#225 Diabetes Pro Tip: Bump and Nudge

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

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

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

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

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

Scott Benner 0:00
Hello everyone and welcome to Episode 225 of the Juicebox Podcast. Today's show is a continuation of the diabetes pro tip series with Jenny Smith. This installment is the eighth in the series and it's called bumping nudge. You'll find out why in just a second. I briefly want to thank our sponsors on the pod dex calm and dancing for diabetes for always being there, you can go to dexcom.com slash juicebox dancing for diabetes.com that dancing the number four diabetes.com or my omnipod.com slash juice box to find out more. There are also links in the show notes of your podcast player and that Juicebox Podcast comm

pumping nudge is the eighth in my diabetes pro tip series with CDE Jenny Smith, don't forget that you can hire Jenny. She works for integrated diabetes calm and she would love to help you do better with your type one. There are links in the show notes to Jenny's email address where you can go to integrated diabetes comm let's please remember that nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise and to always consult a physician before becoming bold with insulin or making any changes to your health care plan. This is a short but really powerful and important episode. Please remember that the diabetes pro tip series is designed to be listened to an order don't just jump in here. Go back to the beginning. This is installment eight of the series. The first one was called newly diagnosed. We're starting over

Jenny Hello How are you?

Jennifer Smith, CDE 1:47
I'm good. How are you got so good. Yay.

Scott Benner 2:08
short episode going over the idea of bumping and nudging blood sugars, which is something we talked about on the podcast all the time. I'm a huge believer in the in the infuriating statement that you won't get high if you never get high. Sure, that's not as easy as it sounds, but that's how I think about it in my head. Right? So I want to fight with the high blood sugar if I don't experience high blood sugar. Of course, that's not always gonna work. I'm not saying that. But I am saying that it's avoidable a lot of the time. I think of it as bumping and nudging just bumping and nudging it could be bumping. I love that

Jennifer Smith, CDE 2:48
term. I love that. I love it.

Scott Benner 2:50
Right? Yeah, you can do it with insulin can also do it with food. You can also do it with a deficit of insulin, which you can create with Temp Basal. We're going to talk about it all right now.

Jennifer Smith, CDE 3:02
We also do it with exercise.

Scott Benner 3:04
Do you know i just i just interviewed somebody who you won't hear for six months. But a girl who has had Type One Diabetes since she was a little kid and she's like she was so compliant like with whatever her mom asked. So she'd eat like celery all there for blood sugar was high. But if she but if she wanted a cookie, she would go exercise and then come back and say to her mother, I just ran around the house this many times and went up and down the steps this many times I would like my cookie now. And this is this was back when she was doing Oh gosh, the words just slipped out of my head. What what's the old timey insulin regular insulin regular an MPH that's what she was mph. Back then she would do a little exercise to get her cookie. But I you know this by the way, this girl is delightful. You have to find the episode with her.

Jennifer Smith, CDE 3:54
My, my mom would do the same thing with me. We're at my grandparents house, usually in the summertime for a couple of weeks. Usually at that time of the year, it was rainy, at least several days out of that time and I couldn't do anything outside. She would have me run around my grandmother's kitchen table and they had a pretty big dining room because it was a farmhouse. And I would literally my mom would be you need to run around. You need to move you need to move. And I was like, Okay, I mean at that point.

Unknown Speaker 4:23
That's all movie. You know, there'd be a snack

Scott Benner 4:25
after this. I guess it's all right. So yeah, yes. Okay, so. So basically, we'll start with this if you have a glucose monitor. You can't think about the alarms. The way you're thinking about them right now you have to your low alarm, you should put wherever you think you need to know like whatever gives you enough time to react. I don't care what that is. That's up to you completely. Ours is at 70 Some people put theirs at 60. You know, 80 whatever, I don't care. It's the high alarm that I care about. Because you need to be able to react to a rising blood sugar quickly. If you react to it quickly, you're able often to react to it with less insulin, you're present, right? It takes less insulin to stop a 120 diagonal up than it does to stop a 150 or a 180. Straight up or 202 arrows up, you could have avoided the problem that you're having now 45 minutes ago, if you knew it was coming, right, right, right now people will say, but Scott, I don't want this thing to alarm all the time. And it's gonna bother me and my kids at school, and I hear all your complaints, put them away. And here's why. Eventually, if you listen to these podcasts long enough, these concepts will lead to a world where you don't really ever leave your 120 blood sugar. So you won't get a ton of alarms. And on the days when that happens, I don't know mute your phone, but don't make a bad decision to avoid a problem that I think is avoidable. And so I know I've said this a billion times, but it belongs in this episode. And I know I talked about driving a lot. But when you're driving, and you find yourself just kind of drifting off of the road, you don't turn the wheel 90 degrees to the left to avoid the curb. It's this almost imperceivable turn of the wheel, you're just nudging it back the tiniest bit. Yeah, that's how you avoid swerving into the oncoming traffic, because you've only turned it a little bit. This is how you stay off the diabetes roller coaster, it is that simple, right? So you stop arise before it can happen. And you use such a small amount of insulin that the likelihood of being low after you've done that is mostly imperceivable. Right? How much does that make sense? Jenny? Where should this be on the Mount Rushmore of diabetes thoughts?

Jennifer Smith, CDE 6:48
I think it should be right, they're taught along with the early the early information of insulin use, it really should be, it should be it should be right there with when you're prescribed insulin. This is our target for high blood sugar should really in my professional opinion, it should be ratcheted down, we should not be being told that post meal blood sugars of 200 or 224 kids

is appropriate only because it's safe.

Scott Benner 7:25
Right and safe in as much as you're not going to have a seizure. correct? That's

Jennifer Smith, CDE 7:30
correct. I mean, am I saying that you're aiming for, you know, a no rise at all? No, am I saying that you're aiming to stay, you know, if you've been consistently rising to 250, and your alarm isn't set to 250, or 300, maybe you bring it down to 200 for a little bit, and then maybe you bring your high alarm down to 180, or you bring it down to 160. But as you do that, like you said, you're gonna see, it takes a lot less to address a rise than it does to correct a blood sugar that's already too high.

Scott Benner 8:02
And in the beginning, this will take more of your effort. But as time goes on, it takes nothing. It really does. I know sometimes I'll explode a bolus out on screen when I'm doing a talk, right? And when you blow it up like that, and show all the decisions that were made you think, Wow, this does look like a ton of effort. Right? I always have to start by telling people what you're viewing up here, encompass about three seconds of my thoughts spread out over five minutes. Right, right. You'll spend more time in initially then, than you will one day. And so it's the same with this idea. I know it feels like if you set it at 120. It's always going to be beeping, but one day it won't be and And wouldn't you rather be bothered even on a on a bad day and a quote unquote bad day? Wouldn't you be bothered? Wouldn't you like to be bothered five times to bump a 120 back down? That might take up 20 minutes of your overall day, then to be stuck in a 300 blood sugar and comes with it all day long, right? All right, little bits of effort. little bits of insulin, way better way, way, way, way better to avoid the highest because you can't get high if you never get high. You can stop it from happening. Does it always work? It doesn't always work. But mainly, I will say this, Arden spikes about twice a day. And it's timing stuff where we don't have the ability to do what we're doing. But when I tell you Arden spikes, I'm talking about 151 70 you know and we get it right back again. So imagine if you had to 180s or to 160s in a day and the rest was between 120 and 70. That's where you get an A one see it's in the fives.

Jennifer Smith, CDE 9:52
Right. for clarification to even about Arden spikes. It's not that you've waited until she's 172 Dress it, you've gotten the alert, the rise is happening, you've addressed it, you've probably taken a correction at like 120 or 130. Because you see the trend happening, she may still get to 151 70 before that insulin starts to working, but the curve down is probably more like an up down almost like a roller coaster. Right? But you're addressing it so that that ride down then is nice and smooth into the end versus being way too high. And crashing from Bolus, Bolus, Bolus, Bolus, oh, now I'm like 50. And because

Scott Benner 10:33
I reacted sooner, I still am keeping mainly the balance of the insulin action carbon pack. I'm still keeping them pretty well balanced. I obviously missed a little bit in the carbs. Got ahead. But I got back in the game soon enough that I'm not going to create a crazy low later, right, you come in for like a nice landing afterwards, which somebody just texted me the other day and says, Can you please tell me what that means. And I always like I think just put your hand up high, and then dip it down and then bring it flat again. And like that's sort of like this. That's what you're trying to make happen. Right? You're trying to come to

Jennifer Smith, CDE 11:04
the end of a roller coasters, what I explained is kind of where you're the rush of that ride down and then you like roll into the station. That's it. It's a flat and smooth, perfectly

Scott Benner 11:15
bringing in for a nice landing. Right? Okay, so, so sure you can bump and nudge that way, right. But what if I'm at the tail end, for example of a meal bolus, and I'm noticing I'm 110 151 hundred, I'm starting to drift down. But I'm so far past this Bolus that I'm now in that space where people do the thing, they can just go, I hope this stops. Right, right? Like, wouldn't it be nice if this stuff, what I like in that situation is a Temp Basal decrease, right, take away some of the basal rate. So now Jenny can see me which is a little unfair, but I'm holding both of my hands together palm, the palm, and I'm pushing a thumb bazel is so important to think about like this on one side is the impact of your body and carbs. And on the other side is the impact of the insulin. And when you push at the same rate, no side wins, like I'm not going wildly one way or the other. Right. But all of a sudden, we get to a situation like I just described where Okay, the insulins winning a little bit, right, the carbs that were there can't hold up the insulin that's left behind. So we start drifting towards a lower blood sugar, we'll just use your pump to tell it to use less insulin, take away a little bit of the force that that insulin has now maybe you'll catch it with Temp Basal, maybe you won't. But in certain situations, it's the best way to start. You know, he I forever see people were like, Oh, I'm heartbroken. I had to give my kid juice overnight. And you look and you see this 90 blood sugar that was just drifting down, that later, by the way, turned into a 180 because they put all this juice in. So you could have in that situation, if you really felt like you needed the juice bump with the juice, you don't have to drink the whole thing, drink enough to bring it back in for a nice landing. Or if you're far enough ahead of insulin impact, try dialing back your your bazel and see if that doesn't catch it and your natural body functions don't come back up again.

Jennifer Smith, CDE 13:16
And if you're an evaluation time period as just a kind of an aside in the overnight, if you give that little nudge with juice comes up a little bit and address down and you give a nudge again and it comes up and it drifts back down. That's bazel you're in bazel only unless you have a correction from earlier that brought you down so much. That's still working. Visa only that's a good you've got too much bazel there's too much they're up down up, down, up down and it never stays stable. You got too much.

Scott Benner 13:49
Alright guys, you know how I do it short episodes, short ads. Ready rapid fire succession. Check out the new Dexcom g six continuous glucose monitors today go to dexcom.com slash juice box to find out more. You're going to be able to see what direction your blood sugar is moving and how fast it's moving in that direction. And with their share and follow feature, you'll be able to find out what the blood sugar is of a loved one who is away from you that's compatible with Android and iPhone. Like I can see Arden's blood sugar right now, but she's not in the house 109 and that cool. You want that to dexcom.com slash juice box with links in your show notes or Juicebox Podcast comm now on the Omni pod on the pod is the only tubeless insulin pump in the world. It's the insulin pump that art has been using for over a decade. And trust me, you want to check it out. But you don't have to trust me too much. Because Omnipod will offer you for free a pod experience kit. That's right, they'll send that demo right to your house. Just go to Miami pod.com forward slash juice box, put in your name and your address. Click in enter there, whatever. It's called the button I don't know, click like like, and they'll send it right to your house. You can hold it, feel it, try it on wear it, see what you think and decide for yourself, you don't need to trust me, you can trust your eyes. Last thing I need you to support dancing for diabetes, I want you to go to dancing number four diabetes.com. And check them out on Facebook and Instagram, great organization doing wonderful things for children with diabetes, through dance. I say a lot that if you find yourself when you find yourself bolusing too often, your bazel is probably too low. If you find yourself out and doing to address in that situation too often with food, your base is likely to high. Right?

Jennifer Smith, CDE 15:38
Right. And you want to stop nudging as much as you can.

Scott Benner 15:42
We all want to go to sleep and nobody wants to eat juice in the middle of the night. That's all the things we're trying to avoid right here. And I know a lot of it still sounds like oh, yeah, buddy, that. That sounds nice. But how do I accomplish this? I think that by now you're getting towards the end of this series. I think Jenny and I have laid it out pretty well, a couple of different ways here. So and important to remember. Because if you've ever spoken to me privately, if you listen long enough, I will beat into your head over and over again. It's about timing and amount. It's about timing about even with Basal, even though you don't think of it the same way. Because Basal doesn't all go in at the same time. If your basal rate is too high, you have too much insulin and at the wrong time. So with I've simplified diabetes down to like a handful of ideas that are sometimes so distilled, that even when I say them out loud, I go, does it just sound ridiculous to people when they hear it. But please trust me. At the end of this series, I'm going to go over all these ideas in simple sentences. It'll be a very short episode, you remember those sentences, apply what you've heard here. You're going to be on your way I you know, I can't promise but I swear I've seen it happen.

Jennifer Smith, CDE 16:54
And I believe a little print off sheets got,

Scott Benner 16:57
oh, I don't want to get away.

Jennifer Smith, CDE 17:00
I know. I know. Well, the full full ideas are really behind all of those little simple statements. So if you had just a little simple fit, and you're like, I don't even know what that means. And those reminders,

Scott Benner 17:11
I actually, I use them too. Yeah, I've had times where I'm like, What is happening? Because it's life, right? Like stuffs going on. You don't know like, why am I bolusing all the time. And I actually stopped myself one time. And I remember standing in my kitchen thinking, what would I tell someone? If they asked me this? And oh, that's ridiculous. But I was like, Oh, my God, or bazel needs to be increased. Boom. And there I was, I was like, Oh, that was I should have listened to me. But like for days, I was like, what's the problem here? So you're gonna get those like simple ideas broken down into sentences that you can kind of repeat and keep in your head, you know, that that'll should reignite the ideas that you heard in the podcast. Okay. So, to go over this again, because it's in a different episode. You need to think about how food affects your blood sugar. Sure, you need to think about how in some affects your blood sugar, sure, but always to remember that you need to understand how the food affects the insulin so you can reverse engineer ideas. You're so used to thinking, I have this high blood sugar and I'm trying to force it down with insulin. Well, what if you have a low blood sugar you're trying to force it up with food and I don't want to use too much. That starts us off on that rollercoaster, right we forget to believe that what we know is going to happen is going to happen we put in this food for low blood sugar, we shoot up now our insolence Miss time, we eventually put in enough insulin it gets Miss time with the food, the food now digest to your system. All the insolence left, you fly back down again, oh my god, what do I do, I throw in more food than I wait and I get high and you start looking at the garage and thinking I just gonna pull the door down Start the car put on my favorite. But we don't need to do that. What we need to do is to bump in nudge with the food as well. And so this is crafting

Jennifer Smith, CDE 19:00
and nudging with the food might actually be a little different. If you know and pay attention to in those, let's say the drops where you're going to nudge with some food. Why is it declining? Is it truly bazel? like we talked about overnight, right? Where you meet need a lot less nudge, little incremental nudge versus you've got three units of iob. And you're dropping, and the drop is actually happening a lot more precipitously, right? You're really like coming down? Well, that little nudge of three sips of juice. If that's not the time to like nudge us, you need a little bit more aggressive nudge than that.

Scott Benner 19:42
Yeah, I tell people all the time if you see a 65 and it's really stable and you want to try to shut your Bayes law for half an hour to see if it comes back up right on but if it's a 65 and dropping like a stone for the love of god drink a juice eat a banana shut off like like, you know, you've really messed up somewhere so

Jennifer Smith, CDE 19:58
right but Right, but

Scott Benner 20:00
the opposite idea of that is not I'm gonna quote a mom that I spoke to. She said, Why did I always give the whole package of gummy bears? Why did I just automatically think because I opened the package he had eat all of the gummy bears. Why not? You know why are three because 15 carbs, 15 minutes 15 carbs 15 minutes. Right bad advice you got from a doctor one time.

Jennifer Smith, CDE 20:25
And it was again it comes to the safety. Right? It comes to the safety piece of this is an easy rip off. None in the moment. This is just please do this because it will at least

alleviate the wall, right? You'll be safe.

Scott Benner 20:40
It's jamming on the brakes 100 yards before you have to stop because you can't be 100% certain you're gonna be able to stop but before you get the hundred yards away because a doctor is not with you because they don't know the situation. Because they don't want you calling them on the phone every five minutes. Now I bolused because I'm going to tell you when some people start explaining to me their bosses. I'm like, Look, I'm good at this. But that is hard to get straight in your head when somebody and you know they're keeping something. They're forgetting something. And so you're like, I can't make sense of this. Like show me a graph. Like when did you eat and sometimes they don't even though, right?

Jennifer Smith, CDE 21:15
I like that's the reason I like little tiny like the Jelly Belly jelly beans. They're a gram of carb apiece. doodles are a gram of carb apiece. They're an easy way to nudge with food in a counted way. Rather than like sips of juice really guy I don't know, I might have had a bigger sip or a little or sip, right? Whatever my sip might be the whole container. I don't know.

Scott Benner 21:39
I'm telling you again, Ninja like level of understanding, I can sometimes stick a straw in Arden's mouth from a juice box as she's drinking it, I just go and that's enough. That's just something that comes with time, right? Like, you're not gonna figure that on day one. But the idea that it might not be all of it. And this and I alluded to earlier, it's gonna sound a little crass. But there are times when you just have to have the balls to wait. Like, you can't just, you can't just over treat an 85 you know what I mean? Like I said it before, I've saw a woman online who told who once said that, that's a mom, and I'm sure she was scared out of her mind. I don't mean to make light of her. But she's like, I saved my kid's life last night. With a juice box. A kid was like 110 diagonal down. I was like, wait a minute, you may very well have been on your way to the greatest night's sleep ever. You're never gonna know. Right? And because this wasn't like what you were talking about. It wasn't like a big bolus that was gone wrong. This was just like a drifting blood sugar. And I was like, Oh, you gotta wait, the you know, you have to. And so let's talk about here, like, because we're gonna try to bump a nudge and in and out of an area. What is that area? And so I mean, you have to define your target. Yes. What is it you're going for? Right? I don't need Arden's bunch are gonna be at five constantly. I don't feel that way. But I and I don't like her blood sugar to be under 70. But I got to tell you that if she drifts under 70 for a couple of minutes, I'm not running around looking for the glucagon. You know, like, let me see how I can just get this to kind of gradually come back up again. Same thing if she gets the 140. And it sits in a guy. I really missed this. But you know what, now I'm only an hour and a half past this Bolus, I really do have to wait a second to see what's going on here. Or I have to decide I'm not gonna look at this 140. And I may need to redress with food later. Right. Right,

Jennifer Smith, CDE 23:33
right. Absolutely. And, you know, that also speaks then to the benefit of now we've got the CGM, right, because with the CGM, you can see more often what's happening that 140 hour and a half after eating, it might be a stable 140 you don't know whether the next three blips are going to start a downtrend or they're going to start an uptrend or they're just going to kind of stay stable. So you have to really have that same thing with your 70 before if she's laying on the couch watching a TV program at 70. Okay, yes, she's not out running a marathon. She's not going to go to the amusement park and walk around for four hours. sitting on the couch.

Scott Benner 24:11
Yeah. Yeah. Even when Arden is like incredibly active on a hot day playing softball, I still like a blood sugar right around 90 and so if I see 90 trying to get away from me it's it could be just you know, you have a Gatorade with you take two splashes of Gatorade, then go back to the water, or, you know, have half of this juice box or are you hungry? You know, sometimes people are hungry. You'll think about it like that. Because you have diabetes. You always think about food as being this like surgical strike. But if you're playing you know a sport, maybe it would be nice to take a bite of a banana every time you sat on the bench or something like that, right? performance energy is different than blood sugar strategy energy. for athletes, there's about 1000 different ways to think about bumping and nudging your blood sugar around so I want you to open your mind to it think differently. Try to really make sense of it. Jenny's Gotta go she's got a life. Okay? work. So I'm gonna let her go and say thank you.

Jennifer Smith, CDE 25:07
Absolutely always, always nice Jenny,

Scott Benner 25:09
I'll talk to you soon. Everything I'm about to say can be found in the show notes of your podcast player at Juicebox Podcast calm but if you'd like to hire Jenny, go to integrated diabetes.com or email her right through your podcast player. Thank you Dexcom Omni pod and dancing for diabetes for supporting the show. You can go to dancing for diabetes.com my omnipod.com slash juice box or dexcom.com slash juice box to find out more. Don't forget on the pod we'll send you a free no obligation demonstration of the pod just for filling out a little bit information and saying you want it even though they're not on this episode. Don't forget real good foods calm you'll save 20% of your order by using the offer code juice box. That's a lot of money you can save. This was installment number eight of my diabetes pro tip series. installment nine is available now and it is called the perfect Bolus. I hope you're enjoying the podcast. I hope you're enjoying the series. If you are please go to iTunes and leave a wonderful rating and review for the show. It helps it to be found by more people

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