#1007 Diabetes Pro Tip: Bump and Nudge

September 21, 2023Scott Benner

In this episode of the Juice Box podcast, Scott is joined by CDE Jenny Smith for the eighth installment of the Diabetes Pro Tip series, titled "Bump and Nudge." They discuss the concept of bumping and nudging blood sugars and its importance in managing type one diabetes. Scott emphasizes the statement that avoiding high blood sugars is key to maintaining good control.

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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 0:04
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 healthcare plan or 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 juicebox. Jenny Hello how are you? I'm good. How are you? Scott so good. Yeah. short episode going over the idea of bumping and nudging blood sugars, which is something we talk 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 you to fight with a high blood sugar if I don't experience a high ledger. Of course, that's not always going to work. I'm not saying that. But I am saying that it's avoidable a lot of the time.

Speaker 1 3:05
I think of it as bumping and nudging just bumping and nudging it could be bumping that term. I love that. But I love it 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 a Temp Basal. We're going to talk about it all right now.

Jennifer Smith, CDE 3:24
You can also do it with exercise.

Scott Benner 3:27
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 needed like celery all there for blood sugar was high. But if she wanted, 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. So went up and down the steps this many times I would like my cookie now. And this is back. This was back when she was doing oh gosh, the words just slipped out of my head. What was the old timey insulin, regular insulin regular and mph? That's what she was talking pH. So back then she would do a little exercise to get her cookie. But you know this by the way, this girl is delightful. You have to find the episode with her.

Jennifer Smith, CDE 4:17
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, at that point. That's all move. You know, there'll

Scott Benner 4:47
be a snack 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 it 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, at 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, you react to it quickly, you're able often to react to it with less insulin, under percent, 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 hours out. 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 million 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 rollercoaster. It is that simple, right? So you stop a rise 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 to me? Where should this be on the Mount Rushmore of diabetes thoughts?

Jennifer Smith, CDE 7:10
I think it should be right there 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 220 for kids is appropriate only because it's safe.

Scott Benner 7:47
Right and safe. And as much as you're not going to have a seizure.

Jennifer Smith, CDE 7:51
Correct? Correct. I mean, am I saying that you're aiming for you know, no rise at all? No, am I saying that you're aiming to 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 arise, then it does to correct a blood sugar that's already too high.

Scott Benner 8:24
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? So I always have to start by telling people what you're viewing up here encompassed about three seconds of my thoughts spread out over five minutes. Right, right. You'll spend more time in initially then, then 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 on a quote unquote bad day wouldn't shouldn't 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 than to be stuck in a 300 blood sugar and everything that 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 highs 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 aren't in spikes, I'm talking about 150 170 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, right?

Jennifer Smith, CDE 10:15
Well for clarification to even about art and spikes, if not that you've waited until she's 170, to address it, but 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 staying way too high. And crashing from Bolus, Bolus, Bolus, Bolus, oh, no, I'm like 50.

Scott Benner 10:55
And because I reacted sooner, I still am keeping mainly the balance of the insulin action, carb impact. 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. And then you come in for like a nice landing afterwards, which I somebody just texted me the other day and says, Can you please like, 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 in the end

Jennifer Smith, CDE 11:27
of a roller coaster is what I explained. Yeah, kind of where you're the rush of that ride down and then you like roll into the station. Yeah, that's it exists nice and flat and smooth and perfectly

Scott Benner 11:37
bringing in for a nice landing. Right? So okay, so, so sure you can bump in nudge that way, right. But what if I'm at the tail end, for example of meal Bolus, and I'm noticing I'm 110 151 100, 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? Wouldn't that be nice of this that what I like in that situation is a Temp Basal decrease, decrease, right, take away some of the Basal rates. 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 it them. Basil 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 insulin is 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 of that insulin has now maybe you'll catch it with a Temp Basal, and maybe you won't. But in certain situations, it's the best way to start. You know, I forever see people who are 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 Basal and see if that doesn't catch it in your natural body functions don't kind of pull you back up again.

Jennifer Smith, CDE 13:38
And if you're in 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 it drifts down and you give a nudge again and it comes up and it drifts back down. That's basil, you're in basil only unless you have a correction from earlier that brought you down so much. That's still working. Basal only that's a good you've got too much Basal. There's too much there, up, down, up, down, up down and it never stays stable. You got too much.

Scott Benner 14:11
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Jennifer Smith, CDE 17:41
Right. And you want to stop nudging as much as you can.

Scott Benner 17:45
We all want to go to sleep and nobody wants to drink juice in the middle of the night. And we're trying 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 an important to remember. Because if you've ever spoken to me privately, if you've listened 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 basil. Even though you don't think of it the same way. Because basil 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 we've 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 enough that I believe

Jennifer Smith, CDE 18:56
a little print off sheets got,

Scott Benner 18:59
oh, I don't want to give it away. Come back. I know.

Jennifer Smith, CDE 19:05
Well, the full full ideas are really behind all of those little simple statements. So if you had just a little simple statement, you're like, I don't even know what that means.

Scott Benner 19:12
And those reminders, I actually I use them too. So 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 I know that's ridiculous, but I was like, oh my god are basil needs to be increased. Boom. And there I was. I was like, Oh, that was so I should have listened to me. But like for days, I was like what's the problem here? So you're gonna you'll 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 in a different episode Do 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 and you're trying to force it up with food? I don't want to use too much. That starts us off on that roller coaster 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 then and then you start looking at the garage and thinking I just gonna pull the door down, start the car, put on my favorite album and go to sleep. But we don't need to do that. What we need to do is to bump and nudge with the food as well. And so this is crashing and nudging

Jennifer Smith, CDE 21:03
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 basil, 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? Yeah. 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, you need a little bit more aggressive nudge than that.

Scott Benner 21:44
Yeah, I tell people all the time, if you see a 65 and it's really stable, and you want to try to check your basil 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 your basil off, like like, you know, like you've really messed up somewhere so, but it's just not quite right. But the opposite idea 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 to eat all of the gummy bears. Why not two bears or three? Because 15 carbs? 15 minutes?

Jennifer Smith, CDE 22:21
15 carbs? 15 minutes. Right?

Scott Benner 22:23
Right. Bad advice you got from a doctor one time.

Jennifer Smith, CDE 22:27
And it was again, it comes to the safety. Right? It comes to the safety piece of this is an easy rip off. Non in the moment. This is just please do this because it will at least alleviate the law. Right? You'll be safe.

Scott Benner 22:42
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 100 yards away because the 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 Bolus 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 someone's 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 know.

Jennifer Smith, CDE 23:15
Right? I like that's the reason I like little tiny like the Jelly Belly jelly beans, they're a gram of carb a piece. Skittles are a gram of carb apiece, they're an easy way to nudge with food in a accounted way. Rather than like sips of juice where you're like, I don't know, I might have had a bigger SIP or a little or SIP or a whatever my SIP might be the whole container. I don't know.

Scott Benner 23:41
I'm telling you again, Ninja like level of understanding, I can sometimes stick a straw on Arden's mouth from a juice box as she's drinking it. I just go and that's enough. And that's just something that comes with time, right? Like you're not going to 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 do you 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. And 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 going to 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 an agent in and out of an area. What is that area? And so, I mean, I'm sure to define your target. Yes. What is it you're going for? Right, like, I don't need Arden's blood sugar to be 85 constantly. I don't feel that way. But I don't like her blood sugar to be under 70. But I gotta tell you that if she drifts under 70 for a couple of minutes, I'm not running around looking for the glucagon, you don't even I'm like, let me see how I can just get this to kind of gradually come back up again. Same thing if she gets the 114. It said, Senegal, 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 her or I have to decide I'm not going to look at this 140. And I may need to redress with food later. Right.

Jennifer Smith, CDE 25:35
Right. Right. So absolutely. And you know, that also speaks then to the benefit of now we've got the CGM, right, because with a 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 gonna go to the amusement park and walk around for four hours. She's sitting on the couch. Yeah.

Scott Benner 26:15
Even 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 don't 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

Jennifer Smith, CDE 26:49
energy is different than blood sugar, strategy energy. For athletes,

Scott Benner 26:53
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 got to go she's got a life. Okay, she's got she's got to work. And so I'm gonna let her go and say thank you. Absolutely. Always, always nice to me. I'll talk to you soon. I want to thank assenza 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 juice box for E 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 voc glucagon.com. Forward slash juicebox. you spell that GVOKEGLUC AG o n.com. Forward slash juicebox. 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. 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 are 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 naj 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 one 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 it in digestible ways. 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. 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.