#1006 Diabetes Pro Tip: Mastering a CGM
Understanding the value of CGMs is an important aspect of managing 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 0:03
Hello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right, you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CD and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisit double. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. While you're listening please remember that nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your health care plan are becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have an amazing offer for you right now at my link only contour next one.com forward slash juice box free meter you can get an absolutely free contour next gen starter kit that's contour next.com forward slash juice box free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries G voc hypo pen. Find out more at G voc glucagon.com. Forward slash juice box.
Jennifer Smith, CDE 2:25
What's on our agenda today
Scott Benner 2:26
we are going to talk about continuous glucose monitors.
Jennifer Smith, CDE 2:30
That's a big topic it is right.
Scott Benner 2:33
So I tell a story that I think is going to fit here in this episode. We were in my daughter's endocrinologist visit a long, long time ago, probably a decade ago. And the nurse practitioner asks me Are you going to get one of these CGM M's. And that's how new the whole idea was. And I said, I don't know what you're talking about, you know. And so she begins to tell me a story about this 17 year old kid in the practice, who loves m&ms but can't seem to eat them without a spike. So he gets the Dexcom, which I think back then would have been the seven plus maybe 10 years ago was that the first one with a seven seven.
Jennifer Smith, CDE 3:11
I know that in 2006 is when I got my first CGM and the seven was on the market, along with whatever came with Medtronic and then Abbott's navigator had come out. And that's actually the first CGM that I had. And I loved it. It was unbelievably accurate.
Scott Benner 3:29
Yeah, I remember that one, too. Yeah. So it probably was
Jennifer Smith, CDE 3:31
the seventh when
Scott Benner 3:32
you were there. And so she's telling us about this thing called Dexcom. I don't know what it is. I don't know what she's talking about. The letter CGM mean nothing to me. It's like Chinese, right? I just I was like, it could have been any language except English. I didn't know what she was talking about. But then she tells me this story. And she says that the boy gets the glucose monitor. And he goes home to the grocery store and buys those little single serving packs of m&ms. But he grabs seven of them. And the first day he goes home and he eats the m&ms as he always would, he puts in his insulin as he always would, and he watches his blood sugar go up. And it kind of stays up after that. So the next day, he thought, Okay, I must need more insulin. So it gives himself more insulin, his blood sugar goes up less. So the third day he thought he had it fixed. He's like, This is it. I just need more, but give himself more. He barely goes up at all, but then he crashes low later. So the kids like Okay, so the next day a little sooner, a little less, a little more. And he messes around back and forth, back and forth with this, and then she looks at me, I'll never forget the look on her face. Because she was astonished, right? And she goes, I saw his graph. He put his insulin in, ate the candy and his blood sugar never moved. And she's telling me a story about that. And all I could think in my mind was well if that's possible with that, then that's possible with anything. Like that's what I left with that feeling of like there's information coming back to me that can do that. That's amazing because I used to be one of those guys. People, we'd go into the, I don't really show them the pump anymore. But we used to go in and they download your data. They'd look at, you know, your boluses and all this stuff and where your blood sugar's were and she'd say to me, Hey, you tested she, you know, Arden ate lunch at noon, then you test it at 1230. She's like, why would you do that? And I said, Well, don't you want to know what's happening? Like, like, I want to know what's happening. So it was a number of years later that she she said back to me, she was I realized, now prior to you having a glucose monitor, she's like you were doing it yourself. Like you were trying to act as a glucose monitor. You were figuring out what was happening, which made sense to me back then.
Jennifer Smith, CDE 5:35
My finger sticks prior to CGM, on average were about 14 a day,
Scott Benner 5:41
I'd have to say that's where we were to, because I literate
Jennifer Smith, CDE 5:43
similar as you. I wanted to know where things were not only before, but especially after because it's a learning piece. Yeah, it's just like the m&ms. It's how did this work or not work? And what do I need to do to make sure that it works the next time because I like this, or I like to do this kind of exercise or whatever it is.
Scott Benner 6:03
I was so amazed. Just doing that just you know, it fried my mind back then like to test and go but but she went to 300. And then 45 minutes later, she was 340. But then she fell in like all that stuff. It was it was interesting information. It was valuable. But it wasn't enough. Right. Right. Like it was It wasn't enough to make sense. At least for me. I couldn't make sense of it still.
Jennifer Smith, CDE 6:25
Because you literally when you do finger six, then you have to do the connection of the dots yourself. Yeah. And I couldn't do nothing in between.
Scott Benner 6:32
I couldn't make that leap. I just couldn't figure out what, like what you're like those gaps. Like I couldn't figure out what it was. And it's not Jurassic Park, I couldn't just use frog DNA to fill in the gaps. Right? Because you see the gap. You see what happens and they're they're, you know, they're making babies by themselves. And it's just it's not good. But you don't want to fill the data in with something unknown is what I'm getting at. So I did as best I could. I heard her story. Oh, my goodness, I ran to get a CGM. You know, we got the Dexcom right away. I can still remember sitting in that we the endos office, right. And the nurse practitioner put it on for the first time and Arden didn't like it. And I remember breaking my heart. Like I remember thinking like oh, God did that hurt. You know and and now you know with the G six Arden Arden honestly says like, I can't even I don't feel it at all. Yeah, it just it's but back then, you know, there she was. Gosh, I don't know it'll four or five years old right? When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. G voc hypo pen is a ready to use glucagon option that can treat very low blood sugar in adults and kids with diabetes ages two and above. Find out more go to G vote glucagon.com forward slash juicebox G voc shouldn't be used in patients with pheochromocytoma or insulinoma visit G voc glucagon.com/risk. There she was four or five years old, this little dress and she's so like sitting up on the table and trying to be tough and everything and oh, and it wasn't good. But we stuck with it. Because of what I was getting back from it. I just found it to be amazing. And now today, today, I think that if you're listening to this podcast and is of any value to you, I have to give half of the credit to the Dexcom. And the other half of it's on the pod like I I took those two tools and figured out how to use insulin with them.
Jennifer Smith, CDE 8:39
But you also have to give yourself a big part of that credit because you took tools. It's like any kind of tool, you could have a hammer as one of the simplest tools that there is. And if you don't put it to use. It's a great tool, but it doesn't do anything else for you except sit there.
Scott Benner 8:57
Well, you're very kind I was avoiding saying something nice about myself. But let's do that for a second. But let's let's translate it out to the people listening. My goal with this podcast is just to be your Eminem story, right? Like, I want you I want to hand you off tools that you then take home and learn how to become proficient with right I'm not I'm not gonna stand with you forever, Jenny can't come to your house, right? But we're gonna, we're gonna throw these tools. Somebody said to me once can you come live with me with me? I started thinking there might be a number or I'd say yes to that. But I don't know what it is exactly. How much would it cost for me to abandon my family? And guys, I'm leaving. But But But seriously, I genuinely mean that like you, you're gonna get these tools. You learn how to use them in situations and before you know it they work in more and more what you would have called complex or difficult situations is exactly the same thing. When people come to me and say, Sure this is great, but how does this work during hormonal time or during a growth period during illness or during you know, when your daughter is playing softball, I always say the same thing. exactly the same way. This tool
Jennifer Smith, CDE 10:02
makes me more comfortable, of course, right? Especially when I mean, we talked already about insulin. And it's actually, I mean, this tool shows you not only effective food, but more. So how to be more comfortable with insulin use. Yeah. No, it does.
Scott Benner 10:20
So not unlike the first time I thought about an insulin pump. And while everyone else was yelling, oh, you won't have to inject so much. I was thinking, Oh, I could manipulate the Basal insulin. Like that seems like the exciting part to me. And we CGM and you probably you've heard people say this before if you have considered a glucose monitor. But the most exciting thing about a CGM isn't the number that it shows you. I'm sitting here now Arden's blood sugar 75. She got insulin for lunch, I'm going to find out when 47 minutes ago, she was 9547 minutes ago when we put the insulin in. She's 75 now. So that's comforting to see that she 75. But what you don't hear me talking about when I tell you that is that there was a moment when she was 89 Diagonal down and she was drifting down. But she wasn't falling that fast. I could see how quickly she was falling. That's the information from the CGM. That's just mind blowing. Sure, she's going down. But she's going down at a speed I'm comfortable with based on the food that I know is going in, because that battle is about to start really happening, the foods really going to kick in. And the second. I love that she's drifting down at that moment, because you know, when lunch hits her, I like like, you know, we've talked about before, I like the insulin to have momentum. Right? If you think it's about the number you're misunderstanding the CGM. If you think about the m&m story, you have to know it's about timing and amount. It's about speed and direction. Right? Like, which way is my blood sugar moving? And how fast is it going? When you know that it's everything, it's the difference between treating a 75 blood sugar and leaving it alone. So I can see right now Arden's blood sugar is steady, which means I want you because
Jennifer Smith, CDE 12:14
the trendline is horizontal, and her arrow is probably horizontal. And
Scott Benner 12:19
that arrow is still telling you something, right? Like even being horizontal, it's telling you we're steady and Dexcom gives you the breakdown of what that means study could still mean plus or minus a point every five minutes. But great, you know what I mean?
Jennifer Smith, CDE 12:36
But it's happening so, so slowly, at that horizontal arrow, they usually say that it's less than a point a minute, right? And so and that's where to bring in that that angle, the arrow that you saw with the ad something blood sugar, I mean, had it been angled up or angled down, it's still the same rate of change, right? It's about one to two points per minute.
Scott Benner 12:56
Yeah, yeah, it's it right. And so when people talk about, Scott, I don't know I don't understand how you don't count carbs. So here's here's a way I don't count carbs. That remastered diabetes Pro Tip series is sponsored by assenza diabetes, makers of the contour next gen blood glucose meter, and they have a unique offer just for listeners of the Juicebox Podcast. If you're new to contour, you can get a free contour next gen starter kit by visiting this special link contour next one.com forward slash juice box free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and to carry case but most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen. It fits well on your hand and features Second Chance sampling which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one. Contour next one.com forward slash juice box free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips you can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now through your insurance. Contour next.com forward slash juice box free meter go get yourself a free starter kit. while supplies last US residents only time reached by type one has a wide array of resources and programs for people living with type one diabetes. When you visit touched by type one.org. Go up to the top of the page where it says programs there, you're going to see all of the terrific things that touched by type one is doing and I mean, it's a lot type one at school, the D box program, golfing for diabetes, dancing for diabetes, which is a terrific program. Just click on that to check that out, both for cause their awareness campaigns and the annual conference that I've spoken at a number of years in a row. It's just amazing, just like touched by type one touched by type one.org, or find them on Facebook and Instagram links in the shownotes links at juicebox podcast.com. To touch by type one, and the other great sponsors that are supporting the remastering of the diabetes Pro Tip series touched by type one.org. Sure I go historical I look at a plate and I say I think this is 10 units, right? But Arden had pancakes this weekend. Big homemade not measured pancakes. And I have a feeling that pancakes are going to be 12 units ish. So I double her Basal rate for an hour and a half. 15 minutes before she gets the pancakes her blood sugar is already 78 Then she's coming out of bed 10 minutes ish before the food starts. I do the 12 unit Bolus. But I take out one unit that I've added from the Basal right so now it's an 11 unit Bolus I extended out 80% Right away 20% over an hour. Now I'm creating kind of like that blanket events on like we talked about. Now if I get it wrong, I adjust. The most times I expect by getting it wrong means I won't even be aggressive enough. And I'll have to come back and bump it down again. When I see a diagonal up arrow 30 minutes after pancakes. I say to myself, ooh, I messed this up. Maybe I shouldn't have extended the Bolus or maybe I should have put more up front. But anyway, I'm going to bump that arrow back down again. In this situation last weekend. I was so aggressive that I had to bail on the Temp Basal rate. So about 45 minutes after Arden ate. She was 70 which was fantastic. But I was like I still have insulin going. I don't need any more clearly. So we cancelled the Temp Basal rate. And she wrote low forever. I mean, it was was great. 85 like right in there. Right.
Jennifer Smith, CDE 17:29
Healthy. That's not low. That's right. Healthy. She wrote health lower
Scott Benner 17:33
than you. Yeah, of course. I definitely misspoke. They're lower than you would expect after pancakes. Yep. But But I had a great blood sugar. Because I was able to use what the CGM was telling me and what the CGM was telling me was she was starting to drift lower from like 90, and I read that drift as these pancakes are through her now to enough of a degree that we shouldn't be going down anymore. Right. Alright, so I bail on the Temp Basal. I don't shut her Basal off, I just go back to the regular Basal rate. So we're going along like that for hours. I mean, hours and hours. Now there's nothing. There's nothing now I know the insulin is gone from the pancakes. Now I know the pancakes are definitely out of her body. And at some point, that arrow kind of diagonals down a little bit. And we were getting ready to go out to the mall, her and her friend. So I said to her, Hey, take your vitamins, the little gummy vitamins, they must have like six carbs and she pops her vitamins and we get in the car. The arrow kind of bangs back up a little bit again, right in that 75 area. So we get to the mall. And I'm like, Okay, I'm gonna ride this out to see what happens. Like, I'm not panicking here. But we were there for about 20 minutes or so. And I wasn't sure if like the excitement of the shopping was going to make her go up or not. And it didn't. She was walking around. And my wife and I left her alone. Went did something else. And I texted her at some point. Hey, I think you should shut your Basal off for a half an hour. And she did. And we stayed right at like at the whole time she was shopping without the CGM. There's just in my opinion, I don't know how to make any of that happen. Like maybe there's a way. But if there is a way you're listening to the wrong podcast, because I can't quite figure it out. Right, right. So I think those CGM are absolutely stunning. I want to know how you talk about using a glucose monitor with with your patients.
I want to know how you talk about using a glucose monitor with with your patients.
Jennifer Smith, CDE 19:36
One of the big things I usually say when people are really either considering one or they have been using one for a long time, they've may not really be using it to their benefit. Let's say they're looking like you kind of alluded to just the number, right? What's the number? What's the number? They're not learning from it because there certainly is some optimization when you start using a continuous monitor but of any form of technology. GM I have said this before, I mean, if I were to have to choose between a pump or a CGM, I would say please let me keep my CGM. Right, right. Because even then, if I had to go back to multiple daily injections, I can micromanage that as long as I know the direction of where things are headed. I can you know, and with a pump, then it just brings in more precision. So using a CGM, along with a pump is a another huge beneficial tool, you know, to management. So I guess as far as that it's really helping people to learn what is what's the benefit of that trend that they're seeing? And I think, in the end, many people I find, tend to overreact to the trend too. And you know, oh, my goodness, I you know, things are going up or going down? Well, you do have to make you have to make some considerations within that trend then to because have you just eaten? Is there a load of insulin here? Have you just exercise all of those variables that could be there? There a reason for some of that trend? That trend just like the guy with the m&ms, right. He knew something was going on with his m&ms. He didn't want to be high. So he was like, awesome. I'm gonna use this and fiddle with it and figure it out. So you know CGM is can give you that figuring piece that you don't have with finger sticks alone. I mean, you know, again, doing a million finger sticks before I actually had a CGM. per day, I was still missing all of the pieces in between. I was missing. When did it start to rise? Or when did it start to fall? Yeah, I know that I'm like, 40 points higher now than I was after I ate my meal. But why and where did the rise actually start? Right. So those are some of the biggest pieces. And I think getting people over the over the overreaction to the trending is something it's hard for many people to be able to try to say, okay, things are rising. You eight now let's do some self experimentation. Let's see. You know, is this happening today, around 80% of your most common foods, which most people have about 20 to 25 foods that are pretty common for them to eat over and over. Use your CGM to your advantage. That's 85% of your management then is figuring out and that's the reason that you have outside of not, let's say carb counting in the real sense of doing it. You have a sense just based on the meal because you've done it so much. You can say this should probably be about 12 units, or that's more about five units. I mean, Ginger actually does the same thing. She doesn't really carb count. Truly, she's like this green apple that I eat every morning with peanut butter takes two units. Yeah, you know. And using a CGM, then I think that's the biggest thing for management is the fingering that it allows.
Scott Benner 23:06
Yeah, so I think that you hear a lot of people in the beginning talk about like that anxiety, right? There was a huge concern in the beginning of CGM, a lot of old school people in the in the diabetes space were like, This is gonna make people crazy. They're just going to stare at that thing all the time. And that probably did happen to some people. But again, it's like I say all the time, like if you're looking at what's happening to your blood sugar and thinking of it as a mistake, that's your mistake. Right? It should be like let me experience this let me see what this is. Let me see what happens when I put the insulin in here versus in there. And that quickly died down i You quickly heard even some of the more ardent I don't know what to call them. But naysayers calmed down after a while, you know, and saw the value in it. I thought the most important thing was to explain to people that it's not just an alarm for when you're allowed. And I use that phrase in anytime I speak somewhere on this podcast. I say, Look, if you're looking at your CGM as a don't die alarm, you're making a huge mistake. But it is it is the it is the very least of what it does. And so I mean, it's cool that it tells you oh my god, oh my god, your blood sugar is getting really low really fast. That's amazing. Don't get me wrong. It's gonna it's gonna help can't
Jennifer Smith, CDE 24:15
turn one of those alarms off that it's always there. No matter how much you hate that, that noise. It's, it's there. The FDA
Scott Benner 24:21
tells them look under 55 We're gonna bang and we're gonna bang an alarm in people's ears and there's nothing they can do about it and fair fair, right? But that's what you're looking at it as it's incredibly short sighted. When people say to me all the time like Arden's tolerances are. Her low alarm is set at 70. And on my phone, her high alarm is 120 on her phone, it's 130. So I like to have a if she's raising up, I like to be able to think about it for a couple of minutes before I involve her in the conversation. I don't want her beeping at 120, right. But people say Oh, it must be all the time. It must be beeping constantly. And I'm like, No, it never beeps. And that's actually how Don't worry, I'll get back to my thought about moving down the hi Dexcom alarm after these messages from Omnipod and Dexcom. Let's start first with Omnipod. The tubeless insulin pump that Arden has been using since she was four years old over a decade now, choosing on the pod all of those years ago was, and remains to this day one of the best diabetes decisions that my family has ever made. And I'd like to tell you why. Without the pod, you do not have to disconnect for activity. With a tube pump, you'll have to take your pump off to play soccer or to go swimming to take a shower, you know, and if you're an adult, and you're having adult time, you might want to take it off for that too, but not on the pot on the pot is always with you. And why is that important? Because you're always getting your Basal insulin. It's a completely under appreciated idea. But when you take your pump off for half an hour, an hour, two hours to go play a sport, you're not getting insulin. And sure while you're running around, it might seem like oh, this is fine. But eventually you're going to experience a high blood sugar from that getting a constant flow of background insulin is incredibly important. And only Omni pod allows you to wear their device throughout your life without having to take it off for any of the you know, activities that you enjoy so much. I want you to go to Miami pod.com forward slash juicebox. Or to the links in your show notes or at juicebox podcast.com. You can do that today. And absolutely for free. And with zero obligation on the pod, we'll send you out a pod experience, get a free demo of the pod that you can actually hold feel touch, keep it in your hands, see what it is. And then where it you get to test drive it before you buy. It's a nonworking pod Don't worry, it doesn't have insulin or, you know, a cannula or anything like that. But it's an exact replica of what you'll be wearing. So you can feel the weight and the size and decide for yourself if you'd like to try it, my omnipod.com forward slash juice box. Now on to Dexcom. The Dexcom G six continuous glucose monitor is without a doubt, the Cadillac of continuous glucose monitors. Everything you hear me talk about on this podcast is predicated on the data and information that comes back from Ardens Dexcom G six, we don't need a big long ad for this dexcom.com forward slash juice box get started right now. You need to see what direction your blood sugar is going and how fast it's getting there. And you want to be able to see your loved ones remotely with an Android or iPhone. Come on dexcom.com forward slash juice box get going today. If you've been hesitant, please trust me when I tell you there's absolutely no reason to not move forward with Dexcom. There are links for all of the advertisers that juicebox podcast.com Or in the show notes of the podcast app that you're listening to right now. I implore you don't wait another second. Go to Bliss with Omni pod. Get the information you need from DAX calm and support dancing for diabetes.
Unknown Speaker 28:31
It must be beeping constantly.
Scott Benner 28:32
And I'm like no, it never beeps. And that's actually how the kind of this way that we talked about doing this here. This being fluid. It it makes diabetes a very much a very much a smaller part of your day because you're not thinking about it. Because when it does beep, you know, oh, it's trying to leave this tight range. I'll just bump it back down again. Right when you put that threshold up at 400 because you're like I don't want to hear this thing beep. Well, that means that by the time you think to look at it two hours later and your blood sugar's 280. Right now you're dead. Yeah. And now you've all this mistimed insulin. Now you're putting in a bunch of insulin to bring it down your insulin resistance so it doesn't work as well. Suddenly, you're going to be low later, later, you'll feed the low, you won't have the Bolus you get on the roller coaster. I'd rather know now I talk about it in a million different ways. I open bills. I don't think I can pay you on day one, because I want to know what they are right. I want to know when her blood sugar is trying to go over 120. And if you do that, there's a great episode way back in the podcast with a scientist from Dexcom. There was a study done the lower you lower your high alarm on your CGM the lower your agency goes yeah because you react sooner with less insulin stopping arise and staving off a future low because you're only using a tiny bit events when we talked about before you're gonna listen through these things again, they're going to make total sense to you. I want to address when people say why don't want to wear a bunch of stuff You know, some, some adults just don't want to wear things. That's fine. But I hear a lot of parents. I don't want to look at her. I don't want to look at him and see him attached to something I don't he's not a robot. He's not like that kind of stuff. Arden hated that CGM. The first day she put along right. And I wouldn't think she thinks twice about it anymore. Not even a little bit. She rolled out that she rolled out the door this morning for school. In a pair of leggings. You can see her CGM on her hip. She doesn't care. She's wearing a top that doesn't go all the way down to her to her belt, her her on the pod is sticking out like in that gap of space on her belly. She doesn't think twice about it. You can make those things normal and they will be you know, at some point. So I don't know for me, CGM is about reacting. And instead of, you know, appropriately
Jennifer Smith, CDE 30:51
reacting rather than, rather than being you're being proactive, really, if you have a CGM, you can be proactive, rather than having to always be reactive at the like you said, Have you CGM set at 400. And you're finally seeing it at 280. Because you're not feeling the greatest? You could have been proactive well above are well ahead of that, right.
Scott Benner 31:14
And that proactiveness, by the way, takes less time and less of your involvement than it does to be to 80. And fighting with it for hours after that. It seems it seems counterintuitive, because people say to me all the time, you must be so involved all the time. And I'm like, Man, I don't think about diabetes for more than about 10 minutes a day. You know, like on the really bad days, 20 minutes, but but I'm not mired down in it. Like there's no hand wringing in my house all day long, like staring at big numbers wondering when they're going to come down, or they're going to make lows. We just don't have that. I mean, don't get everyone. I'm generalizing to make my point. It happens sometimes, right? But but as a day to day idea, it is not something that occurs here. And I if you've heard me speak somewhere. In my slide presentation, there's a picture of Muhammad Ali standing over top of someone he's just knocked out. And I always start that part by going Has anyone ever been in a fistfight? And inevitably, it's always a little kid who's like, I have, like going off into the background. And I was like, Well, you shouldn't hit people. But but but you know, I tell people all the time, like you, you want to act, like like we talked about, you want to react, but really, you want to be able to act be first, right? You want to make a decision first, because besides stopping an arrow, there's the concept of cause and effect. Right? And there's this idea that, you know, people always run around yelling, well, that's just diabetes, every time something happens, they don't understand that was just diabetes. And I always say that when you're saying, well, that's just diabetes, what you really mean is, I don't know how to use insulin correctly. Right, right. Right. And so your blood sugar doesn't go up to 400. Because the diabetes fairy tapped you on the head. Like, there's a reason I don't know what it is. Maybe you might not know what it is. But there's a reason. So at the very least, if you act first, then with some some confidence, you can say that what happened next was a result of your action. At least you're not always covering your face in defense, like, like a boxer who just can't, can't get a punch anymore, right? diabetes is not pummeling you in the face. You you maybe you hit it too hard. Maybe you end up with a 65. You didn't mean to, but at least you know, wow, I put that insulin in here. And I got to 65. Next time, I'll use less. Next time, I'll do my Pre-Bolus, five minutes shorter, whatever it ends up being I don't know. Right? Right. But I'm a big fan of acting first, and then taking that feedback and making a better decision next time with it.
Jennifer Smith, CDE 33:41
Absolutely. And that's why I think it's, it's when you're especially if you're new to CGM, or starting out, sort of over with a CGM, or you haven't used it consistently on a day to day basis, because you have felt more frustrated about it, I think, if you get it down to some basics of use to begin with, and like you said, kind of tighten up those targets. Even if it's just a short time period, you can designate and say, Okay, for the next seven days, I'm gonna have my target set the high alert for 130 in the low alert set for maybe 70 or even 80. If you're hypo, you know, hypo unaware or you just really worried or whatever about the lower end, because tightening it up helps but also then fitting in more of your more more of your regular habits. In that testing time period, your typical foods, the things that you like to eat for breakfast or lunch or for dinner or for snacks. Because if you're committing to using something by applying it to your body, and you know being a robot, essentially,
Scott Benner 34:48
for a pound. That's right, exactly.
Jennifer Smith, CDE 34:50
If you're committing to using it, then get everything that you should be getting out of using it and there's
Scott Benner 34:56
a there's a way to start in my opinion. I'm interested in what you think But I think that when you first have a CGM on and you're accustomed to wearing it finally, you know what this information means. The first thing you do is you get your basil, right? Like to me it's basil. First, make sure your basil is right. And I tell people all the time, if you haven't had insulin or food for three or so hours, and your blood sugar is not 85, your Basal is not right. And so and so, if you're 180, or 200, shoot lower, I don't like don't shoot for 85 right away, shoot for lower and keep kind of just cranking it down and cranking it down. After you've got your basil. In a situation where you're staying pretty stable most of the time without getting low. That's then you can start thinking about Pre-Bolus. And then and then the CGM can really help you with that, too. If I'm 120 and I haven't had food or insulin for hours, when I put in some insulin here, how soon before I started seeing a diagonal arrow is it 10 minutes 1520. Some people say a half an hour, everybody's numbers different. So once your basil is right, and you can trust the cause and effect that I've Bolus now and it took 15 minutes, let's say for my blood sugar to start going down. Within reason trust that that's probably your Pre-Bolus 15 minutes right when your blood sugar is in range. Now keep in mind if your blood sugar is higher, you'll be more insulin resistant that Pre-Bolus Time won't be the same but but for the for the sake of the conversation. Now you have your Basal rate. Now you know your Pre-Bolus time. Now you can start using insulin. And being a little more aggressive with it. I've put a Pre-Bolus in I'm 90 Diagonal down, I've started to eat my blood sugar shot up. Now here's where the CGM becomes incredibly helpful. So you've you've got your insulin and you've eaten, but you're going up. Are you going up? Like a sharp a sharp incline, right? Or is it what I call the prices right? You know, the prices might the the which is at the miner, the climber, the gates like yo lay he and he's got the pic in his hand. He's going back and forth. And it's it's this very gentle grade that goes on forever. And you watch it the whole time. God, he's gonna stop, he's gonna stop. He's going to stop. Oh, he'll definitely stop. There's no way he's gonna fall off the edge. It's not gonna happen through the whole thing. And it just keeps going. That's that CGM line that it tricks you. Because you keep thinking it's not on a crazy incline. I'm not shooting up. I'm just climbing it's going to stop in a minute. But no, it's not. So not most of the time. Most of the time, I find a gentle grade up means not You almost got the amount, right. And your Pre-Bolus deficit. Right, right. And your Pre-Bolus might have been not quite long enough, right? The sharp up is a complete. I just thought the curse but it's a complete cluster. Like you have not you didn't have nearly enough Pre-Bolus And you did not use nearly enough food. So there is nothing about your Bolus that even gave resistance to that carb impact at all. So you can even
Jennifer Smith, CDE 37:58
more often with that arrow up more often it's a Pre-Bolus. Especially if you are using a ratio for your carbs and counting your carbs and whatnot. Most often, if you have a pretty significant quick, straight up or double up arrow, within 30 minutes, 45 minutes of a meal. There's a deficit there and or the deficit is more because you did not Pre-Bolus There wasn't time like that tug of war between the insulin that you said, you know, in a podcast before, there was not enough time to let insulin get the upper hand,
Scott Benner 38:34
right. And I'll tell you that that exact situation, that scenario you're describing. That taught me how to over Bolus. So once the first time I put in insulin and her blood sugar started to shoot up, I just made the leap. I was like I missed big time. And I didn't just put in like another half unit. Like I crushed it, I was like I'm going to stop these errors. If I have to feed them later, I will but I'm not going to let this blood sugar go up like this. And so I realized a meal that I thought was going to take five units with no Pre-Bolus needed eight units. And so that taught me in the future when I don't have time to Pre-Bolus I'll just give eight units for the five unit meal because I can create that action of insulin and overpower this even without a Pre-Bolus if I use too much, it's a little more I call it like that's definitely more of a pro level tip kind of a situation I'm like you're you're more of a more of a diabetes ninja. Once you're doing stuff like that i i Hold that up with the same ideas after you've had a 30 too low and you start coming back up again and you Bolus like when you're 50 Diagonal up like you're a ninja at that point. You're just like, right
Jennifer Smith, CDE 39:39
you're like yeah, I need a lot more because I know I ate 60 grams of carbon I really only needed like 50 and
Scott Benner 39:46
start knowing how much insulin to Bolus to overcome not Pre-Bolus thing again, you've been at this a while but I learned that from the Dexcom like I never would have liked so you know when you see those arrows Flying up? Not it's not what was me time, right? It's what is happening. But what what could I do next time? Over bossing is an incredible tool. So an over
Jennifer Smith, CDE 40:10
Bolus thing in the way that you're doing it is very I think we talked about this before probably is, it's actually what John Walsh from pumping insulin, he calls it a super Bolus, right, right. And he does it in a little bit more of a calculated way. He says, you know, you take the Bolus that suggested by your pump for the food that you're going to eat or the calculated, let's say, you said, Okay, she needs five units for this all the time. Well, today, there's no time to Pre-Bolus. And usually, you would have done a 20 minute Pre-Bolus For that five units. Okay, he says, You're then going to take the insulin and basil that's running behind that meal for two hours. And you're going to actually add it on to that five units, or whatever your pump is suggesting. So maybe if your basil is running at a unit an hour, that's two units of extra insulin, you're gonna pop that on top of the suggested Bolus. But then behind the scenes, and you probably do this a lot, too. With that heavier Bolus up front, you're like, I'm probably going to need to watch and do a Temp Basal decrease for a little bit after because I know that this is too much in the end result, right? We don't want to cause a low. He says to start by just taking the basil down to zero for about two hours. Yeah. And then evaluating I've got people use it and say, you know, I tried it. The Super Bowl is part of it works. But I don't need to turn my basil completely off. led to do a 50% Basil instead of 100% off. Yes.
Scott Benner 41:27
And that's where the Dexcom again comes in incredibly handy. You need it when you need it. You don't when you don't, right. And then I consider that idea trading Basal for Bolus, like there. There are times where I think, oh, Ardens you know, Basal rates. 1.4 an hour, I just Bolus a unit and a half. Listen, there's going to be a moment, right? There's a moment for everybody. And there's going to be a moment where you see the arrow up, put in the insulin, five seconds later, the arrow flattens out and you go, Oh, my God, I didn't need that insulin, right. That's when I'll trade the basil for the ball. So you
Jennifer Smith, CDE 41:59
can always say cut it out the basil off. Do you know that? Do you know that if you don't have a CGM, you don't know don't know when that transition was happening. Right? If you had none, and you were very aggressive about just finger sticking, you're like, oh my gosh, you know, 20 minutes ago, it was here. And now it's like 50 points higher. I have to slam this with more insulin. Yep. Awesome. But if you're not willing to do finger sticks, then like every 20 minutes after that, to see where things are going. You never know when that horizontal is coming, or when a downtrend is coming, either.
Scott Benner 42:30
Yep, I am right now texting Arden while you and I are talking. So what I say it has now been an hour and 12 minutes since she got her Bolus for her food. I got a little I didn't panic. But because you and I were talking and I could see what was happening. I shut off for the very tail end of her extended Bolus and her Temp Basal. Yep. And now she's 105 Diagonal up. I'm bolusing that, because I'm putting in the insulin that I bailed on from the extended Bolus and the Basal I should have trusted myself, right. And so instead, I'm putting it back again. And I will stop this diagonal up arrow around 115 120, she'll float there for a while, we'll come back down. I expect you to be at five by like an hour and 45 minutes from now.
Jennifer Smith, CDE 43:17
And the interesting thing about that, too, is what you're saying in terms of her management. And I know her agency has been like in the 5% for a long keynote for a long time. But the bigger beyond that, and we had a whole we had a whole we did a whole long podcast about eumc. And kind of what that all means right? But I think bringing in to the fact here CGM translates into that CGM, because what we're really hoping for is more gentle rolling hills within our target, rather than these major rises and falls of a roller coaster. And if you start to analyze your data in CGM, you can actually start then to be able to say, Okay, I need to tighten things up here. I've got an awesome looking a one C, but I have a huge what's called standard deviation, which speaks to the variability between highs and lows, right. So you may have this awesome looking a one C. But if you're going up and down, and you look like a big jagged, you know, roller coaster or mountain range, that's not helpful. Your standard D deviation value should actually be low, which means the variance between the highs and lows are also more gentle, rolling,
Scott Benner 44:29
rolling, rolling, right? And the way I found to say that to people is that if you were 350, and then 60, and then 350, and 60, all you're doing is tricking the a one C test if it comes back and tells you hey, you have an average a one C of seven, which you do when you average 60 and 350. Again, but you also have a you're also not living in a healthy way in any specific way. So don't let that number for you. And Jenny's right there is an episode called all about a onesie that she and I did probably more than a year or so ago. Yeah. And I'll link it in the show notes, you can find it. But I have Arden's last five days. And her. Her let's see, her average blood sugar over the last five days has been 114. She has been in range 56% of the time, which probably seems low, except that her ranges from 70 to 120. That's another thing you need to be careful of when you look at these reports. If you have your high set at 300, and your low set at 60, and you tell me I'm in range 100% of the time Well, I'm sure sure you are. Yeah, I mean, good.
Jennifer Smith, CDE 45:37
Standard deviation within that time and range,
Scott Benner 45:39
right? What what is that and standard deviations? Just a simple mathematical idea that I didn't understand in school and still don't understand now. But it's a basic, right? It's it's an average, is it an average of maybe it's a mean, I don't know. See, I didn't pay attention to math. You know, it's funny, you were talking about Walsh earlier talking about like all these ideas about like, over bowl, his Super Bowl is, and I call it over bolusing. And when I think about all I think about is more like the word more just pops into my head more insulin and a half. He's over there, like with his college degree being like, what you want to do is for two hours, and this is I'm like more?
Jennifer Smith, CDE 46:16
Right? But you've also figured it out. I mean, you're more is not a dangerous more. It's not a random more No, it's not a random you've figured it out in your you know, this is your diabetes may vary. You've figured it out in in Ardens diabetes, you know how much more to give, it's not like you're slamming in five more units you're like, she needs based on experience about a unit more, or she needs based on experience two units more based on what went in what has transpired up to this point.
Scott Benner 46:46
So people who listen to the podcast know that if this wasn't a special episode called diabetes, pro tip, continuous glucose monitor, I would just call it Roger Moore. Because you have no idea how many times I hear from people they're like, could you just make the title something about what's in and I'm like, No, I can't that's not fun at all. I want to talk for a second about what happens when you get your brand new, shiny Dexcom on and it tells you your blood sugar's 90, but then you test with your meter and your meter says your blood sugar's 140. niggle I don't know which one of these things to believe. So I think it's important to note that a CGM is measuring interstitial fluid around your meter is measuring your blood.
Jennifer Smith, CDE 47:28
Thank you for bringing that up. Yeah, both of them
Scott Benner 47:31
have an FDA requirement of only being within 20% of range. So if if a meter says your blood sugar is 100, it could very easily be 80, or 120, or somewhere between 80 and 120. As people living with type one diabetes, and the 2000 z's, you're gonna have to accept this is pretty much the best we have right now. And not to make yourself mental. So imagine that your CGM tells you you're 100. But it's off by 20%. High. So you're really 120. And your meter says you're 140. But it's really off by 20%. Low. So you're really 120. They both agree the numbers you're seeing don't agree. You can not spend a ton of time being upset about that. No, you have to pick something and believe in it. And I know that's crazy. But I tell people all the time, there's somebody online, it's like look at my meter says this and my Dexcom says this, and I'm like you're holding a brand new Dexcom G six in your hand. And a meter that was made 12 years ago. And you're telling me I believe the meter and I always asked him the same thing. Why did you decide to believe the meter over the CGM? Is it because you had it longer? Because it's testing blood? And that seems like something that's more accurate to you like what is the random thought your brain has had that's made you decide that one of these is more accurate than the other one? Which do you I test sometimes when I don't when I'm
Jennifer Smith, CDE 48:54
so really I mean blood glucose is the first line of glucose change it is first interstitial glucose follows blood glucose. And so with those random, you know, differences, most often I would say people on G five and G six, for the most part have pretty good accuracy finger stick to actual CGM, where I think a lot of discrepancy can honestly come in is from a finger stick value of let's say it's telling you 140. Right, and you're looking at your CGM, and it's 100. Well, as we kind of started out saying, it's not about the number on the CGM. It's about the trend. And like you do very often you're saying okay, now there's a trend going up, you know, you just bolused what you missed giving before because you started to see a trend up. Well, her fingerstick might actually be reflecting a higher glucose than what the CGM is showing right now because again, glucose changes first in your bloodstream screen. And so CGM is going to leg especially in those time periods of more significant glucose change such as after food or after or during exercise, that that can be a varying time. So finger stick 140, your CGM is trending up, or you've got an angled arrow heading up and it's telling you you're 102. And you're like, Huh, what do I do about this? The CGM just hasn't met yet the glucose value in the bloodstream, it will catch up, right? It will, it's just that it hasn't gotten there yet. Because really, if you think about the way that glucose sort of moves in a simplified form, it moves out of the bloodstream sort of has to move through insert interstitial fluid before it gets to the cells to get absorbed, essentially, I mean, that's simplified, but so your, your, your interstitial fluid is also always for the most part gonna leg, especially in special times, like food and movement.
Scott Benner 50:53
And I'll tell you to and to circle back around to the idea of the quality of your meter. Arden's had an on the pod forever, like since she was four, so she's going to be 15 Soon. Point is, that thing's been around a long time. It's got an old freestyle meter in it. They've always been kind of wonky. And now we're using the Contour. Next One, it's the little tiny meter that's going to start calling accurate on the market. Yep. So when Omnipod decided to switch over to dash, which should, you know, you might be listening to this, and dash might be a thing already, but it's about to happen. They're gonna offer you a free Contour Next One meter to come with it. So I've been using it for a few months to get my head around it. It's spectacular. Like what a great accurate meter. It's absolutely insane. Like I just compared to what was in that PDM. It was nuts. how much better it was? Well, and this brings
Jennifer Smith, CDE 51:47
up for the people to who might still be using a G five, or a CGM. That requires calibration. What you calibrate with. Yeah, that really makes accuracy on the CGM hold better,
Scott Benner 52:01
right? Right. And if you're calibrating with a Band Meter, say you have a G five, it still asks for calibration. And the G five says it's 90, but you've tested with a 10 year old meter, it's like it's not it's 150. What if you really are 90 and now you're telling the G five everything you think is wrong? You're 150. But the algorithms like that's not right, we're nine. And did you confuse it? And then it blows up?
Jennifer Smith, CDE 52:23
Three, three, question marks for three hours. You're like, calm down,
Scott Benner 52:26
and then you go this something wrong with a CGM? Actually, no, it was you, you put the wrong information. And so none of this technology is obviously Perfect, perfect. But again, I always like to say you're not boiling your urine to find out what your blood sugar is. So you're doing right, yeah, right. You're doing greatly. i All I can say for sure, as we as we kind of come up on the end here. And I'm gonna ask you to kind of sum up in a second. But what I can tell you is that, as I've said, before Arden's a once he has been between five, two and six, two for five solid years. And it's going to be a lot to do with the tools that you hear is talking about here on the podcast and how I've learned to implement them. But how I learned to implement them was the information coming back to me from ordinance glucose monitor. So if you have an opportunity to get one, and I know they're not covered by everybody's insurance, and they can be expensive, but if you can get one you absolutely in my opinion should do absolutely will just change your life. So Correct. Yeah.
Jennifer Smith, CDE 53:20
I 100% agree. Yes.
Scott Benner 53:22
Did we forget anything? Because at this point, people who listen, probably aren't surprised. But I don't pretty play on these with Jenny. She put on her headphones. She goes, what are we talking about? I'm like CGM. And she goes great. And then we just started talking. But But again, I like the way these conversations flow. So Did I forget anything? That is like wildly wrong?
Jennifer Smith, CDE 53:43
I don't think so. I, I do think that if, I mean, this is just from an education standpoint, your own education with your CGM. If you really need some pointers, I mean, it's helpful to look or ask more of your care team. You know, if you do need some pointers, some some endos. And CDs are really awesome. Some don't know much more than just telling you how to slap it on. But look beyond I mean, because there is there's a wealth of of benefit to knowing. And some of it is self experiment, experimentation. In fact, I think a lot of it's self experimentation. But if you need some help with looking at things, I think searching out somebody can be helpful.
Scott Benner 54:27
Yeah, yeah, somebody who can look at the graph and just make sense of it in a second. We've talked about before I can at this point, I can look at someone's three hour graph and go, is this where you're putting the insulin and they're like, how did you know I'm like, Yeah, because it should have been here. And it wasn't enough and this would have stopped that and like, it's pretty easy to see after you can see it right. It's like those, you know what it's like, it's like those posters that you look at it. You're like there's somebody tells you it's a tree and it's a sailboat and you stare at it long enough, it turns into a tree. I think that's what happens like after you look at it long enough. I don't People can get scared of the idea of data. I don't like the word because I think it I think it scares people off. Like, you need to understand the data. Well, that sounds scary to me. It does, right? Right, there's a little line on your thing. Okay, that line tries to go in a direction, you look and see where you put the hands on. And you see how harshly the line tried to go in that direction, you make a better decision next time.
Jennifer Smith, CDE 55:20
You know, I think that actually brings in one point that we may have missed is that, especially Dexcom does allow you to use event markers. So if you are really wanting more, you know optimization, and you're the only one who can really look at your your lines and your info. Using the event markers. I know in G six at the at the bottom of your at least your screen on your on your phone app, you can just choose events, you can log things like food, or exercise or illness or even alcohol and like your your cycle or monthly and all that kind of stuff. It'll put little marks on your actual trend graph. And that way you can make more sense of the if you're again, the one that's really trying to look back for what what happened, why did it happen, you
Scott Benner 56:08
don't have to remember that I ate lunch at 1130 You can just say food and maybe the amount of carbs and make a note about what the food was. Right? And that helps you when you look back. See again, that's well more way better thought out than I can ever be. But that makes a lot of sense. And that's why you're here. You're the you're the smart part of this conversation. I'm the chit chatty part of the conversation.
Jennifer Smith, CDE 56:30
We're both important for reasons. Yeah,
Scott Benner 56:33
I'm pretty sure that's true. Okay, I think you'd have to go in a couple of minutes, right? So I'm gonna let you go now and say goodbye. I want to thank smz diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free contour next gen starter kit at contour next one.com forward slash juicebox free meter, while supplies last US residents only. If you're enjoying the remastered episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org. A huge thank you to one of today's sponsors G voc glucagon find out more about Chivo Capo pen at G Vogue glucagon.com forward slash juicebox you spell that GVOKEGLUC AG o n.com Ford slash juice box. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed or starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bumping nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low Beegees in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two in Episode 1008 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025, we talked about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics. Scott brings useful information and presents indigestible weighs, learning that Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active, took me already from a decent 6.5 A one C down to a 5.6. In the past eight months, I've never met Scott. But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Jenny Smith 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 on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years, and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link. If you're living with diabetes, or the caregiver of someone who is and you're looking for an online community of supportive people who understand, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, there are over 41,000 active members and we add 300 new members every week. There is a conversation happening right now that would interest you, inform you or give you the opportunity to share something that you've learned Juicebox Podcast, type one diabetes on Facebook, and it's not just for type ones, any kind of diabetes, any way you're connected to it. You are invited to join this absolutely free and welcoming community
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