the algorithm is not just going to keep your blood sugar where it wants to be where it wants it to be. It's going to teach you how it's doing it visually. Yes, that's what I'm seeing here. So now, you'd have to translate that back to a pump without a loop or injections, if you got stuck in that situation. But you wouldn't be starting from zero, you'd actually have a fairly fast forwarded understanding of it. You're going to put this podcast out of typo, you're going to need to hire me if I can't get down listen this podcast anymore, because your loop seriously, if flu puts my podcast out of business, Katie, I'm gonna be pissed.
Katie DiSimone 1:05:58
I tell you what it really does. It's like a truth serum are the assumptions that people had about their diabetes? Understanding? This
Scott Benner 1:06:05
is wrong, guys. You're always wrong. Everybody. I'm sorry, can I cut you off? Everybody who sends me an email is like, I think this is what's happening. I'm like, that's not what's happening. You're basals. Wrong. You're like, like, no one ever really knows. Because it's, it's, it's, it's this false idea. And then I had somebody on recently who said this thing that just struck me, he said, you know, if you put a pencil in your back pocket, then you rob a bank. pencils don't cause bank robbery. But yeah, but somebody thinks it does. somebody sees this cause and effect, and they just say, I saw this, then this happened. So that thing must have been the reason why and we make that mistake. So often in diabetes, it's not funny.
Katie DiSimone 1:06:42
It really it's such a true serum is that people get on when things are automated. That means it's using the same assumptions you've put into it. And when those assumptions show, hey, you're trending high, or you're trending low, consistently, people like what but these numbers were set in stone, I these were fine. I was doing fine. And what they don't realize is no, you weren't doing fine. You were you were taking a lot of manual actions to make it fine. Or you were adjusting in other ways that you hadn't realized. And so when it to two wrongs can make a write in diabetes, you can overlook things very easily by having two wrongs equaling the right. Yes,
Scott Benner 1:07:29
there are so many times that people are having a good outcome at 3pm. That's really just from mistake at noon, and they have no idea. Yeah, it's really it really is. Once you see it, it's I joke about that it's a little old of a reference. But once you see it, it's it's like at the end of the matrix when the bullets stopped moving for Neo, and he's just kind of like walking in between them and moving away. Like once you can see it, it's fascinating.
Katie DiSimone 1:07:54
Well, loop provides that visual, that visual interface to be able to see it. So one good example. So for example, let's take your correction factor or your insulin sensitivity. A lot of people have a wild guess at that, but they don't really know and they haven't tested it. And when you see your blood sugar's on an automated system, kind of roller coastering, up, and then down and up, and then down, you're also probably gonna see what I called lightning bolts of Temp Basal. So you'll get a lot of Temp Basal action trying to correct a rising blood sugar, and then suddenly, you'll turn low, and are not low, but you'll start heading down and then you'll come back up, and you kind of get on this oscillation a roller coaster. That's usually because your ISF is, needs to be higher number. So I don't know I'm avoiding using the word weak or strong because people have different impressions of what that word means in terms of where the actual number needs to go. But if you had put in, if you told loop, each unit of insulin will drop my blood sugar 50 points. And you start seeing that roller coaster pattern, that's a really good indication that your your value of 50 actually might need to be up near 70 or a different number higher than 50. Because you've basically undersold insulin to loop, it's actually doing more than it expected. And so some of these things about loops, ability to inform you of your diabetes assumptions are really like strikingly obvious. As soon as you start using it, as you start seeing that you go, Holy smokes.
Scott Benner 1:09:33
That's crazy. Okay, so I have a couple of just like, like fast paced questions here. So, first day of a dexcom sensor in the first few hours, I don't really lean on it for like, you know, I don't want to put a time on it. But until it's right, like until it's soaked in and it's really working. So do I just go into open loop during that time? Is that what Yes? Is that what you you could?
Katie DiSimone 1:09:52
You could No, it's not what I do, but you could, um, my daughter basically usually ends up changing herself Sir at night, which is I think the worst time to change a G six. And so the whole first night, we basically get a lot of false lows or compression lows. And what we have found is that basically, loop still does, okay, it doesn't. And in essence, what happens is that you get some higher basal rates, you get some suspensions, and they all even out over the course of the night to be okay.
Scott Benner 1:10:26
numbers out the kinks and gets it gets you Yes,
Katie DiSimone 1:10:29
yeah. And then when she wakes up in the morning, finally, the dexcom is back on an even path, and everything's fine. So for the first 12, I, for us, it's, you know, it will depend on the person, but for us, the first six hours of a new sensor are kind of jaggedy. And if it's really far up, we can go into open loop mode, and it's no problem.
Scott Benner 1:10:51
Okay? What about different insulins? Do Do people see different? Or does it not like we use a pager? That's gonna be good?
Katie DiSimone 1:10:57
You send me up on that one? Yeah, actually, within loop, we have three different insulin models. So there's four, but three are based on the type of insulin and the user. So there's a rapid acting adult, which is like, no blog humalog. For adults, there's one setting for children. And then there's another setting for fiasco. So um, and then each of those settings basically describe how the insulin curve works. If you after knowing your data and kind of looking at how things work, say, wow. On our particular insulin, we think it peaks at this amount of minutes, that's actually something you can customize within your loop to say, it peaks at this time, we have numbers put in there that are based on the published data of how these things behave, and clinical trials and all of the published data. But if you find that for you, your diabetes is different, you can actually tweak and customize some of those things.
Scott Benner 1:12:01
Okay. And so a lot of it's customized, like for instance, can I pick her target blood sugar?
Katie DiSimone 1:12:05
100%.
Scott Benner 1:12:08
That's the one thing I would just not like, I don't I would I want to sleep more but not at the you know what I mean, not not to say that, I don't know what the, the Medtronic, artificial pancreas, but it's like at 120 or 140, or something like that, like, I couldn't do that, I wouldn't be able to make that decision,
Katie DiSimone 1:12:25
I'd say out of all of the feedback, I consistently hear on the development of closed loop in the commercial market, that target setpoint is, is the real critical piece for a lot of people. And on this one, you can set it anywhere you want. We have people setting it that are ultra low carbers and have a single number target that they really aim for. And there's other people that are doing a much wider range and are so yeah, it's totally up to you what you want to set it up. Okay, is it
Scott Benner 1:12:55
my so my last kind of nuts and bolts? question is, do I tell it when a new pumps going on? Like, how much does it care about how old the infusion set is?
Katie DiSimone 1:13:02
If you're on Omni pod, it keeps the theme, standard change cycle as Omni pod, it will alert you it's well at 72 hours Omni pod tells you this pods done. But at 80 hours, it really makes you change it and says you're done done. And loop has the same things. And you can set a custom notification for when you want it to tell you hey, it's coming up.
Scott Benner 1:13:24
What about this? Here's another I said I wasn't gonna ask anyone not symbols question. I have one more. What if a canula like comes out a little bit? And I'm getting some of my insulin but not all of my insulin? does it know that? What's that? It's not seeing what it thinks it should be saying?
Katie DiSimone 1:13:39
That's a great question. And the answer is no, in a way is that basically it thinks you delivered a whole unit, the kanila actually only managed to get half of that under your skin and absorbed loops calculations will be a little off, it will think that you have more insulin than you do. And so what you can do is there's a couple of different options, you can open your loop until that discrepancy wears off, and you get it all changed and figured out, you can open loop and just go back to normal pump therapy. Or you can enter in a fake carb, where you say hey, I'm going to eat five grams Bolus me for these five grams. And basically you're tricking the algorithm to think your blood sugar will rise because you were eating and so therefore, it will offset some of that it's a more advanced technique and people kind of start using that in those situations once they become a little bit experienced. But that is an option as well to kind of say, Hey, I'm going to need extra insulin that you think is there but what we call
Scott Benner 1:14:45
that stuff ninja level. So yeah, okay, so all right, so here's what I'm gonna do it because we've been going at it for a while and I want to make this digestible for you. We're gonna stop. I'm gonna say thank you. I'm going to ask you, after I get this back when you come back on and talk with After I've been using it for a little bit,
Katie DiSimone 1:15:02
I would love to, I think that would be great. And can I have an ask of you?
Scott Benner 1:15:06
I guess so. But I'm not taking my pants off.
Katie DiSimone 1:15:10
So the the ask is, is that, um, I want to make this system better for everybody else and make sure it goes there, you know is able to incorporate all of these things like soliciting impact feedback. And that jabe loop observational study is a really important part. And it's the best way that people have to pay this board and provide meaningful impact, I would love it if people would take a look at the study and donate their data, it can all be done from home. It's super convenient. It's very fast and easy. And it provides important user information, especially from new users, or like just getting on the loop. You're asked questions about, like, how did the setup go? How hard was it? Are you technical? Are you not technical? How do you view diabetes, all of that's going to paint this incredibly awesome mosaic of what kind of user experiences have been and just kick the system into a better place.
Scott Benner 1:16:09
Okay, so when we've talked about it here, but the next time we talk, I'll give direct, you will be able to give direction instructions to people about how to donate their their data to that. That'd be great. Excellent. Okay, I don't want anybody to worry, I still understand how to be bold with insulin after a day and a half of looping. As a matter of fact, that loop, just like Katie said, is showing me things that I don't think I understood. But I'm starting to, and then I'll be back here to report to you. So whether you want to loop or not loop, or Lulu skipped your Lu. Or just keep doing what you're doing, or do what I've been doing for years, which might be what I'm doing again, I don't know how long we're gonna do this loop thing. We're trying it. I can't do a podcast if I don't understand looping. I mean, it's 2018 Wait, is it 2019? Wait, I mean, it's 2019. It is so late at night here. I'm out of my mind. I hope you found this episode. Interesting. And what Katie had to say intriguing. I certainly did. It got me off my butt to try looping. And as soon as I know what I think I'll report it back here. Huge thanks to the sponsors Dexcom real good foods, and dancing for diabetes. The links to everything you want to know about them are in the shownotes of your podcast player or at Juicebox podcast.com. But you can always go to dancing the number for diabetes.com real good foods. com use the offer code juice box, or of course dexcom.com forward slash juice box. I'll see you next week.
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#226 Diabetes Pro Tip: The Perfect 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
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 Episode 226 of the Juicebox Podcast. Today's episode is called the perfect Bolus, and it is installment number nine of my diabetes pro tip series with CDE Jennifer Smith. I'm gonna make this episode ad free, but I'll probably give them a mention here and there, you know, not a whole like big sell, but still, I really love the advertisers. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And the Always consult a physician before becoming bold with insulin or making any changes to your medical plan.
If you find yourself loving Jenny as much as I do, and you'd like to hire her personally, you can go to integrated diabetes.com. To find out more. There's also a link to Jenny's email address right in the show notes of your podcast player. And at Juicebox. podcast.com.
Hey, everyone, Jennifer's back. And we're here today to talk about the perfect Bolus. So that already sounds like a topic that everyone's gonna get upset about when they hear but i think but there's a lot of different ideas here. So Jennifer, what I was thinking was, Bolus is different differ depending on situation, right? You might have a high blood sugar a low you might be falling, you might be rising, you might have a new site. There's
Jennifer Smith, CDE 1:39
exercise, you might Yeah, keep going. Right? You may have just exercised you might have you might be ill you might have your period, you may be coming into having your period, you know, your dog might have eaten the other dog next door and like you're dealing
Scott Benner 1:54
with a little bit of anxiety going and there's a different tick, Good dog, maybe your next door neighbor's dog Jennifer, Has that ever happened in your life? So psychologists say that if you make up something like that, it comes from something. I don't believe that because my my humor is so bizarre that I look back sometimes. And I think, but that was something really strange. I just said does that have any real connection to my thoughts? And I've really looked closely because I've been worried in the past. But I don't think that's true for everybody.
Jennifer Smith, CDE 2:22
I got a chocolate lab and I don't think that that's even in there. Totally not in the nature. So anyway. No, it's never happened, thankfully.
Scott Benner 2:31
So you people have already learned the chocolate labs are not carnivorous. At least towards other dogs.
Unknown Speaker 2:39
Pog, Oh,
Scott Benner 2:41
my gosh, okay, yeah. So anyway, so I want to start with I mean, we're just going to pick one, right? Let's say your blood sugar's where you mean for it to be your bezels are in check, they work? Well, you haven't eaten in a while. It's the perfect scenario, the one that they described you in the doctor's office, the first time you're diagnosed, right? Your blood sugar is 95. And you're hungry. And you're thinking, What am I going to do? So? Ideally, we know at this point, now from listening to the episodes, we have to figure out what our length of time for our Pre-Bolus is. Right? But how do we know? How much to Pre-Bolus? And I think the answer always has to be, I can't tell you, Jennifer can't tell you it's situational, but that you'll learn through trial and error. So but let's make this one general, right, it's a it's a nice balanced meal, you've got some vegetables, some carbs, there's protein, it looks like it looks like a plate from a superfriends episode that the government told you how to eat in the 70s. The food triangle, it's called
Jennifer Smith, CDE 3:47
a triangle.
Scott Benner 3:48
So so if you're a nice steady blood sugar, if if my daughter was at 95, and I thought this was a pretty, you know, average meal, as far as what I expect, as far as impact back from it, I might put in all of the insulin, you know, in the beginning, but I also might even say, hey, there's bread in there a potato that might stretch out the action of the impact of the carbs over more time. So maybe I'll put in, I don't know, 50% or 60%, and stretch it out over a half hour an hour just to create, like we've talked about in the past that kind of blanket of insulin to cover the entire impact timeline of the carbs. I think that the thing to remember is, is that there can't be really a set idea for what that means. Like maybe you'll figure out a meal eventually and say it's 70% and 30% over an hour. You might get to that point at some point.
Jennifer Smith, CDE 4:39
And many people do many people who have pretty consistent intake, or like the same things over and over. But the variables would be around that will sometimes change even near more standard figured out meal.
Scott Benner 4:54
Yeah. And so I think so my first my first step, I'm telling you Any good Bolus, that one that has any chance of working, I think it's a nice simple way of saying it has to have a Pre-Bolus. Like you have to start, you have to start getting the momentum of your blood sugar moving down, so that when the carbs start acting, they move up. So so that's that, to me, that's step one. Now, do you talk about or do you in your own life use combination of Bolus and Basal in situations like this?
Jennifer Smith, CDE 5:29
Ah, in some situations like this, perhaps more often, more often what I do and more often what I eat is Pre-Bolus based on some of the meal content, because some of that does. It does work together things like glycemic index. And also, as you brought in to begin with the where the blood sugar starting, is it coming in standard at your target? Are you coming in, but it's already dipping down? Are you coming in, in target, but it's already drifting high. All of that is where you can also look at Bolus timing, and how much Pre-Bolus you may need. So you know, coming in at a blood sugar of 95 with a straight horizontal line the past hour, awesome, that looks great. But the minute you put food in, that, that blood sugar line is gonna start to change a quick after that, if there's not time for that insulin to talk first to begin with, right?
Scott Benner 6:33
Yep, I hear what you're saying too, about, like, understanding the glycemic load of different like foods, if you have something like you know, using Chinese food, such a great example, because it normally incorporates rice, which stays for a long time and hit you hard, and usually some sugar that'll hit you fast. So if there's something sugary in there, you may need a real, you know, push of insulin in the beginning to combat that initial rise. But that initial rise could get beat up by that insulin very quickly. And now what's left over is the, you know, the rice they can linger in the back, right? It's an excellent, good.
Jennifer Smith, CDE 7:08
So yeah, yeah, yeah, I was just gonna follow with Yes, you could, in that instance, then have the potential for meeting both Bolus and bazel. Potential change, and also where we talk about Basal. And most doctors are like, well, Basal shouldn't ever be used for food or covering anything. Well, we've learned very differently, especially with fat. Fat requires a huge amount of bazel change in the aftermath of eating your typical pizza, or, you know, burger and french fries, or mac and cheese that's homemade, or whatever it might be. Oftentimes, you need 4050 60% of an increase in bazel for many hours after that meal, or you're gonna stay stuck high,
Scott Benner 7:50
right? Or you could end up hitting it with so much insulin up front that you think you've avoided that and then three or four hours later, you start rising, and you think it's for no reason. Right? And it's still that fat. Is it still the fat? Yep. So I like a in what I call karbi situations, I, which is not a word, but
Jennifer Smith, CDE 8:08
hyrecar in our world, in our world, karbi is absolutely a word.
Scott Benner 8:13
So with carbee foods, there's a couple different ways I use Temp Basal, and we talked about it before, but in this situation, if I thought a meal was 10 units for sure, but I wanted it to be spread out more Arden's basal rate being 1.4. I might double Arden's bazel for an hour and a half and catch two and a quarter units that way, and then take some of that out of the of the bottom line, right?
Jennifer Smith, CDE 8:37
Absolutely. Because we get a lingering effect from the bazel. And you get less upfront, but you're still getting the whole bolus you determined you need it. Okay,
Scott Benner 8:46
same meal. Jenny rapidfire, same meal, but I walk in the door from work, and my spouse says dinner's ready, and it hits the table. I can't Pre-Bolus I didn't know this was gonna happen. What do you do? And that's where I'd like you to lay out the idea of overhauling for people here.
Jennifer Smith, CDE 9:09
Yeah, and that's over Bolus thing. Essentially, that's a good Super Bolus, as you can kind of be talked a little bit about before, that's a situation where 100% unless that meal is like a plate of broccoli, in which you would never need a Super Bowl, or Pre-Bolus. right in your typical meal that we're saying we're having 100% of Super Bowl, this would be beneficial, where you actually do take a load of insulin that would be your bazel behind you added on to the suggested bolus for what you're going to eat. And then you may actually knock off the bazel behind so you don't go low later, but you've gotten the load of insulin, the push up front, right. The other option that many people do in that situation too is they take the bull and they may actually turn their bazel off 100% for an hour.
Scott Benner 9:56
Okay to also try to spike
Jennifer Smith, CDE 9:59
right in actly so that they're getting a bolus, they're maybe not quite sure if the food in the bolus, even though it's happening at the same time is going to cause as much of a rise. But they're definitely saying, I know I need a lot more because I wasn't able to give that 2030 minutes before this.
Scott Benner 10:14
Yeah. And, and I think of over bolusing in two situations. So the one I don't have time to Pre-Bolus. So in my mind, the way it strikes me is I now need the insulin for the food for the high number I know is going to come because I didn't Pre-Bolus and some to stop the momentum or stop the arrow, right? And so if I thought the meal was definitely six units, but I thought, wow, there's no way this doesn't go to 250. I Bolus the six units. And I Bolus like I'm trying to bring down a 250 at the same time, right? Well, that's again, listen, we're calling these you know, we're calling these this series diabetes protests. So this is like ninja level stuff. Like you don't don't try this on day one. But at some point, right. On day one, don't go I didn't Pre-Bolus I'm gonna double my balls, please. Right. Yeah, right. But as you're figuring things out, that's a great place to do. As you've heard in past episodes. There's a very famous book called, is it pumping insulin?
Jennifer Smith, CDE 11:13
pumping insulin is john Walsh. And he's the one who lobbies for bowling. Yeah.
Good. Oh, you got you know, you call it something else? Yeah, we call it
Scott Benner 11:23
I call it over bolusing. But I don't know why.
Jennifer Smith, CDE 11:27
No, I was gonna say the other. You know, the other concept that kind of comes in here that you'd sort of just alluded to is, where is the blood sugar going to likely be? And that trajectory, you know, assuming that okay, I might be 95 right now. But if I haven't Pre-Bolus, I could easily be to 50 in the next 30 to 60 minutes. Okay, you're taking that value. And it's looking at the trajectory of where it will probably be, and using that glucose value to add on to the current Bolus. So you're avoiding that really high blood sugar.
Scott Benner 12:00
And what I say on the podcast, which people might remember is I just say you have to trust that what you know is going to happen is going to happen, right? So you can't just pretend this will be the time this doesn't happen. You know, oh, I'll get away with not Pre-Bolus thing today, there's, that doesn't make any sense. It might happen once in a while. But that's some random reason from something earlier. That's not you know, that's not
Jennifer Smith, CDE 12:20
me, I ran 10 miles and don't usually ever do that. And now, look at that my blood sugar doesn't.
Scott Benner 12:26
So now another place to use an over Bolus as a Pre-Bolus is a is a place where this the concept in my mind is the same, the situation is different. What if I've been fighting with my blood sugar all day, and I just can't get it down. It's 200. But I know I'm gonna eat an hour, like it's dinnertime and an hour and I've been, you know, pushing and pushing little boluses little bays or anything, I can't make this 200 move for whatever, maybe it's a site not working well, whatever it is, in my mind, I Bolus the meal. I Bolus the number I over Bolus upfront and create a fall that I then catch with the food. So I reverse. I we're going to talk about this in the next episode. But I reverse the way I think about I think most of the time we consider how does the food impact my blood sugar? How does the insulin impact my blood sugar? We don't often enough think about how does the food impact the insulin? Right. And that's, and we've talked we talked about that in earlier episodes where we put a little, you know, we put a little boy's blood sugar into a freefall and got it by eating at the right time. So all we're talking about any of these situations is timing, right? It's the right amount. It's the right amount of insulin at the right time. And if your blood sugar's 300, and you have to eat an hour from now, well, the right amount of insulin is now and you know, it's it is now and you can't you can't just wait and do your 15 minute Pre-Bolus on the 300 blood sugar because you've lost already. Right? Right.
Jennifer Smith, CDE 13:58
And you know, something that that kind of goes along to with the concept that catching catching the potential drop while also sort of avoiding or taking care of a higher blood sugar. in pregnancy with the women that I work with. It's kind of similar, we actually at some point get to bolusing. That's like a split a split meal where you actually load the front of that meal time with the whole bolus. Yeah, but you only actually eat about 70% of the food now. And you catch the drop about an hour later with the rest of the meal.
Scott Benner 14:29
Interesting.
Jennifer Smith, CDE 14:30
So what you get is not a spike, not going above those post meal ranges for pregnancy. But you also catch the drop on the back end and you never go low.
Scott Benner 14:40
Yeah, that's very similar to how I handle days like Christmas or Thanksgiving. The idea that there's always going to be eating. So I all I'm always Pre-Bolus in the next grazing opportunity, right like that's interest
Jennifer Smith, CDE 14:56
you for holidays is I actually knowing I'm coming into a grazing time period that's going to be a lot less than precise, a lot less. And a lot of little nibbles along the way behind any holiday where I know I'm going to be up hours of nibbling and eating 25% increase in bazel. And then again, I Bolus along the way. And depending on where glucose is, I might nudge that along the way, too. Yep,
Scott Benner 15:23
yeah. Okay, so now, what happens if dinners taking a little too long to make, and my perfect 95 is turned into a 90 that turned into an 80 that turned on 85. And now it's 75. And now, now someone's yelling, dinner's gonna be ready in five minutes. I know that for most people that makes them feel like Well, I'm too low to Pre-Bolus. But No, you're not. And and so you have to get some insulin moving. And you'll learn how much you can do over time. But in the in the interim, it's got to be some subtle, right, you're just you're drifting low. I'm not even talking about FedEx computer, somebody we're talking about diagnol down, I'm just this, this blood sugar just is kind of drifting down. Your Pre-Bolus still takes as long as it takes to eat to excuse me as long as it takes to work. So if you're 75 and drifting down, Pre-Bolus thing right now is not going to make you start crashing down. If that does happen, that was a coincidence. That's not you. Again, the insulin didn't just start magically working like that, right? Science didn't change. So you still need a Pre-Bolus. Now I get if it's a it's a big meal, and you're like, well, I can't put in eight units. While I'm 75 diagnose, you're right, you probably can't. But you could put in some 20 20% of it even. And we do this a lot while Arden's at school because we Pre-Bolus 20 minutes ahead of Arden's meal at school while she's still in a class. I'm still Pre-Bolus if she's 85. So if I give an ardent gets a big bolus at lunchtime, that while she's in school, much larger than most any other times in her life, 12 sometimes 13 units right for 145 pound kid. So I might do a zero percent upfront, and the balance over a half an hour. So it's all kind of getting squeezed in. But it's not all going to come on line and be active right away. It might be 20% up front, but you have to get some sort of that momentum happening again, on the on the action of your insulin, your insulin to be pulling down when the food goes in. Right, right. Okay.
Jennifer Smith, CDE 17:22
And that's important even for kids, I think in what you're doing that is important, especially for little kids, where you're not quite sure. I know a lot of the people I parents I work with, what I don't know how much Billy is going to eat, or Susie is a really slow eater or, you know, today's she might love spaghetti and she'll love it for the next three days. But then she hates it and I prepared it and I Bolus for it. And now what's going to happen, right? You, for the most part kids and teens will always eat as you said a percent. Let's say that you always know they're going to eat 10 grams of something, even if you have to change what it is they're going to eat something for you. Yes. So if you can Bolus for that little bit up front, it's giving insulin again, more action before you put food in.
Scott Benner 18:08
And one of the many, many reasons that Jenny is on the show is because if Jenny wasn't here, that would have been the next thing I would have said. It's perfect. You, you parents of little kids, it's a perfect idea. Get something moving, even if it's a little bit, just get something moving, give yourself a fighting chance. And to Jenny's point, there's an amount of food if you look back at your kids meals, they always eat at least a little bit. And by the way, if they really flake out and don't worry if, as in the case of the interview I did yesterday with a mother who said she was so excited, she put the insulin in, grab some like fast food and drove away and the kid fell asleep while they were driving away. Right? You know, okay, that might happen. It's happened to me, but still a little bit of juice, right? You only put a little bit in all you've done is Pre-Bolus a couple of sips of juice, you don't have to worry about the food. The point is, is that the Pre-Bolus is always important. It's it's Listen, if you're crashing down as the foods hitting the table and you're literally 50 and your blood sugar's falling. Okay. That's your Pre-Bolus. Right. Right. Okay, you're now prepared.
Jennifer Smith, CDE 19:14
Because there's already insulin that's causing the crash.
Scott Benner 19:17
Yes. Something whether you meant for it or not. You have been Pre-Bolus by so long, right? So good. So see that put the food in. And as soon as that stops, right, as soon as that down arrow goes away, it is time to get your insulin in. You absolutely cannot then say well, I don't know. I'm 60. And that seems dangerous. Now what's dangerous is that you've put all that food in your body and it's going to start hitting you the other direction happened to us last night. And I had to Bolus I had to make a significant bolus at a 75 diagonal up blood sugar because I was like, well, this is I know what's gonna happen. Let me get let me stay ahead of it right.
Jennifer Smith, CDE 19:59
I'm the hardest about using CGM now, as wonderful 100% as they are, the hard thing is that CGM do lag in times of quick change. And so if you have been diagonally down and you're waiting for, you know, you want to Pre-Bolus, but you're not quite sure, sure, go ahead and eat as. But as soon as you see that horizontal or a bit of a trend up, I guarantee your finger stick is higher in the sij than the CGM is showing you. You're already at a deficit of insulin.
Scott Benner 20:29
Yes. Yes. The deficits an important way to think of it and you. And this is again, something you'll learn over time.
Jennifer Smith, CDE 20:35
Well, yeah. It's a bit like the first month. Again,
Scott Benner 20:39
not on your first day, right? Yeah, listen to all the episodes of the podcast to really absorb everything, go through the pro tip stuff, and then say to yourself, I and then you have to see it, right, you have to recognize it. There's a way for CGM users, you have to be able to look, there's like a bend in the line. It's hard to put into words, right. But on the three hour graph on the Dexcom, the last three dots on the right side, tell a story about what's happening. And you will get to be able to glance at that at some point and say, Oh, this is heading down. This is heading up, I can tell I know what and so it's not day one, and it might not be the first month. But if what most of you report back in your emails is anywhere close to true for most, somewhere in the three to six month range. This all just starts making sense in a way. Yeah. Early on the podcast, I used to talk about it like in the matrix, when Neo stopped the bullets. But that has become such an old reference at this point. I'm afraid right now there's like a 19 year old going to what what are we talking about? Now?
Jennifer Smith, CDE 21:39
I'm old enough. I totally know at
Scott Benner 21:41
some point, at some point, diabetes makes so much sense to you, the bullets aren't even moving, you can just walk in between them. And so you get there at some point, right? Okay, so I'm low, I'm high, I'm falling like in the end, I think you're hearing. It's all about the right amount of insulin at the right time, just like we've been saying over and over again, a new site is a good example of, I'm gonna put this in here, even though it doesn't sort of fit, but it does fit. And so if you put a new site on, and you find that your sites don't work as well, immediately, once you put them on, or you know, you just have a site that doesn't seem to be as reactive as you're accustomed to. You still have to do what you have to do. You might have to do it sooner, you might have to do it more aggressively. And I know you're gonna say But what happens when that site starts working? Suddenly? Well, then it does. But you can't not be aggressive when something like that's going on. Because then you that's how you end up at 300 all day long, staring at it wondering what to do next. Right,
Jennifer Smith, CDE 22:44
right. I think the biggest the biggest piece of that Pre-Bolus message is unfortunately, really learning. And it's a daily relearn in the beginning of starting the Pre-Bolus. Rapid insulin is not rapid. Rapid is a bad word for it, it's a better word than our regular insulin used to be, which they called short acting, and I'd actually call that longer than short. I mean, rapid is not instantaneous rapid, as they tell you it is it takes a minimum of 15 to 20 minutes to really get moving.
Scott Benner 23:24
Yes. If you don't leave this episode, and in general, this series, believing that understanding how insulin works in your body is the core of this entire thing. You are not paying attention. So go back and start again.
Jennifer Smith, CDE 23:36
When you get a slap on the hand. Well,
Scott Benner 23:39
I didn't go to Catholic school, but I mean, if I did, yeah, well see Jenny's like, I know what happens when I don't listen, someone hits me with a ruler. So now I guess the last piece of this right about this perfect Bolus thing, right is in my heart, it's about remaining fluid. Now, you know, a lot of people are going to tell you, you really have to count your carbs correctly, right, which is true. You can't use the wrong amount of insulin like you know, you can't have a 50 carb meal in front of you and only put in 30 carbs and then act like oh, I don't know why this didn't work that but you know from listening for me and for a lot of people have been around type on for a while like you just I don't think about it as much as carbs. I think about it as units. I look at a plate and I think that looks like eight units to me. But if I'm wrong, and I am frequently for reasons that I don't care why, right like maybe it's a bad site, maybe I missed on my Pre-Bolus maybe Arden sick I don't care why but I miss then I readdress immediately, right based on my historical knowledge of how Arden acts I know that if I see a double arrow up after a meal bolus, I screwed something up pretty big. And I go more insulin. That's when you guys are starting to hear this. I'm starting to see you on online like talking to other people that people are just going more insulin. I'm like, Yes, I know. That's one of the podcasts and so But is she diagonal up, well, then maybe I missed by a lot less so a little more insulin, or I'll try to bump it back down again, or try to just try to stop the arrow. But staying fluid is the rest of it. Mm hmm. 100% staying fluid as the rest of it. And I know that I heard someone say this the other day. And I like the way they put it, that the idea of stacking insulin in a glucose monitor world is not quite accurate anymore, like you. But this person kind of went a little farther and said, You can't, you can't really stack insulin, when you have a glucose monitor on because you're seeing that you need more insulin. Right? I thought, Boy, that's a big idea. I agree with it in totally in theory. But most of you are going to be taught when you're diagnosed, don't stack and so on. And what they mean when they say that is don't put insulin in at one o'clock, and then put more in it, you know, 130, because you're gonna get low eventually. And if you're not using a glucose monitor, that very well may be true. But right, you can't follow it. Yeah. But if you can see your blood sugar, the direction and the speed it's moving in, you'd have to be incredibly insane to stack to the point where you'd call it some sort of a low that would make you incapable of responding.
Jennifer Smith, CDE 26:13
And that's where even you know, in the CGM, one that we talked about, I had mentioned using those event markers. And the event markers can be hugely beneficial now that they also show up right on your screen. So you can actually see, where did I put the insulin and you don't even have to go back to your pump to look at that. Or remember, when you took your injection, if you just mark it, you will know when those injections went in, you can follow the trend line and you see, okay, do I need more? I don't need very much more. I need a little bit more or a lot more, right?
Scott Benner 26:44
Yep, I've been this is gonna get away from this. And we'll stop in a second go to the next idea. But I've been talking to college students a lot through Instagram messaging. And if you just heard that and think oh my god, that's me. You're adorable. It could be any number of you. But but but but this one person just had a long, protracted high blood sugar that wasn't coming down. So finally, I just said, Look, you you have to like, crush this number, and crank up your bazel like do a Temp Basal raid for hours, like six hours, let's do 30% more and put in however much insulin you think is going to bring this down. And it took most of the afternoon but they got there. And then just with that idea of oh my gosh, I don't have enough basal insulin. The next day, here comes the 24 hour graph hundred and 30 blood sugar, because they're trying to live with not enough base. So as much as as much as we're talking about the perfect bolus here. Remember, you can't make the perfect bolus if your basal insulin is wrong. Correct, right, you'll never be able to. Because you'll always be replacing bazel that doesn't exist. Or if your basal is too high, you'll be causing lows and thinking oh, this is the bolus when actually
Jennifer Smith, CDE 27:59
it might not. Or if you are trying to really be aggressive with your Bolus thing. Then you're Bolus thing and Bolus thing and then finally Bolus thing too much. And that actually brings you back down. In which case then you might be eating, you're sending yourself back up. The Basal isn't enough in the background. So it becomes a roller coaster.
Scott Benner 28:16
So infuriating is this is going to be and then we'll we'll end up this episode. But if you're bezels, right, and you haven't had insulin or food for a few hours, your blood sugar's like 80 it's sitting right there. That's how you know you have your bazel right, and
Jennifer Smith, CDE 28:31
so be stable,
Scott Benner 28:32
right stable. And so and so if you stability at 140 a little more might have stability at 120 a little more you that's how you can learn to play with it, but I'm just telling you that if it's if it was, you know, as intended, you know, by the heavens, then your blood sugar would be around 85. without food or insulin. It's not always going to be like that. I'm not saying that. But I'm saying if you're that far away from that number, you've got work to do on your basal rates, right. Okay, so we're gonna wrap this one up, and then record the next one right away. Okay. Thank you, Jenny for taking the time to be here on the podcast. Don't forget, you can hire Jenny at integrated diabetes.com. Her email address is in the show notes of your podcast player, and at Juicebox podcast.com. As always, I appreciate the support of the sponsors Dexcom on the pod dancing for diabetes and real good foods. You can save 20% on your entire order at real good foods calm by using the offer code juice box. This was the ninth installment of my diabetes pro tip series with Jenny Smith. There are more coming in the beginning I call it like a 10 part series. It might go longer. What do you think of that? If you're enjoying the podcast, please go to iTunes and leave a rating and review. The Five Star kind are the best where you say nice stuff. The better the podcast is reviewed on iTunes the more searchable it is for new people looking for Type One Diabetes support. Thank you very much. For those of you who share on Instagram, Facebook and privately, I love that you guys are telling your endos and your friends and anyone who will listen about the Juicebox Podcast. It's helping us grow. I appreciate it immensely.
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#225 Diabetes Pro Tip: Bump and Nudge
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
DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.
Scott Benner 0:00
Hello everyone and welcome to Episode 225 of the Juicebox Podcast. Today's show is a continuation of the diabetes pro tip series with Jenny Smith. This installment is the eighth in the series and it's called bumping nudge. You'll find out why in just a second. I briefly want to thank our sponsors on the pod dex calm and dancing for diabetes for always being there, you can go to dexcom.com slash juicebox dancing for diabetes.com that dancing the number four diabetes.com or my omnipod.com slash juice box to find out more. There are also links in the show notes of your podcast player and that Juicebox Podcast comm
pumping nudge is the eighth in my diabetes pro tip series with CDE Jenny Smith, don't forget that you can hire Jenny. She works for integrated diabetes calm and she would love to help you do better with your type one. There are links in the show notes to Jenny's email address where you can go to integrated diabetes comm let's please remember that nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise and to always consult a physician before becoming bold with insulin or making any changes to your health care plan. This is a short but really powerful and important episode. Please remember that the diabetes pro tip series is designed to be listened to an order don't just jump in here. Go back to the beginning. This is installment eight of the series. The first one was called newly diagnosed. We're starting over
Jenny Hello How are you?
Jennifer Smith, CDE 1:47
I'm good. How are you got so good. Yay.
Scott Benner 2:08
short episode going over the idea of bumping and nudging blood sugars, which is something we talked about on the podcast all the time. I'm a huge believer in the in the infuriating statement that you won't get high if you never get high. Sure, that's not as easy as it sounds, but that's how I think about it in my head. Right? So I want to fight with the high blood sugar if I don't experience high blood sugar. Of course, that's not always gonna work. I'm not saying that. But I am saying that it's avoidable a lot of the time. I think of it as bumping and nudging just bumping and nudging it could be bumping. I love that
Jennifer Smith, CDE 2:48
term. I love that. I love it.
Scott Benner 2:50
Right? Yeah, you can do it with insulin can also do it with food. You can also do it with a deficit of insulin, which you can create with Temp Basal. We're going to talk about it all right now.
Jennifer Smith, CDE 3:02
We also do it with exercise.
Scott Benner 3:04
Do you know i just i just interviewed somebody who you won't hear for six months. But a girl who has had Type One Diabetes since she was a little kid and she's like she was so compliant like with whatever her mom asked. So she'd eat like celery all there for blood sugar was high. But if she but if she wanted a cookie, she would go exercise and then come back and say to her mother, I just ran around the house this many times and went up and down the steps this many times I would like my cookie now. And this is this was back when she was doing Oh gosh, the words just slipped out of my head. What what's the old timey insulin regular insulin regular an MPH that's what she was mph. Back then she would do a little exercise to get her cookie. But I you know this by the way, this girl is delightful. You have to find the episode with her.
Jennifer Smith, CDE 3:54
My, my mom would do the same thing with me. We're at my grandparents house, usually in the summertime for a couple of weeks. Usually at that time of the year, it was rainy, at least several days out of that time and I couldn't do anything outside. She would have me run around my grandmother's kitchen table and they had a pretty big dining room because it was a farmhouse. And I would literally my mom would be you need to run around. You need to move you need to move. And I was like, Okay, I mean at that point.
Unknown Speaker 4:23
That's all movie. You know, there'd be a snack
Scott Benner 4:25
after this. I guess it's all right. So yeah, yes. Okay, so. So basically, we'll start with this if you have a glucose monitor. You can't think about the alarms. The way you're thinking about them right now you have to your low alarm, you should put wherever you think you need to know like whatever gives you enough time to react. I don't care what that is. That's up to you completely. Ours is at 70 Some people put theirs at 60. You know, 80 whatever, I don't care. It's the high alarm that I care about. Because you need to be able to react to a rising blood sugar quickly. If you react to it quickly, you're able often to react to it with less insulin, you're present, right? It takes less insulin to stop a 120 diagonal up than it does to stop a 150 or a 180. Straight up or 202 arrows up, you could have avoided the problem that you're having now 45 minutes ago, if you knew it was coming, right, right, right now people will say, but Scott, I don't want this thing to alarm all the time. And it's gonna bother me and my kids at school, and I hear all your complaints, put them away. And here's why. Eventually, if you listen to these podcasts long enough, these concepts will lead to a world where you don't really ever leave your 120 blood sugar. So you won't get a ton of alarms. And on the days when that happens, I don't know mute your phone, but don't make a bad decision to avoid a problem that I think is avoidable. And so I know I've said this a billion times, but it belongs in this episode. And I know I talked about driving a lot. But when you're driving, and you find yourself just kind of drifting off of the road, you don't turn the wheel 90 degrees to the left to avoid the curb. It's this almost imperceivable turn of the wheel, you're just nudging it back the tiniest bit. Yeah, that's how you avoid swerving into the oncoming traffic, because you've only turned it a little bit. This is how you stay off the diabetes roller coaster, it is that simple, right? So you stop arise before it can happen. And you use such a small amount of insulin that the likelihood of being low after you've done that is mostly imperceivable. Right? How much does that make sense? Jenny? Where should this be on the Mount Rushmore of diabetes thoughts?
Jennifer Smith, CDE 6:48
I think it should be right, they're taught along with the early the early information of insulin use, it really should be, it should be it should be right there with when you're prescribed insulin. This is our target for high blood sugar should really in my professional opinion, it should be ratcheted down, we should not be being told that post meal blood sugars of 200 or 224 kids
is appropriate only because it's safe.
Scott Benner 7:25
Right and safe in as much as you're not going to have a seizure. correct? That's
Jennifer Smith, CDE 7:30
correct. I mean, am I saying that you're aiming for, you know, a no rise at all? No, am I saying that you're aiming to stay, you know, if you've been consistently rising to 250, and your alarm isn't set to 250, or 300, maybe you bring it down to 200 for a little bit, and then maybe you bring your high alarm down to 180, or you bring it down to 160. But as you do that, like you said, you're gonna see, it takes a lot less to address a rise than it does to correct a blood sugar that's already too high.
Scott Benner 8:02
And in the beginning, this will take more of your effort. But as time goes on, it takes nothing. It really does. I know sometimes I'll explode a bolus out on screen when I'm doing a talk, right? And when you blow it up like that, and show all the decisions that were made you think, Wow, this does look like a ton of effort. Right? I always have to start by telling people what you're viewing up here, encompass about three seconds of my thoughts spread out over five minutes. Right, right. You'll spend more time in initially then, than you will one day. And so it's the same with this idea. I know it feels like if you set it at 120. It's always going to be beeping, but one day it won't be and And wouldn't you rather be bothered even on a on a bad day and a quote unquote bad day? Wouldn't you be bothered? Wouldn't you like to be bothered five times to bump a 120 back down? That might take up 20 minutes of your overall day, then to be stuck in a 300 blood sugar and comes with it all day long, right? All right, little bits of effort. little bits of insulin, way better way, way, way, way better to avoid the highest because you can't get high if you never get high. You can stop it from happening. Does it always work? It doesn't always work. But mainly, I will say this, Arden spikes about twice a day. And it's timing stuff where we don't have the ability to do what we're doing. But when I tell you Arden spikes, I'm talking about 151 70 you know and we get it right back again. So imagine if you had to 180s or to 160s in a day and the rest was between 120 and 70. That's where you get an A one see it's in the fives.
Jennifer Smith, CDE 9:52
Right. for clarification to even about Arden spikes. It's not that you've waited until she's 172 Dress it, you've gotten the alert, the rise is happening, you've addressed it, you've probably taken a correction at like 120 or 130. Because you see the trend happening, she may still get to 151 70 before that insulin starts to working, but the curve down is probably more like an up down almost like a roller coaster. Right? But you're addressing it so that that ride down then is nice and smooth into the end versus being way too high. And crashing from Bolus, Bolus, Bolus, Bolus, oh, now I'm like 50. And because
Scott Benner 10:33
I reacted sooner, I still am keeping mainly the balance of the insulin action carbon pack. I'm still keeping them pretty well balanced. I obviously missed a little bit in the carbs. Got ahead. But I got back in the game soon enough that I'm not going to create a crazy low later, right, you come in for like a nice landing afterwards, which somebody just texted me the other day and says, Can you please tell me what that means. And I always like I think just put your hand up high, and then dip it down and then bring it flat again. And like that's sort of like this. That's what you're trying to make happen. Right? You're trying to come to
Jennifer Smith, CDE 11:04
the end of a roller coasters, what I explained is kind of where you're the rush of that ride down and then you like roll into the station. That's it. It's a flat and smooth, perfectly
Scott Benner 11:15
bringing in for a nice landing. Right? Okay, so, so sure you can bump and nudge that way, right. But what if I'm at the tail end, for example of a meal bolus, and I'm noticing I'm 110 151 hundred, I'm starting to drift down. But I'm so far past this Bolus that I'm now in that space where people do the thing, they can just go, I hope this stops. Right, right? Like, wouldn't it be nice if this stuff, what I like in that situation is a Temp Basal decrease, right, take away some of the basal rate. So now Jenny can see me which is a little unfair, but I'm holding both of my hands together palm, the palm, and I'm pushing a thumb bazel is so important to think about like this on one side is the impact of your body and carbs. And on the other side is the impact of the insulin. And when you push at the same rate, no side wins, like I'm not going wildly one way or the other. Right. But all of a sudden, we get to a situation like I just described where Okay, the insulins winning a little bit, right, the carbs that were there can't hold up the insulin that's left behind. So we start drifting towards a lower blood sugar, we'll just use your pump to tell it to use less insulin, take away a little bit of the force that that insulin has now maybe you'll catch it with Temp Basal, maybe you won't. But in certain situations, it's the best way to start. You know, he I forever see people were like, Oh, I'm heartbroken. I had to give my kid juice overnight. And you look and you see this 90 blood sugar that was just drifting down, that later, by the way, turned into a 180 because they put all this juice in. So you could have in that situation, if you really felt like you needed the juice bump with the juice, you don't have to drink the whole thing, drink enough to bring it back in for a nice landing. Or if you're far enough ahead of insulin impact, try dialing back your your bazel and see if that doesn't catch it and your natural body functions don't come back up again.
Jennifer Smith, CDE 13:16
And if you're an evaluation time period as just a kind of an aside in the overnight, if you give that little nudge with juice comes up a little bit and address down and you give a nudge again and it comes up and it drifts back down. That's bazel you're in bazel only unless you have a correction from earlier that brought you down so much. That's still working. Visa only that's a good you've got too much bazel there's too much they're up down up, down, up down and it never stays stable. You got too much.
Scott Benner 13:49
Alright guys, you know how I do it short episodes, short ads. Ready rapid fire succession. Check out the new Dexcom g six continuous glucose monitors today go to dexcom.com slash juice box to find out more. You're going to be able to see what direction your blood sugar is moving and how fast it's moving in that direction. And with their share and follow feature, you'll be able to find out what the blood sugar is of a loved one who is away from you that's compatible with Android and iPhone. Like I can see Arden's blood sugar right now, but she's not in the house 109 and that cool. You want that to dexcom.com slash juice box with links in your show notes or Juicebox Podcast comm now on the Omni pod on the pod is the only tubeless insulin pump in the world. It's the insulin pump that art has been using for over a decade. And trust me, you want to check it out. But you don't have to trust me too much. Because Omnipod will offer you for free a pod experience kit. That's right, they'll send that demo right to your house. Just go to Miami pod.com forward slash juice box, put in your name and your address. Click in enter there, whatever. It's called the button I don't know, click like like, and they'll send it right to your house. You can hold it, feel it, try it on wear it, see what you think and decide for yourself, you don't need to trust me, you can trust your eyes. Last thing I need you to support dancing for diabetes, I want you to go to dancing number four diabetes.com. And check them out on Facebook and Instagram, great organization doing wonderful things for children with diabetes, through dance. I say a lot that if you find yourself when you find yourself bolusing too often, your bazel is probably too low. If you find yourself out and doing to address in that situation too often with food, your base is likely to high. Right?
Jennifer Smith, CDE 15:38
Right. And you want to stop nudging as much as you can.
Scott Benner 15:42
We all want to go to sleep and nobody wants to eat juice in the middle of the night. That's all the things we're trying to avoid right here. And I know a lot of it still sounds like oh, yeah, buddy, that. That sounds nice. But how do I accomplish this? I think that by now you're getting towards the end of this series. I think Jenny and I have laid it out pretty well, a couple of different ways here. So and important to remember. Because if you've ever spoken to me privately, if you listen long enough, I will beat into your head over and over again. It's about timing and amount. It's about timing about even with Basal, even though you don't think of it the same way. Because Basal doesn't all go in at the same time. If your basal rate is too high, you have too much insulin and at the wrong time. So with I've simplified diabetes down to like a handful of ideas that are sometimes so distilled, that even when I say them out loud, I go, does it just sound ridiculous to people when they hear it. But please trust me. At the end of this series, I'm going to go over all these ideas in simple sentences. It'll be a very short episode, you remember those sentences, apply what you've heard here. You're going to be on your way I you know, I can't promise but I swear I've seen it happen.
Jennifer Smith, CDE 16:54
And I believe a little print off sheets got,
Scott Benner 16:57
oh, I don't want to get away.
Jennifer Smith, CDE 17:00
I know. I know. Well, the full full ideas are really behind all of those little simple statements. So if you had just a little simple fit, and you're like, I don't even know what that means. And those reminders,
Scott Benner 17:11
I actually, I use them too. Yeah, I've had times where I'm like, What is happening? Because it's life, right? Like stuffs going on. You don't know like, why am I bolusing all the time. And I actually stopped myself one time. And I remember standing in my kitchen thinking, what would I tell someone? If they asked me this? And oh, that's ridiculous. But I was like, Oh, my God, or bazel needs to be increased. Boom. And there I was, I was like, Oh, that was I should have listened to me. But like for days, I was like, what's the problem here? So you're gonna get those like simple ideas broken down into sentences that you can kind of repeat and keep in your head, you know, that that'll should reignite the ideas that you heard in the podcast. Okay. So, to go over this again, because it's in a different episode. You need to think about how food affects your blood sugar. Sure, you need to think about how in some affects your blood sugar, sure, but always to remember that you need to understand how the food affects the insulin so you can reverse engineer ideas. You're so used to thinking, I have this high blood sugar and I'm trying to force it down with insulin. Well, what if you have a low blood sugar you're trying to force it up with food and I don't want to use too much. That starts us off on that rollercoaster, right we forget to believe that what we know is going to happen is going to happen we put in this food for low blood sugar, we shoot up now our insolence Miss time, we eventually put in enough insulin it gets Miss time with the food, the food now digest to your system. All the insolence left, you fly back down again, oh my god, what do I do, I throw in more food than I wait and I get high and you start looking at the garage and thinking I just gonna pull the door down Start the car put on my favorite. But we don't need to do that. What we need to do is to bump in nudge with the food as well. And so this is crafting
Jennifer Smith, CDE 19:00
and nudging with the food might actually be a little different. If you know and pay attention to in those, let's say the drops where you're going to nudge with some food. Why is it declining? Is it truly bazel? like we talked about overnight, right? Where you meet need a lot less nudge, little incremental nudge versus you've got three units of iob. And you're dropping, and the drop is actually happening a lot more precipitously, right? You're really like coming down? Well, that little nudge of three sips of juice. If that's not the time to like nudge us, you need a little bit more aggressive nudge than that.
Scott Benner 19:42
Yeah, I tell people all the time if you see a 65 and it's really stable and you want to try to shut your Bayes law for half an hour to see if it comes back up right on but if it's a 65 and dropping like a stone for the love of god drink a juice eat a banana shut off like like, you know, you've really messed up somewhere so
Jennifer Smith, CDE 19:58
right but Right, but
Scott Benner 20:00
the opposite idea of that is not I'm gonna quote a mom that I spoke to. She said, Why did I always give the whole package of gummy bears? Why did I just automatically think because I opened the package he had eat all of the gummy bears. Why not? You know why are three because 15 carbs, 15 minutes 15 carbs 15 minutes. Right bad advice you got from a doctor one time.
Jennifer Smith, CDE 20:25
And it was again it comes to the safety. Right? It comes to the safety piece of this is an easy rip off. None in the moment. This is just please do this because it will at least
alleviate the wall, right? You'll be safe.
Scott Benner 20:40
It's jamming on the brakes 100 yards before you have to stop because you can't be 100% certain you're gonna be able to stop but before you get the hundred yards away because a doctor is not with you because they don't know the situation. Because they don't want you calling them on the phone every five minutes. Now I bolused because I'm going to tell you when some people start explaining to me their bosses. I'm like, Look, I'm good at this. But that is hard to get straight in your head when somebody and you know they're keeping something. They're forgetting something. And so you're like, I can't make sense of this. Like show me a graph. Like when did you eat and sometimes they don't even though, right?
Jennifer Smith, CDE 21:15
I like that's the reason I like little tiny like the Jelly Belly jelly beans. They're a gram of carb apiece. doodles are a gram of carb apiece. They're an easy way to nudge with food in a counted way. Rather than like sips of juice really guy I don't know, I might have had a bigger sip or a little or sip, right? Whatever my sip might be the whole container. I don't know.
Scott Benner 21:39
I'm telling you again, Ninja like level of understanding, I can sometimes stick a straw in Arden's mouth from a juice box as she's drinking it, I just go and that's enough. That's just something that comes with time, right? Like, you're not gonna figure that on day one. But the idea that it might not be all of it. And this and I alluded to earlier, it's gonna sound a little crass. But there are times when you just have to have the balls to wait. Like, you can't just, you can't just over treat an 85 you know what I mean? Like I said it before, I've saw a woman online who told who once said that, that's a mom, and I'm sure she was scared out of her mind. I don't mean to make light of her. But she's like, I saved my kid's life last night. With a juice box. A kid was like 110 diagonal down. I was like, wait a minute, you may very well have been on your way to the greatest night's sleep ever. You're never gonna know. Right? And because this wasn't like what you were talking about. It wasn't like a big bolus that was gone wrong. This was just like a drifting blood sugar. And I was like, Oh, you gotta wait, the you know, you have to. And so let's talk about here, like, because we're gonna try to bump a nudge and in and out of an area. What is that area? And so I mean, you have to define your target. Yes. What is it you're going for? Right? I don't need Arden's bunch are gonna be at five constantly. I don't feel that way. But I and I don't like her blood sugar to be under 70. But I got to tell you that if she drifts under 70 for a couple of minutes, I'm not running around looking for the glucagon. You know, like, let me see how I can just get this to kind of gradually come back up again. Same thing if she gets the 140. And it sits in a guy. I really missed this. But you know what, now I'm only an hour and a half past this Bolus, I really do have to wait a second to see what's going on here. Or I have to decide I'm not gonna look at this 140. And I may need to redress with food later. Right. Right,
Jennifer Smith, CDE 23:33
right. Absolutely. And, you know, that also speaks then to the benefit of now we've got the CGM, right, because with the CGM, you can see more often what's happening that 140 hour and a half after eating, it might be a stable 140 you don't know whether the next three blips are going to start a downtrend or they're going to start an uptrend or they're just going to kind of stay stable. So you have to really have that same thing with your 70 before if she's laying on the couch watching a TV program at 70. Okay, yes, she's not out running a marathon. She's not going to go to the amusement park and walk around for four hours. sitting on the couch.
Scott Benner 24:11
Yeah. Yeah. Even when Arden is like incredibly active on a hot day playing softball, I still like a blood sugar right around 90 and so if I see 90 trying to get away from me it's it could be just you know, you have a Gatorade with you take two splashes of Gatorade, then go back to the water, or, you know, have half of this juice box or are you hungry? You know, sometimes people are hungry. You'll think about it like that. Because you have diabetes. You always think about food as being this like surgical strike. But if you're playing you know a sport, maybe it would be nice to take a bite of a banana every time you sat on the bench or something like that, right? performance energy is different than blood sugar strategy energy. for athletes, there's about 1000 different ways to think about bumping and nudging your blood sugar around so I want you to open your mind to it think differently. Try to really make sense of it. Jenny's Gotta go she's got a life. Okay? work. So I'm gonna let her go and say thank you.
Jennifer Smith, CDE 25:07
Absolutely always, always nice Jenny,
Scott Benner 25:09
I'll talk to you soon. Everything I'm about to say can be found in the show notes of your podcast player at Juicebox Podcast calm but if you'd like to hire Jenny, go to integrated diabetes.com or email her right through your podcast player. Thank you Dexcom Omni pod and dancing for diabetes for supporting the show. You can go to dancing for diabetes.com my omnipod.com slash juice box or dexcom.com slash juice box to find out more. Don't forget on the pod we'll send you a free no obligation demonstration of the pod just for filling out a little bit information and saying you want it even though they're not on this episode. Don't forget real good foods calm you'll save 20% of your order by using the offer code juice box. That's a lot of money you can save. This was installment number eight of my diabetes pro tip series. installment nine is available now and it is called the perfect Bolus. I hope you're enjoying the podcast. I hope you're enjoying the series. If you are please go to iTunes and leave a wonderful rating and review for the show. It helps it to be found by more people
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