#239 Dexcom Suggestion Box
Leach-Centric!!!
Jake Leach is Dexcom’s Chief Technology Officer and he's on the show to receiver your feedback, talk G6 enhancements and spill the beans about how Apple Watch will soon be helping you with your type 1 diabetes.
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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.
Scott Benner 0:00
Hello friends and welcome to Episode 239 of the Juicebox Podcast. Today's episode of the show is sponsored by dancing for diabetes, Omni pod, and Dexcom. You can go to dancing the number four diabetes.com, my omnipod.com, forward slash juicebox. We're dexcom.com forward slash juice box to find out more about the sponsors. If you have trouble remembering those links, don't worry. They're available at Juicebox podcast.com. Or if you're listening in a podcast app, they're right there in the show notes, just tap on it. Only about 10 days ago, Kevin Sayer, the CEO of Dexcom, was on the show kind of sharing the big picture of where the company was going over the next year or so. And of course, as always, I reached out to you all and asked if you had questions for Kevin, which you all did, and I really appreciate it. So many of you asked really fantastic questions on my bold with insulin Facebook page and actually, on the Instagram page for the podcast as well, that we had just a repository of great feedback for Dexcom. So I asked Jake Leitch to come on. Jake, of course, is the Chief Technology Officer at Dexcom. Because he's in charge of scientific research, engineering, product development, Product Management, like he's the big overseer of this technology. And I thought, How great would it be if I could funnel your feedback right into his notebook. And that is exactly what Jake and I have done here over the hour that you're about to listen to. So if you want to hear your questions and other people's questions, ask Jake. If you'd like to hear the suggestions going right into his notebook, literally, you'll hear him writing in his notebook, then you're going to love this. And along the way, Jake is going to share things that are coming. Jake is going to explain the Apple Watch launch what no data means and much more.
Okay, are we all ready to find out what Dexcom is gonna be offering us over the next year or so? Huh? Are you getting excited? Are you jacked up? Are you ready to believe that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise? And to always consult a physician before making any changes to your medical plan for becoming bold with insulin. If you are ready for those things. Then I say to you, ladies and gentlemen, this is Jake Leitch.
Unknown Speaker 2:31
Hello, it's Jake.
Scott Benner 2:32
Jake Scott Benner. Hey, Scott, how you doing? Man? Good. Listen, hey, right off the bat. I gotta say, first of all, we're recording. But I need to tell you. Kevin doesn't answer his own phone anymore. So I don't know what you need to do at your next contract negotiation or something like that. But
Jake Leach 2:48
I'm just saying, Well, I was I was expecting your call. So I knew it was probably you. But I yeah, I don't I don't always answer my own phone either. Only when I know I've got someone calling me.
Scott Benner 2:58
I just didn't know he was saying he's making a power move on you there something like that.
Jake Leach 3:02
Exactly. Funny. Jake, I
Scott Benner 3:04
have to tell you, I had a call set up with Kevin that was kind of wrapped around ADA. And then I had a problem. on my end, I couldn't do it. And it actually gave me a little more time to reach out into the community of people who listen to the podcast and ask if they had questions for Kevin. And they did. But then they asked a lot of other questions that seemed more leech centric, let's call them I guess. Awesome. We're gonna have to come up with a different word. Because I can't just keep saying Jake's back on the podcast. Again, we have to find different ways to say it. But I was wondering if we couldn't treat this time together as sort of, I don't know, like a feedback thing for you. Instead of like the great Yeah, can we do that? Or that? That'd
Jake Leach 3:45
be really good. Let's do it.
Scott Benner 3:49
Now that I have your attention, let me just say this very briefly. And then Jake, and I will in fact, get into the podcast proper. hear these words that I want you to remember dancing for diabetes, that's dancing, the number four diabetes.com, check out their blog. Check them out on Facebook, see what they're doing on Instagram, dancing, the number four diabetes.com I'm gonna just start with some questions I have based on stuff they asked. So aware time consideration, like you guys are at 10 days for G six g fives. And if people still have fours, I guess seven days for the older ones. 10s for these?
Unknown Speaker 4:27
Yeah, yep.
Scott Benner 4:29
How come you I mean, I'll just ask a farcical question. How come I can't just wear it forever? Like what stops it from being? What what you need it to be?
Jake Leach 4:39
Yeah. Great. Great question.
Scott Benner 4:41
Yeah. How do you stretch that out at some
Jake Leach 4:42
point? Yeah, yeah, great question. So we see where time so extending the word time is a great way to add convenience to the product. So you don't have to change it as often. But we also recognize that there are challenges to Continuing to be able to wear the device for for longer periods of time, there are two main things that limit the was aware of the sensor. The first one is more obvious. And it's really around the tape adhesive, with the adhesive for always trying to run this balance of it sticks well to the body and allows people to be active and do all the things kids running around exercise a lot of things without it causing irritation. So there is quite a bit to adhesive technology that goes into it about the readability of the adhesive patch, and the amount of adhesives that sum on on the product. And so over time, we've continued to make enhancements to the adhesive to make it last longer. But even today, we know that not everybody can get it. You know, not everybody's getting 10 days out of allergy six sensors. And so we've offered one of the things we've done is we've offered the an overlay, which is another clear adhesive that some people found very helpful. And we offer that for free, people can call into our tech support and get that we send out a quantity of them. That allows the camera I think it's 10. I think we send out but we ended up package of those. But that helps. There's a lot of other folks have figured out other ways to get the sensors to stay adhere to their body. But we do have many active programs, part of our G seven program is a new patch, as well as our future technologies. We're always looking at edge design, and kind of pushing the limits on what's possible. So that's one thing is that he's attached.
Scott Benner 6:39
And one other thing he tell you the free thing I Arden's actually about an hour and 15 minutes into Dexcom swap. So we just moved her site to another place. And as we put cleaner site, put it on, and use your overlay, I mean, like put it right on immediately when we put just the and that's become kind of a common way we do it. We used to not put it on right away and wait to like, I don't know, the first time she's like, I'm getting a shower, like we're in and we just realized eventually, like that's stupid, it's meaningless. So just we put it on. It's been terrific. We were using opsite Flexi fix before, which you can buy on Amazon for like 20 bucks for like a giant roll that lasts forever and ever. But your overlay is pre cut. And it's easy, and it works great. And you know, it's been fine for us. I also kind of want to say, I'm sorry, I know you you had a thought I hope you're able to hold it for a second. Of course. I was thinking earlier today like thinking about our conversation. And just, I don't I think sometimes because we need our insulin pump, or we need our Dexcom that we think of them as these. I know these things that we just I don't know, I don't know what the word is exactly. But it should just work all the time, which is expected and hopefully companies work towards that. But if I was on a heart monitor in the hospital, I wouldn't say to myself, now's the time, I'm going to do jumping jacks, because my leads would fall off and like there's I think you don't mean like I think there's there there has to be some on me to say to myself, I'm a person wearing an insulin pump, I'm in person wearing a glucose monitor, there are some things that are going to affect it adversely. That's not just that can't be fixed by us tell saying to the person that makes it Hey, why don't you just fix this be right, because like, he's a great example, Arden does not get any adverse reactions from wearing adhesive. She could wear your Dexcom for three days, seven days, 10 days. I'm not saying I would reset it, but she could wear it for 20 days. And she never has a problem and other people and that they're absolutely heartbreaking pictures online have really horrible reactions to them.
Unknown Speaker 8:43
Yeah,
Scott Benner 8:44
you know, yeah,
Jake Leach 8:44
that's good.
Scott Benner 8:47
I was just gonna say that it's such an individual issue. And, and we expect it to fit for us all the time, except my situation is different than someone else's situation. But you're still one company trying to make one product.
Jake Leach 9:02
That's right. That's a that's part of the challenge, right, trying to make the product work for everybody. And I think you're absolutely right, Scott, there's a there's a motivation factor about you know, it takes some effort at different times depending on what you're doing and what situation is to ensure that your sensor or your your pump sites are secure to your body but we are always trying to, you know, look at what's the latest technology that we can utilize to make the sensor stay adhered. And your point about isn't one of the points you made earlier was really important in putting that overlay on at the beginning of a sensor where we found in our in our studies where we've really looked at the performance of the adhesives, it does matter putting it on the first day is the best way to do it. You can put it on later, by putting on on the first day really helps out some people. You know, the best longevity is putting that overlay on First,
Scott Benner 10:00
the first day, do you have any guesses as to why or it's just what you're saying.
Jake Leach 10:04
It's basically a lot of when when the adhesive patches start peeling or failing, it generally occurs from the outer outsides and it starts peeling on the outside. This isn't the case where you like walk into something and actually knock the whole patch off. But if it's just overwhelming, it'll start peeling from the outer edge. So if you've already got the overlay on, it protects the outer edge of the white part of the patch from peeling up for appealing. And so it really just kind of stops that that currents of the
Scott Benner 10:34
patch peeling and I stopped you earlier from what I assumed was talking more about the the hardware and how long it can last in the body is my
Jake Leach 10:42
Yeah, yeah, the other major driver for sensor longevity is the performance of the sensor probe. So the the tip of the sensor, probe, the end of the scan is where towards the very end of it is where the glucose measurement is made. And there is chemistry on there. That's consumable. And one of the things that there's a couple things, there's the the consumable chemistry itself on the sensor, and that tends to not be the limiter, because we've designed the sensor to last. You know, even in extreme environments, though, the chemistry will survive for up to two weeks. But the other thing is that everybody's physiology is similar but different, right. So some, the way your body reacts with your sensor, it may begin to start, you know, the foreign body response over time, it starts treating it as, okay, it's a biocompatible as possible, but it's still a sensor probe on your skin. And so some, some people and towards the later days, at times, we'll see, you know, sensor failure message, and we kind of, we call that early sensors shut off. And what that is, it's the algorithm inside the transmitter, that's always looking at the sensor, it starts to determine that the sensor signal is not as expected and so not reliable. And if that happens enough times, it'll actually shut the sensor off. And so that's the other major factor other than adhesive. When it comes to it will essentially last the full 10 days is about that. Looking at that sensor signal and ensuring it's accurate. There's a number of new algorithms that we put into g six, related to ensuring we hit those special controls for the FDA. IC GM requirements, it's really strict requirements, particularly around outliers, where the system is not accurate. A lot of you basically can't have very many of those, not to meet the standard. So we put some algorithms in that look at looks at the sensor signal and shuts it off. It's not reliable,
Scott Benner 12:50
so incredibly proud of myself right now, which is probably a weird thing to say after you spoke and nobody heard from me, but I you got to a moment where you pause and I thought I'm gonna ask Jake if that's because of G six not requiring finger pokes and this stuff that the FDA probably met like and you and then you set it I was like, Oh my god, I'm getting so good at this.
Jake Leach 13:10
You got it. Nice work. Thank you.
Scott Benner 13:12
I've managed to pat myself on the back for doing nothing just now. But No, but seriously, that's exactly what I thought was okay, you guys went to G six, you had you You said I want to be able to say you don't need finger sticks to wear and you can use a G six. And that makes sense to me that then the tolerances for what, what the algorithm will allow out of I guess tolerance would be smaller than and that makes is so is that why and let's just I'm just gonna say it kind of bluntly Is that why some people are getting or no data signals with JSX then they got on G five. Are you ready to see how simple it is? To get a free no obligation demo of valmy pod sent directly to your house? My Omni pod.com forward slash juice box. I hit return. It says request a free experience kit. That's a peck by the way a pod experience kit. I'm going to type my first name Scott, my last name, my zip code, which I won't be telling you my email address Arden's day@icloud.com preferred phone number. Mm hmm. type of diabetes, type one in my case, I certify that I'm 18 years of age or older. And I acknowledge I have been provided access to the insulet Corporation privacy policy and HIPAA privacy, which I have. And then I authorize insulet Corporation its distributors affiliates and wholly owned subsidiaries that contact me by telephone just means they can call you and then I click Request your experience code. There, it's done. Now I'm going to be able to try on and wear the Omni pod for my very self to Find out if it is something that I believe I would enjoy before moving forward with it. Come on. You can't You can't turn that down. They just send it right to your house. And then you figure out what tubeless insulin pumping is all about. You get to say to yourself, huh, that kid the guy talks about on the podcast, you should been wearing this for 11 years? I'm going to give it a whirl. My omnipod.com forward slash juicebox with the links in your show notes, or Juicebox podcast.com. Is that why some people are getting or no data signals with GE Sexton they got on G five?
Jake Leach 15:38
Yeah, that is part of it. Where the data displayed has to be accurate enough to make decisions. And so that is part of it. Now we do have in the pipeline a number of enhancements we're working on. Now that we've had g six in the market for just about a year. And we've got a lot of user data coming back to us about the performance of the product. And one of the things we do is we monitor product performance in the field. And so we're working on algorithms that will and more data will be displayed. And so we have a couple of updates, it'll be coming that you know the kind of users it'll be, it'll be embedded in in some of the newer transmitters that will be coming out for G sex and it should, for some users, it'll they'll see less of those, those instances of data being blanked out. So that's one answer. We're always we're always looking at how to make things more improved. I get it. The other thing I would say, too, is we're really working on how do we ease the burden of center replacement. So if someone's sensor, if the user center doesn't last, the full 10 days, how do we make it easier for them to get a new sensor? And you can imagine, there's a lot of things we can do if they're using the phone app. And so we're really focusing on that because we know that's a pain point as you're sending yours, but your percentage in the last 10 days and you're expecting it to how do we make sure that you've always got a sensor in Tibet as a backup in case that one? This one doesn't last your full 10 days? Isn't? You know, not not all centers will last 10 days for many different reasons. But we talked about the two main ones.
Scott Benner 17:14
Yeah, I have to say, and this is where I hope people listening aren't just like, yeah, Scott's saying that because Dexcom you know, they buy ads on his podcast. It's not why Arden never doesn't make it 10 days. It but it could just be randomness in her body makeup that is allowing that to happen. And so, I mean, again, I don't want to say that I extended a sensor recently, but you know, I saw what other people see 16 or 17 days in? Yeah, yeah, the spotty, no data stuff. And the minute I saw it, I was like, boom, gone, like, get rid of it. It's out of here. But interestingly enough, it just does not happen to her in the 10 day window.
Jake Leach 17:52
Most most people don't have the problem. There's there are some people that have more of an issue. But most of our customers do the sensors the last 10 days. Yeah.
Scott Benner 18:02
So you're hoping one day that they'll be able to pop onto an iPhone or Android app and just say, Hey, I had a sensor failure, here's the pertinent information about it. And then another one will come to them.
Jake Leach 18:12
Yeah, all the app auto detected. I mean, we know, we did the app issues the message so we could auto detected an auto ship. I mean, that that would be a really nice enhancement. Check. That's amazing.
Scott Benner 18:25
Is that like gonna happen before I'm old? or?
Jake Leach 18:29
Yeah, yeah, you know, it's the it's the power of the mobile platform, right? When you're connected on the phone, there are so many more things we could provide, I think we're just starting to, I mean, follow was a really important was kind of our main update for the, you know, kind of moving the mobile platform when we did it on the g4 system. It the connectivity allowed us to do the remote monitoring, and there's so much more we we can and will be doing with with the mobile platforms. And we there will be I do see a day where they're in before year old Scott, where we, we can auto auto replace sensors, if it's an issue, an issue occurs,
Scott Benner 19:07
Jake, I fixed a couple of steps outside in my landscaping the other day, and it took seven days for my knees not to hurt. So I don't have a lot of time. You know, you just had something that made me think of a question. It's not on my list. I feel like this is the first time I'm seeing you guys. say to me, Hey, this G six thing, we're gonna update it and improve it. We're not just going to hold these updates and improvements to the next level. Like, you know, like g five to me came out it was g five. I'm sure you did some back, you know, enhancements that were maybe on the digital side that I didn't say, but is this the first time you're going to actually make an improvement or a change to the transmitter itself during the, I guess the life of the product?
Jake Leach 19:50
Well, it's a great question. We did a little bit of that on G five. But I think one of the things that we've done over time is the the the development teams, our product development teams, we've staffed really we've had a focus on our new products, but also maintaining and enhancing our current products. Because we generally have this, you know, three to four year cycle between major iterations. Sorry, there's a jet flying over the building a little bit of loud background, being in San Diego right next to the marine base in Miramar. Nice. It was an FAA team. So, yeah, so we we've really focused on being able to enhance the system while being working our new platforms. And one of the things that g five introduced is with the lot of the intelligence on and the architecture of the intelligence being on the transmitter. transmitters are replaced every three months. So we really can push it Italy has allowed us to push out updates faster than in previous years where you kind of had a system that was around for longer. And then also with the app updates available, we can really get things out faster. So the architecture of our system allows us to make those updates. And then we've also added more staff that their focus is to improve the products we have,
Scott Benner 21:12
okay. I mean, throw in a comment from a user, and then I'm going to move on to something else. So this is a really honest feedback from someone on Instagram who said, I have to be honest, I almost always lie when I call Dexcom tech support. And they asked me where I put the sensor. And and so I have an interesting background because my wife does drug safety. So I understand why you asked why they're wearing it. But I think people are afraid that if they respond with an answer that's not FDA approved, that you're not going to replace the sensor. And I don't know the answer to this question when I'm asking, but would you prefer to hear where they're honestly wearing it? And you'll still replace their sensor? Or do they need to tell a white lie to get their sensor replaced?
Jake Leach 21:54
Well, I think often, you know, the reason for the question is, is because we can only as a company, we're kind of legally bound, we can only speak to on label use of the product. So that's basically why we asked the question, because if it's if it's off label use alternate site. There's not a lot we can do when speaking to customers about issues. So yeah, I think that's probably the safest thing I can I can say. One of the things. Yeah, exactly. One of the things I always like to add to is that the reason why the current product, my G sex is indicated for abdominal use in adults, and then impedes to dominance. And buttocks is really because that's where during our very large clinical studies that we have to run to show the performance of the product. Those are the sites we've chosen. And there's no scientific reason why it wouldn't work in other locations that we haven't proven with a you know, FDA study that shows performance in those alternate locations. So that's really why we don't have the indication. But as we look towards future products, that's something we're always evaluating is when when is the time to do the study that allows us to claim that it works in the arm versus some people using it there.
Scott Benner 23:10
And I imagine that g7 is going to offer that kind of opportunity because of the new size. So I'm just guessing out loud, but so Okay, so let's play for a minute, Jake, up the customer service representative like, hey,
Unknown Speaker 23:20
Scott, I'm
Scott Benner 23:21
calling because my sensor failed on the third day. And you say, Where were you wearing it? And I say on my forehead? And does that stop down the customer service representative from answering any questions that I understand? does it stop them from replacing it?
Jake Leach 23:36
Yeah, I don't believe it stops him from replacing it. No, but we can Yeah, I'm that I'm less familiar with exactly how that works. Okay, Jake, I
Scott Benner 23:44
appreciate it. I'm sorry, I put you on the spot.
Unknown Speaker 23:47
No worries.
Scott Benner 23:48
Now art, it always wears her on her, like her hip but area, like, like quite literally forever. So I never run into that. But I do understand a bit of the other side of it about the data collection. And you know, what, what ends up happening after that, so, Alright, ready, I'm gonna hit you with a bunch of asks. So this is the feedback part. And then, at the end, I'm going to ask you about Apple Watch which Kevin ran around town after ADA. Like, like Paul Revere, talking about everywhere, somebody would stop and look at himself. We'll get to that last but,
Unknown Speaker 24:21
but Okay, cool.
Scott Benner 24:22
So I have some asks of my own and I have some asks from people. Okay, I've got my notebook. Alright, let's break it down to like, I don't know how we'll break it down. Alright, here's the first one. raw data, like the so there are people who use third party apps who can see what the I guess the what the algorithms thinking it's thinking you might be here, you might be there or, you know, the somebody will say, Look, when my Dexcom app tells me there's no data available. I still see the data on this other thing. I think I know the answer to this, but is there ever a thought to allowing people to see that raw
Unknown Speaker 24:56
data
Jake Leach 24:59
um, I'll enter in different ways the raw data, which is actually the sensor signal. That is, we don't intend to share that. And display that in the real reason why is one of the reasons why we can develop algorithms that ensure sensors are accurate is the volume of data that we have. And that our experience with the sensor manufacturing and how we pair it to the algorithm, all those things, a lot of the what I've seen is folks trying to develop their own algorithms that use the raw data is that they have not seen all the different types of failure modes that can occur, or things in the signal, they just don't have enough. You know, even if you had a number of people trying to capture that raw data, you're never going to get it to an algorithm that has some, you know, seen all of the different things that our team has been able to look at over millions and millions of sensors. So it just kind of, uh, might be a little dangerous to do that. So I think our goal right now is to provide reliable real time data. One of the things we are doing, though that's new is, and I spoke a little bit of about it at our products here theater at ADA was that there's a retrospective API that's available today, or partners who are developing apps, meaning they can develop an app that then goes to our cloud and pulls down three hour delay data. Something that we're working with the FDA on is getting a an approval for a real time API, this would be an API that would provide real time data to other apps through the cloud. As you can imagine, a partner could develop a different type of follow up that maybe offers things different than the way that our follow app works, or other. There's lots of other reasons why people want real time data and not retrospective. And so I think that's going to be an exciting opportunity in the future, for access to real time data, but not raw data.
Scott Benner 27:00
If I dumped it down inside you, it's possible I could walk outside, close my eyes and walk across the street, not get hit by a car. But if I keep doing it, eventually I might get hit by the car. Is that the idea that you can? Exactly, exactly. Yeah, there are things that can happen that unless you have lots of experience with but often those cars drive down the street, you might type it wrong and get run over into somebody could be using this data that you're choosing not to show people for very good reasons. And it went well, it may work out for them. Well, today, it could end up making being a bad decision based on that data later. And that yeah, that's something your algorithm would weed out and never let get to the end user.
Jake Leach 27:37
Exactly. Gotcha.
Scott Benner 27:39
All right, cool. Some things that have that don't exist on like, follow, or there's one little one, that's amazing. And I don't, I'd love to know why I can't see rate of change on my Dexcom apps. Why can't I see that? My blood sugar is 160. And that means it's going down. I don't know three points since the last reading. Oh, so so the so the arrows indicate a rate of change, but you're saying like an actual number, show the number I have to say it's on a couple of third party apps that I've seen. And it's incredibly valuable. Like, like I was, so I was saying something to somebody this morning that is, is in the same vein, but different. So she's using this woman I'm talking to Hi, Brandy is has her low set at 100. But she really doesn't think of herself as you know, needing to do something till after 80. But when she gets under 100, her line turns red. And it changes how she feels about it. And so that the line itself doesn't scare her where it's at doesn't scare but the the color of it makes her brain think differently. So I said to her, just push it down to 80 so that you don't see red and believe it or not, Jake, and I'm sure you do believe it that that impacts how you think about what's going on. Sometimes it takes away anxiety, right? Like I see a falling line, but it's not red, so I feel better about it, the rate of change on other apps, I have a secondary app running behind Arden stacks comm app. And when I look at it, and it says, You know, I hear Oh, she's falling and I look but I see she's only fallen a little bit like he gives me more perspective rate of change would be an amazing update to your stuff. I think a plus or minus and a number.
Jake Leach 29:20
Oh, yeah. I just added it to our list. I do we do really identify with that concept of there's can be an emotional reaction to the way things are displayed in the colors. And that is one of the things that we factored into some of the G original g five and the imageclass design but things that we're also looking at for our next iteration of the app. Because you're absolutely right there there is a react can be a reaction to how you feel about the way the information is displayed. And building on that.
Scott Benner 29:54
I have a question I'm going to ask I don't know the answer to but I might bet a little bit of money on it. The last update to the Follow up. Have you have you changed? How the line is rendered? And I don't know, I don't even I'm using the right words like, but does the do the angles and the pitch of the lines? In that in when I look at that, that follow up? Have they been squeezed or stretch somehow, because I make so many. I manage art and based on so many informations on pitch of the line, which I know is probably a little above, you know how some people think about it. I'm gonna pull it out now, so that I can, so I can talk about a little more
Jake Leach 30:34
thoughtfully. It's a bit that's definitely advanced. But has
Scott Benner 30:38
that changed in the last update, and maybe you don't even know, like, it could have literally been something a graphics person did, just because it looked nicer. But it changed my interpretation of the data.
Jake Leach 30:51
The what? Yeah, I'll give a couple differences. So the, you know, with the new updates to follow, there's the we did it, we introduced the landscape mode, which allows you to turn the phone sideways, and then you can use your finger and you can actually trace along and see the points and what's displayed. And what is there were some enhancements, that basically makes the display on follow the same as the display that's on the G six app. Okay. So if the older version of follow had an older version of that graph display, and so you there may be, as you look at it, you may see it slightly different than the the new one versus the old one. But the, the new follow is identical to what's on the GS six app, when it comes to the way those points are displayed, actually the same physical code,
Scott Benner 31:43
you might want to add me to your beta tester list, as I'm saying, because as this podcaster get this podcast gets, we're about to By the way, this summer, we'll celebrate a million downloads. So as that's happening, I'm actually seeing almost to my amazement, that the ideas we talked about here are I think it's become a way of thinking. And so if it happened to me, it happened to other people. And it genuinely was it was off putting, like I looked, and I was like, Oh, now I can't decide what to do. Just because it interesting, visually looked different, which was just anyway, and they get that might be a ninja level problem. But but it was, it was real. Yeah, that's real. Definitely. Can followers, please see expiration times have sensors on the follow up?
Jake Leach 32:26
We Yes, absolutely. That is we want there's a number of like, there's extra information that we need to provide in the follow app. Because it's really around this concept of your parents are helping their children, children manage diabetes, and the more information we can put into that, the better. I'll give you an example. At one point, we were thinking, Okay, maybe we just take all of the clarity features and put them into the G six app. But in thinking through that, what we realized was, there's a lot of parents who use the follow up the don't get themselves have a G six app there, they have a follow up and they use the clarity app as well. And so that clarity app is an important aspect of being separate from CGM app. And so yeah, we definitely recognize it's a very important use case. And there's a lot of information that we want to update in the follow up. One of the things we did recently is there's now influent data in clarity. For the first time ever, we using if patients are using an in pen, companion medical, that's a smart pen that has its own app, and that data is being automatically uploaded to the clarity accounts. I would love to show that in follow. Show that influence data and follow and roll will add over time will add more of our influence partners will display influence data from their delivery systems, pumps and pens in our clarity software. And so that's another example of just the richness of the data we can provide inside inside the app. And yeah, expiration date. Definitely. Okay,
Scott Benner 34:03
Jake, you just answered a private question I've had that I've never asked anyone I've always wondered like I wonder if Dexcom is pissed at Mike left if it started up in 10 but now I realize you're not
Jake Leach 34:11
so not not at all not at all No I'm Mike and I are good friends and I yeah, they're doing great things over there and they were happy to be working with him
Scott Benner 34:21
is very nice to know that you are uplifting of people who who move on I actually a person who helps me with the business side of this podcast with you guys. She's going back to school. Melissa I want to wish you a ton of luck and success is very cool to know that you're not pissed at her now that she's going okay, so people ask all the time more volume and alarm control like like functionality user defined not just the timing of it, but the volume of it. One lady said I wish I had her. She's like it would be fantastic. Oh, if the high alarm to go off at night and wake me up but not scare everyone. I'm around her. In the day, that's how she put it that was I thought, appropriate because I see my daughter sometimes grab her phone and clutch it to her when her alarm goes off trying to quiet it down a little bit.
Jake Leach 35:09
Right? Yeah. So adding a volume to like the times a day. That the profile. Yep,
Scott Benner 35:15
yep, yeah.
Jake Leach 35:16
today. Yep.
Scott Benner 35:16
So here's one for you talked about how there's the landscape view now on the follow up, which I really like. And you can run your finger and all that. But when you guys did that, you took away the three 612 and 24 options on the portrait view that's made a lot of people unhappy. I'm one of them, actually.
Jake Leach 35:33
Yeah, and is that because you have to turn it sideways to be able to get to it? Yeah, it's kind of an extra step.
Scott Benner 35:39
And I, I can speak for myself, I don't know why other people do it. But I can make better treatment decisions on a three hour line than I can on a six hour line, I look at a 24 hour line for trends, I look at a 12 hour line to see if my boluses are off. So the the the the ability to step back, like you know, the idea of like, you know, when your hands right in front of your face, you can't see much but you step back a little bit, I sometimes I need my hand in front of my face, and sometimes I need to be able to step back. But when you go to landscape mode, you can select the three hour display, right? Yes, but there's something about it. That irritates me that I have to do that. And I couldn't even I can't. I can't quantify that for you. But so many people say it that I don't think I'm the only one.
Jake Leach 36:22
Yeah, no, it definitely It was a big change here it
Scott Benner 36:24
and I also imagine if you thought, here's me, I'm putting myself in your head. I'm in the meeting. And I go, yeah, it'll be on the landscape side. That's fine. And that's probably made sense. But it It wasn't just how do I put this? I thought when it first changed a lot get used to it. And I never have that that I thought I think the important part.
Jake Leach 36:44
That's good feedback. Yeah.
Scott Benner 36:44
Will Will we ever get an app for follow? Will it be excuse me a widget for follow?
Jake Leach 36:51
Yes. Yeah, absolutely. That's that's on that's on the list for sure. That's Yeah, tie a tie on the list for fall.
Scott Benner 36:59
Here's a wind will follow have the features that users can see see this, somebody just asked it in a great like, one liner, like all this stuff we've been going over. So just I wanted to just share that with you. It came back so much at somebody just said, Look, I see all these people have asked these great questions here. I don't know if my questions in here. So I just want to know, when will the features be there for follow? And what will they be? And, and so I'm wondering, as I'm asking you the questions, are you hearing me going, Oh, that's definitely coming soon? Or Oh, that's a good idea. Are you having both reactions to
Jake Leach 37:31
I have Yeah, both both reactions, I think most of the stuff we talked about is on is on the list to do and the way we what we do is we manage we in software development, we call the backlog, we have all these requests of things you want to implement. And we go through and prioritize using the mainly customer feedback. But also kind of level of effort, some features are really easy to implement the ticket and have a big impact. Some features are harder to implement. And they have a big impact, but they kind of take longer. And we try and group a number of those together. And one of the things that we're looking at doing right now is being able to make releases faster. So we've you know, with the classification of G six moving to a class two, from a class three, it's enabled a lot of us our systems to be able to be updated so that we can do things a little faster, doesn't change of the validation requirements or any of the quality, but it just allows us to put things out faster without having to always put it in front of the FDA before long before putting it into the market. So we're in the midst of planning out how can we move faster. And so there'll be updates coming out more frequently than we have in the past, particularly for follow follow really hadn't been updated much since the original version was launched. With g four, we done a lot of compatibility updates, but not new features. And so we're just beginning to start planning out. Okay, what are all these new features, we've got a great list. And many of the things that we've talked about, most of the things you and I've talked about, are on that list, but the timing is going to definitely be within the G six timeframe. So within the next year, or a year or so, there'll be a number of new releases for follow. But we just did our first big one. And we learned we learned some things. Not everything went perfect with that at launch. And we recognize that and so we're looking at Okay, how can we do it better in the future? The exciting thing, though, is that it's going to become faster, faster releases.
Scott Benner 39:33
It's also worth noting, like sure there are like third party apps that people like Oh, look, it has like rate of change is a good example, this one as rate of change. This one's better. Why doesn't Dexcom do that. But I would also tell those people who like those apps, those apps are incredibly confusing and overwhelming. And only the people who really understand all that can look at that and not become confused and overwhelmed by it. I think they have to accept that there is always going to be something from the company. That's for everyone. that there might be other avenues. And you spoke about it before you said it will be an API available where people will be able to make a different app like theirs. They have to understand your Dexcom for everybody there. And I think that way too, because there's some third party apps that people love. And I look at them and I'm like, Oh, my God, that is garbage. And I could never use that. But people love it. It's just it's too much. And I don't think I'm easily overwhelmed by the data coming back from Arden CGM. And sometimes I'm like, That's too much. I have one here for you, Jake. I, but when I saw people ask, I thought, Oh my God, that's the completion of my thought. Because sometimes when you get away from, you know, like, say you go in the pool, and so there's no set, there's no, you know, you can't get a signal. And your kids been swimming for 20 or 30 minutes. You think, Oh, I really would like to know what their blood sugar is. And then they jump out and then you have to wait for a cycle before you get a number back again. Could you use a could there be a button that forces an update? Let's go with this. Scott types into his browser thing one more time. dexcom.com Ford slash juice box. So make knowledge your superpower with the Dexcom g six CGM system. I think your superpowers that you live. I think you're superpowers that you listen to the Juicebox Podcast but we'll make this your second superpower. Okay. Anyway, let's see what does this say your zero finger sticks, glucose readings right on your smart device customizable or salons? Get started with Dexcom collect? Patient name, first name, last name, email address, phone number, city, zip code, birth date, type of diabetes. The pump do use pills injections, insurance information. I agree. I agree. I'm not a robot. And next. Wow, look at this. Thank you for your submission. You are one step closer to obtaining a dexcom continuous glucose monitoring system. One of our representatives will be reaching out to you to take the next step. You know, the next step is Don't you know more finger sticks, seeing what direction your blood sugar's moving, and how fast it's going. They're being able to follow a loved one's blood sugar no matter where they are on your iPhone, or Android. Hmm, that's the next step, baby. The next step is the stuff you hear us talking about on this podcast every night. The next step is freedom. It's ease, it's happy. Take care a happy step dexcom.com. forward slash Juicebox. Podcast share show notes at Juicebox podcast.com. Alright, let's find out about this apple watch thing, shall we? Could there be a button that forces an update
Jake Leach 42:43
right now. So the way that the system is architected, it's the transmitter that earns on and tries to make a connection with the plays that are within range. Okay. And today because of a battery and the technology kind of constraints, it only does that every five minutes. But there's lots of concepts that we've been mulling over for our g7 system that could potentially make that quicker, because we totally recognize the, hey, I want an update now. And, you know, I might have to wait up to five minutes to get get the update. So yeah, there's, I think our approach that would be are more faster updates between the two devices, not just every five minutes, like there is today.
Scott Benner 43:27
So maybe when there's a battery situation that can handle it, you'll be able to ping more, because I saw both sides of it. I thought that's a really brilliant idea. And then I also thought, oh my god, some type A Luna is going to stay on there and push that button over and over again and kill the battery in the transmitter. And And so yeah, just be like, What is it now? What is it now? Like, okay, relax. But but I think this question comes specifically from parents because I've had the same thought like when you have to stop your kid's life and tell them hey, stand here. It's, it's a little. You know what, it's weird, but it's a little demeaning. I don't know another way to put it like, hey, stand here till this thing tells me this number. So you can go back on the field or go back in the pool or something like that, in that specific context. It makes a ton of sense to me. And it's the only other time I've ever considered it. I mean, maybe like when you're battling a low sometimes and you eat something you're like, God, I wish I knew what it was right now. But you just usually test in that situation. But that's good to know. So it's, it's alright, so it's something on your radar. Do we have time? Can I hammer you with a couple quick ones and like your and then go to an option for a snooze alarm was asked a bunch of times, like, Hey, I have it set up so that I repeat every five minutes. Because I want that but so that I hear and I know but once I know, I know. Is there a way I could tell it? Right? Right on Don't tell me five minutes from now again. I have that problem sometimes with high blood sugars. Like I wanted to let you know what I mean. So it's news in the works.
Jake Leach 44:57
Got it? Yes, yeah, actually, there's a number of things that It's actually a great you mentioned I, there's a number of things about the high alert and the intelligence of the alerts that we're working on. I think one of the things that I always think about is, you know, sometimes people want to be alerted when they're going high. Sometimes people know they're going to go high, and they don't necessarily want the alert, at least not within a period of time. So some sort of flexibility there. There's definitely we're trying to design it for you know, for, again, like you mentioned, apps that can work for lots of different people. And so we're looking at how do you turn features like that on for people who want them? And so I think that the intelligence around the alerts the snooze, and all those things are definitely on the on the horizon.
Scott Benner 45:39
Yeah, I know, I mentioned this to you in the past, but I think it bears repeating. Again, here, Photoshop Elements has tabs at the top, you can you can use it in expert, or you can use it in beginner and beginner. It's been it's like PaintShop Pro from like 30 years ago, and an expert it has more options. And I just I think that's a simple way around. Fall alerts for followers that people say is really desperately needed. Like it's not enough to see the number going down. Like they want to be alerted if they're falling fast or not.
Jake Leach 46:10
Okay.
Scott Benner 46:11
Just let's see what thresholds can be set to my time today. Oh, this one comes up a lot. Is there? How did she put it profile options? Like, can I set up a profile that works for the school nurse, but is different from me? Because I don't want the school or like for follow? Yeah, like, I don't want the school nurse know what my kids blood sugar is? After five o'clock in the afternoon, that kind of thing? Oh, okay. So by time of day, okay, yeah. And by person, like so can that person have access to this data, but only in this time of, you know, and on these certain days? Or can I stop them from seeing it without making force like unfollowing? like dropping them from the follower list?
Jake Leach 46:54
Yes, we could we could do some that says that's a not I've heard that a request a similar type of request, not in the same way. But I think, yeah, that's definitely something that could be implemented. I think you can have different settings for different followers. But what we don't have is the ability to turn off follow, like on the weekend, or the exact use case, the nurse, you're talking about them. That was not the original use case, when we designed the follow system was not for that. But we've learned over time, there's a lot of different uses for follow that we didn't originally designed for that we need to consider. And so that's, that's an important one adding when we added up to 10. followers, recently, that was really born out of people were having to add followers and remove followers every week, because there were more than five that needed at a given time. So this is like an enhancement to that it's okay, now that you have up to 10, let's figure out when we could turn them on and off based on a profile.
Scott Benner 47:54
Yeah, I like that. That's a great idea. And I think in a similar, slightly similar vein, someone said, hey, my son's use our app has different thresholds that can be set for different times a day. But can I do that on my follow up, too? Yeah, I guess that's a person saying, you know, maybe they're saying, Look, I'm comfortable with my kids blood sugar being 150 while they're sleeping, but during the day, I want to know when it's over 130 or something like that. So I don't want to get woken up. Like I want to be able to say not now then when the follow side as well. And I guess you could use that the opposite way. I'd like to know, you know, I want to know what I want to know when I want to know it, I guess is the is the crux of it. Okay, so one quick question. And then I want to I'm just gonna say Apple Watch and let you talk. somebody pointed out that there's some seems to be a lag to the Health app. And I don't think a ton of people use the Health app, but I think you would like them to and I use it sometimes. Is there a reason why the information is not live on the Health app? Is that an apple thing?
Jake Leach 48:50
Oh, it's Yeah, that's a great question. There's the Health app on the apple platform. And then on Google, we actually have Google Fit, which is also the same type of a database where users if they activated can it'll deposit their their CGM information in there, it is three it is delayed as three hours delayed and split is an in called retrospective. And that is really, because of the the FDA kind of regulation around real time data. In real time, data is a different classification. In terms of risk than the retrospective data. retrospective data is considered data that you can't utilize to manage your diabetes in real time. Because it's three hours old and full action times and all things factored in, you can't really use three hour old data to manage diabetes in real time. So that is something that we're looking at revisiting the right now that it is delayed three hours, it's because of the way that we got that cleared with the FDA. If you think about it, it's very exact same delay. That's in our current retrospective API. Where we share data with, like gluco and others. That's all three hour delayed for the same type of reason. But we're engaged with the FDA right now in conversations about how do we open up real time data or make it more available to partners and health is Apple Health is one of those things where it's a database, users can use it to share their CGM data with other apps on the phone that they collect. And so we're looking at all the different options there.
Scott Benner 50:28
It's cool that people are using it, that's for sure. Hey, listen, before I say Apple Watch to you, I want to tell you, I got this feedback from somebody recently. And you talk you guys have been talking a lot more about partnerships. Obviously, in the last year or so you have won with tide pool and Omni pod and T slim and I'm sure others and and it's it's really moving people forward quickly. And even though you you know, Dexcom in this podcast aren't partners. Having access to your to your brain and being able to pick your brain like this. And having access to the data that comes back from my daughter's glucose monitor has sort of turned this podcast into that thing. Like, when I recognize that there were people saying that they manage their diabetes. And they were talking about it like they were being bold with insulin, I was like, well, that's something we said on the podcast years ago, and it's become a hashtag that's growing at what I didn't realize is that people think of that as a management style now, and I would never have come up with it without the data that you guys share with me for my daughter. So in some fairly strange way. You know, there are now I'm going to say, I because I want to be conservative, but I pretty sure I hear from a dozen people a day, a dozen different people every day, who are showing me either they figured out a meal, or they're a one CS down 122 and a half points, people that once they've listened to the podcast for a while just get 681 C's in the sixes, like just, it just happens. Now, they don't even stress about it, it's just they do these things, these things turn into an A one c that's, you know, more like sex. So I have to thank you. I mean, my daughter's health aside, I'm a little overwhelmed by how many people it's reaching. So it really is, it means a lot to me. And from what I'm hearing back from all these people, it means a lot from them, too. Because every one of these questions, and with please thank them, you know,
Jake Leach 52:22
I yeah, we really appreciate it in our teams, you know, one of the great things about working at Dexcom is we get a lot of feedback, you know, the both positive and constructive. But when people talk about how the product is helped them, you know, change their lives or help them, you know, manage diabetes better or save their child's life last night, it's one of the things I love to share with our teams, because they I mean just helps drive their motivation and passion for what they're doing. Yeah. And it is, we are company cultures, it was motto patient first, which is you you do right by the patient, and everything kind of takes care of itself. So that is core to our DNA. And it's going to remain part of what we do.
Scott Benner 53:08
Forever. We'll share this one next time I met a person in their late 40s, who's had diabetes for all of their adult life. And their blood sugars are constantly all over the place a onesies are constantly in the eights and the nines. And just by looking at a graph from a dexcom receiver, I was able to tell them, okay, here's what's wrong with your basal insulin. Here's where you're, you know, your boluses are wrong, we have to change your insulin to carb ratio, blah, blah, blah, so decades of living like that. And three days after we talked, they're fine. Blood Sugar, never under 80. Never over 120 they know how to do it now. It was all there the whole time. They just didn't know how to interpret it. Yeah, it's fascinating.
Jake Leach 53:52
It's data that is data that people haven't you know, in the past, we didn't have access to that type of information now that it's there. There's so much can be done with it when there's so much more we can do with it. So yeah.
Scott Benner 54:03
And it doesn't even take long like I am at the point now where I can look at a graph and be like, Oh, I know what's wrong, like immediately. And I trust me you don't know me that well, that I'm the guy that has that skill is bizarre, because it shouldn't be me like I'm really the guy you should be like, oh, Scott, yeah, we go to the movies with him. He's nice. Like, that's pretty much it like that, that I've developed any kind of skill is crazy. So if I can interpret that data back, I can't imagine what it's doing even for the people that I don't know. So okay, Jake. 8,014,253 people asked me when they can use their Apple Watch without a receiver or their iPhone. When's that happened? Okay.
Jake Leach 54:43
Yes, trust me, it is coming. Yes, I you know, we are doing some, we have some prototypes that we've built and been testing quite quite heavily. And so, we're a couple things about it. And it requires an update to our transmitter firmware. So it's kind of invisible to users but, and there'll be a firmware that's going in update, that's the software inside the transmitter. And there's some new features, we had to add to the Bluetooth interface to enable the smooth handoff between when the user is on their phone is in range, and they're using their phone. And then when they walk away from their phone, and they want their watch to take over, we had to make some rather significant changes to the Bluetooth interface to do that, working with the apple profile for the watch. And so we've made those changes. And we've got systems that we've been testing for quite a while to ensure that this thing works exactly where we want it to. But it'll go off, we'll begin shipping transmitters with that firmware in it. And soon, I can't be exactly specific, but we'll ship it. And then as soon as enough of those transmitters are out there, we'll turn on the app feature that allows it to have allows it the transmitter to communicate directly with the watch. A couple things about it, though, you'll always need to have an iPhone to kind of set up and start the session. Because there's a lot of functionality in the app. That is we can't implement all of that on the watch. But once you have the session up and running, then you can walk away from your phone for extended periods of time. And you'll you'll get your alerts and you'll get all your CGM data live. I've been testing the feature myself. It's incredible. I don't have diabetes, but I'm always testing our products and understanding from user perspective. But it's wildly freeing to know I can just walk away from the phone and still get my readings on on the watch. Without having to wait, I gotta go back. And Randy, I like that concept you're mentioning about having a child stand next to you for at least five minutes to get their data. Well, this is one of those are wearing the watch as well, in all likelihood, there's gonna be data on it. So there's, um, yeah, it's a really exciting feature, it's more impactful than I even thought it was going to be when I started testing it. So it will it will come out it will come out on G six. And that's about as much I can say on timing. But well, it's kind of
Scott Benner 57:08
the way Kevin said it was. And because I said to him, I was like, Look, you should just not mention it until it's you know, in everyone's hands and turn it on and be like, hey, guess what you guys have now. But let me ask you a question about, about that about setting expectations for people. And then I'm going to let you go because we've been talking about Apple Watch. And this this usability, it feels like for a really long time. And while most people aren't in the space, enough, in their day to day lives to feel like Oh, God, they told me that two years ago, I don't believe it anymore. I have heard that from people who are constantly in the diabetes space. So my question is, is it did you guys start talking about because nothing happens by mistake in a company, you're a publicly traded company? So did you start talking about it by and think it was going to go faster?
Unknown Speaker 57:56
Did
Scott Benner 57:56
somebody else that was the apple side that held it up? Or were you just like, hey, this thing's coming. But you don't think of time the same way as maybe the people who are waiting for it like, and there's a lot of questions in there. But I'd love to understand that whole, like when we hear about something. And you know when to when we get it like what's the thought process on the back end with you guys like dessert?
Jake Leach 58:18
Yeah, that's a great, it's a great question. The So the short answer is we we thought it was going to go faster. So we usually don't like g7. Right? We've talked about that for quite a while. And part of that's because it revolved around a partnership with verily and we have there was a large financial commitment made in that partnership. So you kind of talk about what are you doing? Well, it's for our g7 platform. But the Apple Watch specifically is about we thought it was going to go faster. And what happened was, Apple turned on the core Bluetooth functionality for certain partners. Dexcom being one of them. That's the ability to actually connect directly to the watch with a Bluetooth interface. And as we started to go through our use case, with the version that they first implemented, it was about two years ago, I think they announced it, we started to realize that the use case wasn't going to work. One of the specific things was pairing our transmitter to the watch was a challenge with the original implementation of how that core functionality worked on the watch. And so giving, you know, working with Apple feedback, we're also not the only folks working with Apple on connectivity to the watches, other types of devices out there that are doing it's all of us working together and basically had to we had to iterate on the implementation. So the new watch OS that was launched at the end of last year has the functionality in it that we need to make the user experience what we wanted. And so, since that release, we've been doing a lot of testing to ensure it covered all the use cases. But what we didn't want to do is launch it and have it not not delight users and have some issues on the usability side. So we've actually had prototypes, and for multiple years that have been out of the functionality, but they didn't work smoothly, there'd be data gaps would be things that happen. So it's taken us this time, and the updates from Apple to make it work properly. So that's a long answer, but we thought it was going to go faster. It's pretty good.
Scott Benner 1:00:20
I'm an Apple Watch user. And every time I buy a new one, I think to myself, why am I buying another one of these things? And I, there's part of me that's like it, because it's gonna start working the way I wanted to. And, and yeah, it is really new technology. Listen, it's easy to joke about this a tiny little thing on your wrist, it's a computer that, you know, probably could have could launch the space shuttle. And if we had a space shuttle anymore, that was an old reference. And it's just this, this stuff takes time to develop. And there's so many different partners and people trying to use it. Like it all makes sense to me. But it's easy in the moment to think, to feel like as I thought to like how they said Apple Watch. And now, you know, I think I'm two more Apple Watches into it. And but you're saying now everything is sort of finally there. Like you're comfortable that when this comes out, it is going to be the thing that people wanted? Yes, yeah, it's excellent. Hey, I'm gonna let you go. But I I don't know anything about Android. But I got a lot of messages that just said Galaxy S 10. Is that a thing?
Jake Leach 1:01:15
Yeah. So what the it's not about it's not that doesn't work. But the Samsung S 10 is a new phone from, from Samsung, the Galaxy S 10. And it just launched at the beginning of the year. And we're currently testing compatibility for it. One of the things that happens with our current testing, particularly for Android, because Android devices, there's more of them, and they release at different cycles, we have to do quite a bit of compatibility testing to be able to add it to our list of compatible devices on the website. There's right now, there's over 40 devices on our website that the G six and G five are compatible with that cell phones, but the Samsung one is that we just finished the testing. So within the next month or so it should be on the supported device list. And so we're working hard to bring that but it does take us about three months to get through all of the testing that's required. One of the things we are looking at and working with the FDA on is there. Now that we've had a lot of experience with this compatibility testing, is there a way to do this faster, because we think there's probably some things we've been doing that we could go faster or reduce that amount of testing, but it is important. And it's important to the FDA that the device works well and that they're very compatible. And there are some Android devices out there, they tend to be lower cost devices that don't work as well. And we don't support them for that reason. Because the the Bluetooth compatibility is not as strong as it needs to be. So that's what we're validating with the S 10. So hopefully, I by the end of this month, which is like a week away, I think we should have it up by then. But I was just actually looking at that the other day. So very soon this time will be sported
Scott Benner 1:03:04
cool. Hey, so other other other watches that I have an Apple Watch. So I'm American, I just imagined nothing else exists. And so are there other like watches and devices that are you guys looking at having the ability to do it on Fitbit, or like I'm just making up words now but others? Are there other things like that that exists? Are you just as far as a watch goes? Is it just gonna be Apple Watch in the near future?
Jake Leach 1:03:26
on the Android platform today, we support the secondary display on on the where I OS system so the lot of different manufacturers manufacturer manufacture of watches that are compatible with them where OS and so that we do that secondary display and we are looking at doing a direct to watch on some other some of the other platforms as well. But Apple is going to be the first
Scott Benner 1:03:53
Okay. Hey, and my last thought is because I just had it now. Hey Siri for followers.
Is that Yeah,
Jake Leach 1:03:59
yeah, definitely on the list, because people like it
Scott Benner 1:04:02
and I hear a lot from people like when I'm driving Hey, Siri is a big help to me. Now. I've said hey, Siri, three times my phone's gonna start yelling at me soon. But cool, Jake, I kept you like for the whole hour. This thing is packed with information. I really appreciate you coming on and doing this. I'm going to say goodbye. And thank you to Dexcom on the pod and dancing for diabetes for sponsoring this episode of the Juicebox Podcast. Please don't forget that there are links in your show notes at Juicebox podcast.com. If you want to find out more about the sponsors. If you downloaded this on Friday or the weekend I hope you enjoyed getting an extra episode of the podcast this week. Please don't forget that defining diabetes also came out on Friday along with this episode. Defining diabetes of course is with Jenny Smith and I where we take a term from your diabetes life and define it in just a few short minutes.
Jake came back, back again. Yes, he's back. Back again. Jake came back Jake came back Jake came back Jake came back
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#238 Defining Diabetes: Basal
Defining Diabetes: Basal
Scott and Jenny Smith, CDE define the terms at the center of your type 1 diabetes care
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
In this episode of defining diabetes, Jenny Smith and I are going to define bazel. Seems simple, doesn't it? Maybe it's not. Maybe it means more than you think. Defining diabetes is made possible by Dexcom on the pod and dancing for diabetes, hang out for just a couple moments after Jenny and I define bazel and find out more about them all. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, the Always consult a physician before becoming bold with insulin, or making any changes to your medical plan. Hey, Jenny, let's define bazel. I'm going to go first this time.
Unknown Speaker 0:40
Okay.
Scott Benner 0:42
I'm online. Right? So Basal outside of diabetes is just forming or belonging to a bottom layer or a base, which makes sense when you translate it to diabetes, right? Because it's a baseline of insulin. Right? It's it's that, that that kind of layer of insulin that, you know, we talk about all the time on the podcast, like, you know, when you hear me tell you, during like a higher carb meal, I think we call them a carb beer meal one time I said, I like to lay a blanket of bazel over top of the lifetime of that food. So that makes sense. But how would you define bazel for diabetes,
Jennifer Smith, CDE 1:18
so bazel for diabetes, essentially, it's a in those who inject it's a long acting insulin, usually inject it once or twice a day, and it covers the background feed the physiologic need for insulin that your own pancreas would do as a drip, drip, drip, drip, drip all day long. basal insulin has
no technical
fees in to cover food, right? We know that it does if you're doing other things and the potential need to increase or decrease but in this definition, Faisal truly covers your physiologic need for a background insulin. And we all need it in our body at all times. Even people without diabetes, their pancreas goes drip drip, drip, drip drip. If you're on a pump, it goes drip drip drip at a rate if you're taking up an injected bazel it is absorbed from the site that you would inject it at once or twice a day, over a long period of time.
Scott Benner 2:29
You don't want to miss the diabetes pro tip series that Jenny and I did recently. It begins back in Episode 210. with diabetes pro tip newly diagnosed starting over after that it's Episode 211. All About MDI Episode 212. All About insulin. In Episode 217. We talked about Pre-Bolus going into 18 Temp Basal in 219 insulin pumping into 24. Or mastering your CGM into 25. bumping and nudging into 26 the perfect Bolus and into 31. We talk about variables. The latest installment just went up a few days ago, and it's about setting your basal rates. Defining diabetes on the Juicebox Podcast is brought to you by Dexcom on the pod and dancing for diabetes. There are links in the show notes at Juicebox podcast.com to all the wonderful sponsors. But if you want to find out more about getting a free no obligation demo valmy pod you can go to Miami pod.com Ford slash juice box to get started on the Dexcom g six continuous glucose monitor dexcom.com forward slash juice box and to learn about the goods that's being done at dancing for diabetes go to dancing the number for diabetes.com Thanks for checking out defining diabetes. Come back every Friday as Jenny and I break down a new word or phrase that is impacting your life with type one diabetes.
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The Juicebox Podcast is a free show, but if you'd like to support the podcast directly, you can make a gift here. Recent donations were used to pay for podcast hosting fees. Thank you to all who have sent 5, 10 and 20 dollars!
#237 Diabetes Pro Tip: Setting Basal Insulin
Diabetes Pro Tip: Setting Basal Insulin
Scott and Jenny Smith, CDE share insights on type 1 diabetes care
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 237 of the Juicebox Podcast. Today's episode you know by the title is with your favorite guest, Jenny Smith, Jenny and I are here today to add an 11th entry into my diabetes pro tip series. Please don't let the fact that this is the 11th episode in this series make you think phased array testing probably not that important. If it was they would have moved it up sooner. Not even close. Having your basal insulin correct is the core of everything you're doing with insulin. You can't trust that your Bolus was right or wrong. You can't understand why you got low or why you got high. When your basal insulin isn't correct. Everything you see coming back to you from your blood sugar experiences from your glucose monitors from your meter testing. None of it is actionable. None of it is valuable. If your bazel isn't right. Every time I speak with someone privately we start with basal insulin doesn't matter if you're pumping or injecting, and most people's basal insulin is significantly incorrect. If you're seeing blood sugars that you don't understand, it's easy to see a low blood sugar and think that means less bazel. But that's not always the case. At the end of this episode, I believe you're going to have a firmer grasp of what basal insulin is, how to make adjustments to it and why it's so important. You really need to listen to this one. This is where it all starts. This episode of The Juicebox Podcast is made possible by Dexcom ami pod and dancing for diabetes Dexcom. Of course the makers of the G six continuous glucose monitor on the pod makes the only tubeless insulin pump in the world. And dancing for diabetes is the organization bringing joy to children in Florida and touching people all over the world. With their generosity, you can find out more dancing for diabetes.com dexcom.com forward slash juicebox in my on the pod.com forward slash juice box. My friend Jennifer Smith is not just the CDE. She's a person who has been living with Type One Diabetes for a very long time. Jennifer holds a bachelor's degree in human nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer I'm most makes and models of insulin pumps and continuous glucose monitors. Not only that, but she's my guest in every episode of the diabetes pro tip series. If this is your first one, you have to go back started episode number 210. From there, it goes to 11 and 212 then jumps to 217 1819 diabetes pro tips picks back up at Episode 224. With mastering of CGM to 25 to 26 to 31. And of course, you are listening to Episode 237. This is the 11th in this diabetes pro tip series. And in my humble opinion, it just wouldn't be the same without Jenny. Last thing, actually last two things. First one's easy. You know, I'm gonna say nothing you here on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making changes to your health care plan. Becoming bold with insulin. And the second thing is that Jenny does this for a living. You can check her out at integrated diabetes calm, or her email address is right in the show notes of your podcast player.
A funny thing happened the other day, I felt like we did such a great job of outlining everything that everyone would need to know. And I was so comfortable with it that I started supporting the podcast episodes with like social media posts like Hey, don't forget how important your basal insulin is. And the right the amount of notes that I got that were like, Hey, you didn't do an episode specifically about setting up your basal rates. And I was like I didn't, I felt like we covered it all with what we talked about. But okay, if you want it like so let's add one that's about setting up your bazel testing and getting it right. And I was like, Alright, well, we'll definitely do that if the people are asking for a journey, then we have to deliver.
Unknown Speaker 4:02
That's right. That's what I'm thinking. That's what we're thinking.
Scott Benner 4:06
So, so I wanted I would like to do that. Now, here's how I imagined this. And I'm recording already. So this will probably all end up in episode. I'm assuming there's a super like specific way, because I remember being taught it like, you know, in the doctor's office, like very specific don't eat food for this much time, like make sure to like this whole thing, and this is what your basal rates gonna be. Now, there are times when I think that's antiquated and as much as if you have a CGM, you may be able to figure out your base more quickly. But I'll cover that when we get to my less technical way of doing it. But I really do want to start with what is the accepted medical process for figuring out what your basal insulin should be? Check out dancing for diabetes at dancing for diabetes.com that's dancing the number for diabetes.com you can also find them on Facebook and Instagram. Fantastic organization, you should check them out at the very least get involved if you like what you say. What is the accepted medical process for figuring out what your baseline slash obey? Go crazy, Jenny, because I feel like you're gonna get to talk a lot.
Jennifer Smith, CDE 5:21
The I mean, the accepted, ethical way to do it can also vary. You know, I've heard, I've heard a lot of different but I've also heard enough similarities for you, I guess, our best ethical way to do it within integrated when we start working with somebody brand new. As a first and foremost question, have you verified that your bagels are working well, and bazel evaluation can also be done using injected basal insulin as well. Not in the same way or as extensively as a pumped Faisal rates, right. But you can evaluate the whether or not your basal injected insulin is working pretty solidly to Okay, so both of them can be looked at. As far as pumping, we always start with an overnight evaluation. And the reason for doing overnight testing first is one majority of people, unless you're a shift worker, or overnight truck driver or something, most people are sleeping in that overnight time period, there's no eating, no exercising, there's no food going in anyway, it's like one of the easiest times of day to actually get a bazel test in. Okay, the biggest thing heading into any bazel test is that there isn't any food that's going to be impacting in that bazel time period. And there's no lingering impact of your bullet. So for an overnight test, we aim to say, have your dinner and bolus by 6pm. Because by 10pm, when most people are going to bed, give or take depending on if you're a little kid or an adult or whatever, by 10pm that bolus itself and 99% of that food impact should be gone by 10pm in out kind of the bell curve of effect, right? So from 10pm overnight and into your normal waking time, then we get a true look at what is bazel doing to hold things steady. Now, the other variables in episode about variables too, right? Dude that comes into play with testing. You know, if you are in those couple of days before your period is starting, if you have a nasty cold if you have a lot of exercise because of training or practice or something you don't want to be able to tap on an overnight when any of those pieces are.
Scott Benner 7:54
Right, you know what I wonder, too, is I'm starting to believe that there's a different bazel rate that my daughter needs depending on our site. So I think there's a leg bazel rate for her and I think there's a belly basal rate for
Jennifer Smith, CDE 8:07
that's actually funny I use when I use my upper bulat for my knee pads prior to looping with a Medtronic pump. Okay, I noticed that on my bus, I need about 10% more basal insulin. And so I set up a bazel profile that I call but
Scott Benner 8:32
I could definitely say But
Jennifer Smith, CDE 8:34
yeah, I called it but and I had it 10% higher than my standard tested Faisal rate, right that ran on my other normal sites, which seemed to work the same, you're not crazy and thinking that it could be the case. And it's something I bring up with people too, especially those use Omni pod, which can you can wear it in a lot of different places compared to conventional tube pumps, right. So overnight, the goal of diesel testing then is to have fair stability, and not like this entirely flatline. But the goal is to not have more variants than about 20 to 30 points up or down from where your finger stick value at 10pm is. And the goal at 10pm. One set bolus from dinner and the dinner food is pretty much gone. 10pm your blood sugar you're aiming for it to be somewhere between 80 and 250. I know that looks like a broad range, right? And you're thinking well, gosh, if it was like 150 i'd totally correct that at that time because I don't want to sit at night All night at bedtime, you know, 150 you let it lie. You don't touch it. You don't take corrective. Just let it sit. So if you go to bed at 188 you leave it alone, because the bazel job is to not correct that. The bazel job is to hold you pretty steady. If you're not going to have more than a 20 to 30% variance up or down from that. That means all night long. shouldn't really go more than like, a little bit above 200? Or maybe down to like the 150s? If you started at like 188.
Scott Benner 10:09
Push that then you imagine that the bazel is pretty steady, correct?
Jennifer Smith, CDE 10:13
Correct. If you accomplish that with little variants, but not a lot, and you wake up, let's say at 169, awesome, your bazel, we would hold it, check marked off in our box of records as stable tested, it's good. Let's move on to the next testing period. Now, let's say your bazel does show that it's not right. Let's say that 10pm, one at blood sugar, but by 1am, you're starting to see a drift up. That's significant. And by two or three o'clock, you're like 50, or 60 points higher than you went to bed at? Absolutely, there's something wrong. Now, where do you adjust? That's the next big question. People are like, Well, I was high at two o'clock. So I changed my bazel at two o'clock, so that it wouldn't be high anymore. It's actually it's kind of missing the boat, right? Because where you really want to adjust the bazel is about one to two hours prior to the drift being too high or too low start. Okay, so if you're too high by 2am, you probably need a basal adjustment, at least by 1am. Or maybe midnight, that's higher, so that you don't have the drift up in the next two hours. Yeah.
Scott Benner 11:27
And that's the end for people listening to get confused by that. If you think about Pre-Bolus, and you put insulin and it doesn't begin working for a certain amount of time, either does basal insulin, and you're using much less of it. So to get a real impact from it could take some time for it to build up its efficacy, I guess, right? And then not be able to hold you stable.
Jennifer Smith, CDE 11:48
Okay, correct. Yep. So that circulating insulin level at the great description, it needs some time to bump up or bump down right to the rate that's going to be then effective an hour to two hours from now at that rate.
Scott Benner 12:01
It's the same reason, same reason why when we tell somebody if your blood sugar is super stable at 70, and it's been like that for hours, and you haven't had any food or you know, insulin, and you want to try to bring it up by doing attempt down, you can but if your blood sugar's falling at 70, shutting off your bazel is not going to do anything to affect what's happening right now. Wow. You'll make your blood sugar high, two hours later, right after your seizure.
Jennifer Smith, CDE 12:24
Right. Exactly. Right. Yeah. Or after you had, you know, a 30 grams of a juice box or whatever. Yes, exactly. Yeah. So it's Same, same thing, you know, if you're drifting down, you adjust the bazel down a little bit, fill in the same timeframe, one to two hours prior to that drift, starting, so that you don't get too low, later. Now by how much? I mean, again, this is where it does vary a bit. But usually, you know, if the drift up is somewhere between like, if the like 30 to maybe 60 points higher or lower than you want to be within that time period, and adjustment by point 05 to the basal rate could be enough to make a change so that you're not drifting up or down. If it's more significant drift, and you're really rising like 100 points, you started at 188 by two as you're at 280. That's, that's a pretty big change. Yes. And again, we would probably adjust the bazel at least by point one, maybe even point one, five. Depending,
Scott Benner 13:32
you know, what's interesting is that I know this isn't like any kind of hard and fast rule, or it is, and I've found that by mistake, but I talked to a lot of people with kids, you know, younger children. And it seems to me that the rule of thumb is point one per 10 pounds of body weight with kids. I don't know, I don't know if that ends up working for adults or not. But the more people I talk to, the more I see, like that's what makes sense. And I don't know if it's an anomaly for me. But when you have somebody on a phone call with you, which you know, telling telling you something about themselves. And it's like, you know, I'm doing this and it's not working and blah, blah, blah, and you need somewhere to start like it doesn't you don't even you need somewhere to start. And I always ask like, well, how much do they weigh? And most the time it bears out but then recently I spoke to somebody, it wasn't even close. It didn't matter. The weight was unimportant that that child just did not use the insole in the same way. Right.
I think of bazel in a completely odd way. I think of it like volume. Right, like on a on a stereo. And I just think if you can't hear it, or if the base is not working, turn it off. And if it's too loud, turn it down. And because Arden's using, you know, a dexcom, g six, I, I just turned it up until she gets where I want to be, and then I dial it back a little bit. Is that a bad thing? Am I doing that wrong? Is that is that irresponsible? Which by the way, in the last 10 years has become a word again, I don't know if you know that. You're irresponsible. There was time grammar people would be like, that's not a word. You can't say that. And all the sudden, it's been come acceptable in like the last half a decade or so. So now I feel comfortable to speak improperly again. So you're responsible? Is it irresponsible?
Jennifer Smith, CDE 15:47
irresponsible? Well, I actually use that word with my six and a half year old all the time. So I guess I've been using it more appropriately now. And I thought, yeah, that is irresponsible to do that. Do not do that, you know. So,
Scott Benner 16:03
anyway, I
Jennifer Smith, CDE 16:04
don't think I don't think that that's irresponsible. I mean, you're doing again, and again, in the topic of bazel, specific adjustment, we talking about temporary bazel adjustment, we do that a lot, to dial it up to dial it back to kind of you know, and that's also the concept of looping, right, is that the system works according to what it sees happening to the blood sugar and the insulin that's active in the food that's active, and it may dial things up, and it may dial things back. So that's, I mean, definitely not irresponsible. When you're talking about setting through bazel, though, we really want to make sure that we set the the bazel rate itself in the profile the right way, and you can dial it up, you know, if you want to be truly bold with insulin, you may want to dial it up a little bit more than you think you may need do another bazel test, and then it doesn't work quite well, because now you're ending up lower than you want. And great, just dial it back a little bit in the adjustment that you made. But at least it'll be a better picture. Um, you know, overall, and you can always test over and over again. Most people hate vehicle testing, myself included.
Scott Benner 17:17
Listen, that's I remember getting the sheet of paper handed to me when Arden was two, and they're like, the first thing we're gonna want to do is bazel test. And I looked at the sheet like, Well, I'm not doing any of this, but okay, and you know, looking back, it really should have done it, you know, especially back then when there was no CGM, and you know, none of that stuff, and I really shouldn't have done it. But, you know, no food being digested, you know, no active insulin, like, how am I going to get like a little kid not to eat for five or six hours? And I did eventually figure out that overnight was the place to begin. And you can, to some degree, infer the daytime from the nighttime meaning meaning, you know, if it takes a unit an hour overnight, you're probably not five units an hour during the day, you're probably somewhere near that unit. Right. Right. Right. And it could be I mean, it could be significant i right now Arden is more like a unit overnight and more like two units during the day. Right. So in, but that also will go back and forth. The just, just I will say this, because you you alluded to it earlier, and you were just talking about the idea of bazel testing, like I know a lot of you don't want your blood sugar to be 180 or 200 overnight. But for this test, maybe that's what has to be, I'm really coming to realize that an incredibly flat line one that's 85 for 24 hours a day, is really not reasonable. It's doable, right? And sometimes you'll get it and maybe you'll get it for days in a row if you're really dialed in. But you can't be upset if a blood sugar goes to 160 for 45 minutes and comes back again. It just my blood sugar goes to 160. Like if I sit down to play two pancakes today, my blood sugar is going to be 160 probably for a couple of hours now. different situation, right? And I don't have the other impacts of Type One Diabetes like people with type one, two, and I get wanting to limit it. But everything we've talked about on this podcast for the last number of years, I've seen it intersect with Arden becoming an adult. And so do I think you can keep a 90 blood sugar forever if your kid hasn't hit puberty yet? I bet you can. Right? I think it's super easy. I think that when you get to puberty, I don't think you should beat yourself up if that doesn't happen. And and I can still do it most times you don't I mean, like don't get me wrong. But I don't know. Like it's it doesn't seem as important to me. It almost seems like a video game. Now when I step back, and I watch people online, do it, for instance. And they're like, look at this graph, and I'm like, That's amazing. And then there's part of me that wants to say show it to me 10 days in a row and then I'll get excited right like don't Just show me one in the middle of May and go, Hey, look what I did here. And that's why, you know, on my blog, I tried to put things up that are like, Look wrong, everything went today, Arden say onesies still under sick? You know, I don't know, I just I want you guys to realize that we don't want spikes when we get them, we want to bring them back down again. But if they happen, you cannot run around like you've lost some, you know, game that that's attached to your mortality somehow, you know if your blood sugar is always 200 Yes, but you know if it jumps twice, come on, like ease up a little bit. Okay, right. So how reasonable is it that once I bazel test, I'm actually going to know what my basal rates are. Normally, I tell you about the dexcom g six continuous glucose monitor about the share feature, you know, you can see your kids blood sugar when they're not home. Or you know, if you're an adult, and you'd like your parents still or a friend to be able to see it, you know, sharing files amazing. It's available for Android and Apple and blah, blah, blah. And you should do that. Wouldn't you be great if you could see the direction of your blood sugar and the trend lines and how fast your blood sugar's moving up, down all that stuff that you hear me talk about all the time, hundred percent true, but with the time that's left in this Dexcom ad, I'm gonna say this year, you are listening to the bazel adjustment episode. By now if you're still listening, you must believe how important it is to have your basal insulin correct. And while you can do it without a dexcom It is so much easier with one I mean, oh my god, it's so much easier. Go to dexcom.com Ford slash juice box to find out more about the Dexcom g six continuous glucose monitor. Let me sweeten the deal by telling you this story. It's summertime now Arden's home from school. Last night, she was up facetiming with friends from all over the country. And they were up way too late. So Arden needed to sleep in today. She slept till 130 in the afternoon. And I was able to keep her blood sugar from going below were high. While she slept all of that time away. All that think about that
6am 789 10 1112 one, no food, no intervention, just the information from the Dexcom to help me make decisions about her basal insulin. And those decisions kept her blood sugar between 70. And you know, 120 is where we get I alarm. But honestly, I never saw over about 95 dexcom.com forward slash juice boxes, links in your show notes at Juicebox podcast.com. Get started today. But before you do, let's talk about on the pod, the only tubeless insulin pump in the world, the insulin pump that my daughter Arden has been wearing since she was four years old to 11 years ago. And it has been nothing but the best friend we've ever had in diabetes. last day of school, Arden went to a friend's house to go swimming, had around the pot on last night, need to make an adjustment to her blood sugar picked up her PDM button button button. Just like that No tubing, she's laying in bed facetiming she's not wrapped in tubing, she doesn't have to bounce her controller on her head or stick it in her pants that doesn't exist on the pod was over on the dresser right there. just just just there, just reach over and grab it, push a couple of buttons, give yourself some insulin, take some insulin away, maybe a Temp Basal decrease. I don't know what you're doing. But trust me, whatever you're doing, you want it to be easy, and you want it to be good. And you want it to be wholesome and fulfilling and make your life better. And that's exactly what on the pod does. The best part is on the pod wants to send you a free, no obligation demo, they call it a pack a pod experience kit, they'll send it right to you right to your house. So you can try one on the pod for yourself before you make any decisions. My omnipod.com forward slash juice box or the links in your show notes or Juicebox podcast.com. No more ads, talking about basal insulin the rest of the way.
Other times I bazel test and then I don't have any better of an answer.
Jennifer Smith, CDE 24:05
There might be especially if like I said before, if you're doing some bazel testing, and there are variables at play that you didn't really think to pay attention to in that time period, then absolutely though that bazel test could be not very purposeful. It could be kind of null and void. And this is something I encountered a lot with women. And something I bring up when I work with them to begin with. And in a first visit is one you said you've done beta testing, but to see you know your cycle impact if you have one and two Did you bazel test in that sweet spot of like two to maybe three weeks whether women are on birth control or not. They're sort of like this two to three weeks of sweet kind of plays of management without significant hormone impact. And that's where beta testing used to happen. It needs to happen without the impact of Pre cycle or oscillation hormones kind of coming into play. So if you haven't been tested in those sweet spots, and you're completely wrong, what's happening and what your basic needs are. And once you do have that sweet spot to put into play, and other, this is an important piece that a lot of people ask about too, is great. So then I need to test in these other times, well, that really, you know, what we find is that women mostly need like a 25 to maybe 40% increase in a hormone specific time period of the month. If you know that what you can do is use the Temp Basal, ie How well does this work? And what you can do because the time periods during the day that your Basal goes up or down, physiologically, those times will remain pretty stable. Those shouldn't need to change, it may be that you just need 25% more between 6am and 10pm. Right. So you can plug that into a bazel profile, set it and turn it on or enable it when you need to. But those time periods of the day, they stay pretty stable. Once you've designated Oh, my basal needs go up at 2am. Up, they shift down again at ADM, they're pretty stable until four or 5pm, they might go up or down again. Another piece for bazel testing is that most most people, again, your diabetes may vary. But most people will have about Orwell, most people have one Valley and one peak to their bazel during the day. So let's say they start midnight at point six, it might go up to point eight by two or 3am. Maybe it goes down around 8am 9am to like point six again. And then through the day, it's phase kind of lower, and then it may shift back up into the evening time. Okay, so you kind of had one dip, but one rise through the course of a 24 hour time period. Again, that's most people, not everyone. Most people also have about three to five basal rates through the course of the day or bazel time periods. So, you know, midnight until 6am 6am until 4pm 4pm to 9pm 9pm to midnight, those time blocks. Most people have about three to five different segments of rate need. Through the course of a day,
Scott Benner 27:25
you have to stay flexible too. You can't just say to yourself, look, I've set this basal rate, it starts at 3pm, it ends at 7pm. It always works. And then Thursday comes in at five o'clock your blood sugar starts to drift up, and it won't stop drifting up. You can't lock yourself into that doesn't make sense because my bazel always works. It's not working now. And the reasons you know, I'll be talking about this throughout the years of the podcast, but the reasons are almost unimportant in the moment. The truth is your blood sugar Yeah, yeah, right. You need more insulin, use more insulin. And and I've come to start, I've begun to start saying privately that that the diabetes, your blood sugar, it's requiring more of you. So give it to it. You know, he's telling you something your blood sugar going up is is your body's saying hey, I don't have enough insulin. Don't like wonder why just believe it. You know, like, there's no reason to, I don't know, if you came up to an intersection. And there was a cop standing there with his hand up it says don't go around the corner. There's a guy with a gun there. Just believe the cop and don't go around the corner. There's no reason for you to peek your head around the building. Oh my god, there is a guy shooting there. Like just take his word for it and walk around the block. And so. So when your diabetes is telling you, Hey, I don't have enough insulin, just believe it and give it more insulin. I got this beautiful note this morning from someone who said they were listening to the last episode. And she said, I think she called it like a bat in the head moment where she was just like, oh my god, I'm an idiot. Why am I not using more insulin like like, you know, running around all day looking at her blood sugar going, what's wrong? What's wrong? What's wrong? What's wrong? And she said, We must have said something on the podcast. And she just was like, oh, but sometimes that that happens like because you get so narrow, focused on the things that are supposed to be happening, that you can't break away from them for a second and look at actually what's going on. You know, listen, this is good life advice, too. If you're fighting with a spouse or a girlfriend, and you're saying to yourself, I have the best intentions here. Why is she upset? It doesn't matter. She is you know, so you're doing something wrong. Forget figuring out what it is. You're wrong. Stop or you're wrong. Right. That's it? Yeah, I've given you a number of ways to think about this. Now, when your blood sugar is going up. Give yourself more insulin. As a matter of fact, Jenny my next t shirt is going to say more insulin. That's the next t shirt. I'm going to print if I can ever figure out how to have one absolutely deserves a T shirt. All right. Everybody's always like telling me it's so easy to print t shirts. How can you not figure it out? It's like I'm very busy. Leave me alone. But I'm trying. Anyway.
Jennifer Smith, CDE 29:59
Yeah, I do. That's also a really good point. Because if this is where you could also say, is it a trend now? It Like you said, 5pm, my blood sugar is going up. I don't know why I don't have any active food. I don't have any active insulin shouldn't be going up. I felt like things were pretty good up until today. Great. Well, you know what, tomorrow if it's happening again, the next day, if it's happening again, something shifted. Why? Again, don't play with the why I mean, you can go back and evaluate and look at some things and whatever. But in the moment, you say, you know what, it looks like my blood sugar starting to go up by 435 o'clock every day, and I'm high by six o'clock and I keep adjusting and correcting. Don't do that. Right? adjust it, make an adjustment and go forward. And then you know, what if it shifts back down, right? If a couple of days, you're ending up low, then you shift it back down again?
Scott Benner 30:50
Yes. See, you're you're highlighting something that I've never understood when people say to me how many days till I think it's a trend, and I should change. And I'm always like, Who, what, like by the time you by the time you suss it out three days later, it might go back again, now you've given away three days of your blood sugar at that level, get just learn. Don't ask your wife Are you really gonna wear those pants, like she doesn't like it when you say that to her right leg, Sue, so stop and don't don't do it again, like, my blood sugar went up at five o'clock, I did something about it. Tomorrow, it went up at five o'clock, I did something about it. The next day, I'm not even letting us get to five o'clock, right? I'm just gonna decide, I'm going to expect that what I know is going to happen is gonna happen. And I'm gonna deal with it ahead of time. And if it happens to not go that way, well, then I can dial it back again. But it's so much easier to ramp up your insulin and bring it back than it is to sooner than later.
Jennifer Smith, CDE 31:46
Many times doctors will say, Hey, you know, follow a trend over the course of a week, well, that's five to seven days, then that you have chunked out higher or potentially lower than you want blood sugars, because you're trying to find a trend. I mean, in pregnancy with the women that I work with, we say two days of a trend, we're making an adjustment. And you know what if we need to dial it back again, for whatever reason, we will, but we're not leaving things travel higher or lower. For more than that time period, we will adjust and then we'll adjust again,
Scott Benner 32:18
and for all of you who have ever said to me, yeah, I'm going to handle that the next time I go to my doctor three months from now, you make my brain hurt when you say things like that. Okay, just please do not wait three months to address something even. I just yesterday, had a person who won a giveaway that I did with dancing for diabetes, and they you know, we had a phone call together. And this person, this is great. A person in their 60s who decided to get a CGM and a pump and you know, very excited for themselves. And then she said, You know, I have a doctor's appointment July, I said, No, no, don't wait till July. I said, write an email right now. Hey, Doc, guess what, I'm getting a dexcom g six, and I'm getting an omni pod. Go ahead and send those prescriptions in for me, I want to do that right now. And when we get I'm excited to come to you in July, and I'm going to bring my new stuff with me, you can show me how to do all of it. And I said if you never make it there to show or maybe you figure it out on YouTube or somewhere, whatever. And you know, and and, you know, but or maybe they'll send a trainer to your house. I think that is the appropriate thing to say right? And and but but I was like don't wait till July. So because July is six weeks from now, six weeks from now you're going to tell the doctor what you want. They're going to wait a week because people don't do things right away for you. They're going to send in their prescriptions for you, then you're not going to get this pump for six months. If you get that like start today. Go right now. Be proactive.
Jennifer Smith, CDE 33:38
Yes, with technology the way that it is and electronic medical records and things like my chart and things that you can send back and forth. There is no to not communicate between with a doctor and you know what if you don't get a response from them within 24 hours, you call that office and you ask to talk to their nurse and you say this needs to get to the doctor needs to be saw and it needs to be taken care of.
Scott Benner 34:01
Arden's endocrinologist and I have been adjusting her Synthroid are just taking Synthroid and site ml now and we've we've been making adjustments by email. But what's taking and it's still taking a long time to get it straight. Imagine if I only made the adjustment every three months when I saw her art, it would be like a puddle on the ground. When Arden doesn't have enough Synthroid. She can't pick her head up off of the ground. She just slumped over and she's like, her blood pressure, her blood pressure gets incredibly low. And she looks like she's dying the whole time. And and so once she has more Synthroid, she sits right back up again. It's it's literally like grabbing a marionette bytestrings when she has an Synthroid. But if I had to only make adjustments to her medication quarterly, it might take us two years to get it right. And we might never because she's growing and gaining weight throughout that time.
Jennifer Smith, CDE 34:53
And think of her education in this time period to what would she be getting out of her classes and the ability to perform And any athletics that she likes to do and enjoyment of fun with friends and everything. I mean, that puts a major cramp in any age, whether you're a child or an adult trying to perform in work or whatever. I mean, any adjustment, it needs to be addressed in the here and now not waiting three months to say, Oh, well, Doctor, you can see my is such a child. I've been having a lot higher blood sugar's I didn't know what to do. But I knew I had an appointment. So I waited until I came at that.
Scott Benner 35:30
Yeah. All right, Jenny. We're standing in front of your house. And you had your garden hose in your hand, and your porch caught on fire. Would you stand there with the hose thing? Or the fire coming? You'll be here soon. I don't need to squirt the hose at this porch. Why would I do that? The fireman is coming. He's a professional. I'll let him handle just hold the hose. Get started
Jennifer Smith, CDE 35:49
with my hose.
Scott Benner 35:50
Yeah, why don't I just see what I can get accomplished here. All right. So bringing this all back to your baseline slim, because no one thinks about their basal insulin with nearly the importance that it is I spent the first 10 minutes of a conversation the other day explaining to a person what it was. And after I explained it, I had to explain it again. And and so and you can still hear people go so that's the level here like people on empty out there like so. And I get it like they're newly diagnosed maybe sometimes, or they never got a firm explanation. But we treat basil insulin. Like it's not important. And it's everything. It's it's so much more important like it. Can we say it all the time. Everything starts at bazel phaselis not right, nothing else works coming off of it.
Jennifer Smith, CDE 36:35
Well, and so many people think that bazel job is to bring blood sugar down. Right? Oh, many people I mean, people I've worked with who've had diabetes long term who've come in and you know, I look at their records to begin with and they are confused and annoyed that their basal insulin isn't letting them wake up at a target blood sugar. I just stay high all night long. Well, you're starting the night high. So something I mean, time chunks of the day. Usually where you are now it's because the hours ahead of that. Something isn't right. Yeah, it's not the here and now. It's the what happened before this that got you here. So let's look I wanted my diesel should is here, here and here. And it should be bringing me down. No, that's not fatal job Faisal. dabit. The whole just it if you didn't eat all day long, you shouldn't have much.
Scott Benner 37:24
Diabetes is like a time travel movie. I've come to think of it this way. Right? Like it whatever is happening to you in the moment when the cameras pointed at you has nothing to do with what's in the frame with you. It's not a it's not a murder mystery. It's not somebody stabbing you and going, Oh, this is what's happening right now. It's the guy in Act One, set something down on a table and enact 325 years later that thing is how come you blah, blah, blah, blah, blah. There are things in the past. And there's decisions you're making right now with your diabetes that are going to affect you in three hours, or six hours. And and it's not now so much like it's interesting to how people overreact to the idea of Pre-Bolus Singh originally, because when their blood sugars are out of whack when they're really first starting to get things together, and they're jumping up and down. They're so reactive to everything they see I did something and then this happened. And I always tell people, if you Pre-Bolus and two minutes later, your blood sugar starts dropping that has nothing to do with the Pre-Bolus nothing. That's why when you know when you guys hear me say Arden's blood sugar was at five and I Pre-Bolus there. Because she was stable at five for three hours, the Pre-Bolus isn't going to start working right away. I only needed her to get to lunch 10 minutes later.
Jennifer Smith, CDE 38:38
The only reason it would start working right away is if you physically had that canula in a vessel. Right on it was literally going right into the van tapping into her bloodstream. Right?
Scott Benner 38:48
So in normal situations, which Jenny's bringing up, probably because she knows we actually had a pump. Probably Nick a vein in Arden one and for two days. I couldn't we couldn't get her blood sugar to go above like 50 most of the time, until we finally just changed her sight and everything went back to normal. But that was anyway that had never happened before. That was crazy. For the I'm texting Jenny, like you should have seen that texted Jenny, I sounded like you guys sound but you email me I was like, I don't know what's happening. I wasn't with her. I was in Florida doing dancing for diabetes. My wife's at home going? Seriously. This is what's happening when you leave. And I was like, I don't know how to explain any of this. I said I've looped in Jenny, we're gonna figure it out, you know, but, but anyway, yes. The point is, is that timing of your bazel just as important as the amount of your bazel. And to Jenny's point, for those of you who are thinking that bazel is in charge, you're bringing your blood sugar down. It's not it's in charge of keeping your blood sugar stable. And I say all the time, it's a stupid thing. But do it with me here. Unless you're driving. Hold your hands together in front of you like you know in like the classic, you know, prayer prayer motion, right. Imagine yourself Body function and, you know, sugar on one side and your and your and your bazel on the other side, and they're both pushing each other towards the center. And when nobody wins, right, when your hands don't move to the left or your right, that's a good basal rate, when you start moving towards body function, then your basal is too high, and when your body function starts pushing you away, then your basal is too low, you're trying to just give the bazel enough strength to fight off the background things that are happening in your body. If, right, and when you eat, you know, a reasonably normal meal, that bazel should also, you know, help with your Bolus. But don't expect that if you're going to eat like an entire pizza that your point six bazel rate is going to be okay. Because it's not. And then so that's, that's another thing. So once you get done bazel testing and figuring out your bazel for all your normal times when you're just standing around being you amazing you. That's one thing, what about your basal insulin while you're eating? And those tests have to happen in real life, while you're eating? You have to say to yourself, when I eat a salad with a burger, my blood sugar tries to go up. I wonder what would happen if I did increase my basal rate during that? And you know, I mean, for those you've been listening for a long time
Jennifer Smith, CDE 41:15
or after that
Scott Benner 41:16
we're right, right, maybe it's pizza, it doesn't hit me for 90 minutes after I've eaten it, you know, or any other thing like French fries, or had french fries the other night, it must have made her high like four hours after she you know. So
Jennifer Smith, CDE 41:29
it's not the nothingness is understanding again, that's why we also start with the overnight test it because if you can wake up in target, you are not fighting being too low from excessive insulin dropping you and you're not fighting being too high and having to correct and add insulin in a time that you're most people are insulin insensitive in the morning, right. So we talked about things like adding fat in Yes, your background bazel. If you know it's solid and set to begin with, then you know how to play with that temporary bazel feature to accommodate for long term impact like that, that causes essentially a stress factor, it releases triglycerides into the bloodstream, which causes insulin resistance in the aftermath, it can last as long as 10 hours after eating high fat. So most people need a bazel increase. It's like fat almost causes your basal insulin dose to be reduced by 50%. So if you're running at a rate of 1.0, overnight, and you have this big ol awesome like cheese, meat lovers pizza night, you go to bed thinking man, I nailed that Bolus, I'm going to bed beautiful. I'm like a 103. I'm going to sit here all night, it's going to look awesome. At two o'clock in the morning, you're at 300. And you're like, what the heck, you know, where did this cut, its fat, usually fast starts to impact by about three hours, you get this like drift, and then you get stuck by and you nail it with insulin and you nail it with insulin and you nail it again. And then finally you might start drift down. By the time you wake up the next morning, you could have fought it ahead of time by using a temporary rate adjustment. If you know your bazel to begin with is set Well, you can increase using temporary bazel and offset the impact of that
Scott Benner 43:12
fat. I wonder if I can explain what's in my head correctly. Because when your blood sugar gets elevated, imagine it's 250 coming off of the pizza and you think oh, a unit brings me from 250 to 100. So I'll put it in a unit. That's great. But what Jenny just told you was you're at 150% need for your Basal. So the unit really just keeps replacing the bazel you don't have. So you put the unit in, replaces the bazel keeps you stable at 250. But you still haven't addressed the number. And so then you wait an hour and you go I can't believe that didn't do anything and you put it in another unit. It doesn't do it again, because you're still just replacing the bazel you need a yak up your basal rate and Bolus for the number. And remember, the turning up the Basal at midnight doesn't make doesn't mean it's going to start working really maybe until one or two o'clock in the morning. So what So in the end, let me get very close to the microphone. What you need. And I don't want to oversimplify diabetes is more insulin. That's what you need. You do not have enough insulin. It's your union that T shirt. I'm talking right now. I can't do this podcast forever people more insulin if your blood sugar is high. Hey, if your blood sugar is low, guess what? Let me just go at it right now. Less insulin. There you go. It's not difficult, right? It's difficult to imagine the whole thing, which is what this podcast episode is about. Like we're talking through a number of different scenarios where your basal rate means something. But I think that i think that's it at the beginning here. Jenny explained a more clinical way to do basal testing. I think if you have a CGM. I tell people when we're speaking privately, and they're like, how do I figure out you know, how much more bazel to use? I just go well, you know, if it's a kid and they're like, at point three, I'm like, well turn 2.4 and see what happens. You know, and as they start getting low, Put it 2.35 you know, and it has because your kids blood sugar's sitting at 200. You know, like, with point, you know, point three going in every hour, point four is not going to make them nothing, it just doesn't stand to any reason. Common Sense and diabetes is, you know, just like I tell people all the time, one of the best pieces of technology for managing someone with diabetes is text messaging. It is a absolutely, like pivotal way in how art and I deal with our blood sugar if you don't, if text messaging is a is a diabetes tool, and it the same way, right? Just trying things is a diabetes tool, like give it a shot and see what happens. You know, point four, Okay, now let's see what happens. Not enough. So
Jennifer Smith, CDE 45:46
even for little kids, you know, even the incremental of the smaller rate, you know, the point 05, or the point 025. You know, all of that is an option. It's not an omni pod, but it is an option on the tandem in the Medtronic pump. So that is an option to get smaller, incremental adjustments, depending also on what your sensitivity kind of seems to be. I think the only thing that we didn't really is like the daytime testing, honestly, you know, daytime means that if you really want to know what's happening behind the meal, to make sure that the bazel is doing its job, the meal can't be there, right. So if you wanted to look at morning time, you really have to, for adults, you can skip a meal, because you can deal with that. You can just you can slug it out until lunchtime, and go ahead and eat your lunch and just see what happens in the morning when you wake up. You know fasting blood sugar, you let it sit you don't bolus you don't take caffeine, you don't eat anything. You can have water, herbal tea, or whatever. Don't go for a 10 mile run either. Look at what happened. Oh, kids, I usually say you know what, if you can get them to sleep in a little bit longer, maybe on a weekend, at least you're going to get an idea behind what their normal breakfast time is in that morning time to see did the bazel carry them pretty well, or what I had one mother I worked with, not too long ago. She's like, he woke up and he just started playing with his Legos right away. And he played with his Legos for a long period didn't even care about eating breakfast. I'm like, awesome. Yeah, that was a bazel test. I was like, there was nothing there. no food, no balls, he was sitting and playing with Legos. Fabulous. We've got information.
Scott Benner 47:28
That's cool. That's excellent. Yeah, whatever you can do, just just but do it. Because you need to know. In the end, if you've ever spoken to me privately, what I'll tell you is, in a perfect world, if your Basal is right, your blood sugar is gonna be 90, it's gonna be 85 or 90. Now, I don't expect it to always be that. But that's your goal. And if that's your goal, then it's when you're at 150. It's not correct. And also, when you're bouncing all over the place. If you're one of those people who right now is struggling and your blood sugar flies all over. You may turn your bazel up and get a low blood sugar and think oh my gosh, that's because I turned my Basal up. But it again, it might be about the Bolus you use before. So you know, there's one thing I say all the time. That I think is how you start your Basal rates. First thing you have to do is find a level, just find a stability point hasn't really almost matter where it is just get your blood sugar to sit still. And if you have to nudge with food, to do it, or nudge with insulin to do it, it's fine. Get stable somewhere and start over even when things go crazy here. I'll say that the Kelly I'll be like, Listen, I said we're out like everything's out of whack. Like we got to find a stable points where we can start over again. And you know, you just can't I don't know. It's like It's like trying to catch up. It's like trying to catch up on you know what I mean? Like he you gotta wait till it lands. Anyway. All right, um, do you feel like we've covered it?
Jennifer Smith, CDE 48:53
For the most part, I don't think
Scott Benner 48:55
we have to. I appreciate everyone who reached out and asked about a more specific episode about bazel testing. This was it. I hope you liked it. Goodbye, Jenny. Ah, thank you for listening to the 11th installment in my diabetes pro tip series with Jenny Smith CD. Don't forget that there are links in your show notes to email Jenny or you can go to integrated diabetes.com if you'd like to hire her personally, and have these conversations private like with her. Thank you also to Omni pod Dexcom and dancing for diabetes for being such wonderful advertisers. And sticking with the show weekend and week out really makes it possible for you guys to get the show. And I appreciate honestly how easy they are to work with. You wouldn't see that behind the scenes but they're good peeps. If you just found this diabetes pro tip episode, go back and listen to the rest they start around Episode 210. Also something new you may not have noticed last Friday, I began to post a second episode of The Week called defining diabetes. In the short episodes, Jenny Smith and I will define a phrase from your daily life with type one diabetes. If you're a subscriber, this extra episode will just show up like you're used to seeing everything else, it will just populate your podcast player, you can listen to it whenever you want. Thanks so much for listening. I hope you have a great day and a better week. And a special shout out to all of you on Instagram who share the podcast so much there. It's amazing. Thank you so much. You're helping the podcast grow in ways that you can't even imagine. Before I go, I'd like to share something that I imagine that most of you who have been listening for a while understand. It took so much restraint not to call this episode Jenny's but but I did it. I'm an adult. And I use the diabetes pro tip series because that's what this is. But when Jenny said she made a bazel rate called but I was like oh my god. This episode should be called Jenny's but, or but bazel or Jenny's but bazel I don't know. But I just so hard not to do that.
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