#1220 Defining Diabetes: Tug of War

June 9, 2024Scott Benner

Scott and Jenny Smith define diabetes terms In this Defining Diabetes episode we define tug of war.

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Scott Benner 0:00
Hello friends and welcome to episode 1220 of the Juicebox Podcast.

Today on defining diabetes Jenny Smith and I are going to define tug of war. 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. When you place your first order for ag one with my link, you'll get five free travel packs and a free year supply of vitamin D. Drink ag one.com/juice box. If you have type one diabetes, or are the caregiver of someone with type one and a US resident, please go to T one D exchange.org/juice. Box and complete the survey. Your answers will help to move type one diabetes research board that may help you to T one D exchange.org/juicebox. 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 now 50,000 members who are sharing stories and ideas. Go check out this amazing private and free Facebook group. Today's episode is sponsored by Medtronic diabetes, a company that's bringing together people who are redefining what it means to live with diabetes. Later in this episode, I'll be speaking with Mark, he was diagnosed with type one diabetes at 28. He's 47. Now that at the very end of the episode, you can hear my entire mini interview with Mark to hear more stories from the Medtronic champion community or to share your own story. Visit Medtronic diabetes.com/juice box and check out the Medtronic champion hashtag on social media. All right, one last one. Yay. Jenny, I'm going to ask you to help me define something that I made up. So okay. But you're uniquely qualified for this. And I'll tell you why. You know, fabulous a number of years ago, you've said a number of kind things to me over the years. But a number of years ago, you told me that my explanation about how meal insulin works was the clearest that you had heard and that you were telling it to other people, which very much touched me. Oh, when I describe a tug of war. Yeah, between the insulin and the carbs. Yes. So apparently, I've said that, you know, enough times in the podcast that now people are like, Hey, what is this tug of war thing? If they haven't, like actually heard the explanation? So we're gonna define tug of war. Yay. As it pertains to meal insulin may give you a tiny bit of back. I haven't. I haven't done this in a while. Do you know that I used to stand in this room by myself. And give this explanation out loud until I got to the point where I could just do it. Because I was giving so many talks that I didn't want to get confused while I was doing it. Anyway, I've practiced this. So I feel you're ready. You're ready to go? No, I just it makes me feel stupid to say it in front of you. But because I like stood up and gone through it so many times. But

Jennifer Smith, CDE 3:25
would you like me to turn my camera on? Look away, please. I can look at your chameleon. So.

Scott Benner 3:31
But that'll sound like a non sequitur to anyone who doesn't know there's a chameleon? Or, okay, so, in the beginning, before I had a podcast, I had in my head that using insulin at meals was like the scales of justice, but they both had little holes in each side. And I used to try to tell people imagine that there's a dish on one side of the scale and addition on the other side, and you're adding insulin and carbs in it in a way that as they're dripping out the bottom and losing their ability to impact the scale. You just add a little more of this and a little bit of that just to keep it balanced. I probably told this story somewhere else. I'll just skip through it very quickly. I was trying to explain that to someone one day. And they said I'm sorry, I don't understand what you're saying. And I was in a position where if I didn't help this person, a very young confused mom was going to go back to a very young baby with diabetes and not understand how to help the baby. Not a good scenario. It was in a private conversation. I felt heartbroken. I didn't want to leave her off the call that we were on together. And so I just re centered myself and I have no idea where this came from. But I said have you ever been involved in tug of war like on a schoolyard? And she said yes. And I was like, Okay, great. I said, Well, instead of one team on one side, one team on the other side, I want you to think about insulin on one side of the rope and carbs on the other side of the rope. And in the middle, of course, there's this flag hanging. And in your tug of war at school, it was your goal to yank the flag onto your side, I said, but in our tug of war, the goal is that the flag never moves, it just stays in the center. And no matter how hard the carbs pull, or how hard the the insulin poles, we can't get that flag to go up and down. And I said, Now right now we're thinking east, the West, you know, but I want you to flip that whole image in your head to North and South. So instead of the carbs pulling West, let's think of the carbs pulling north. And let's think of the insulin pulling south. And we still don't want that flag to move. I said, Now imagine, every minute that goes by a new flag pops up in this timeline. And longer, we keep that flag in the middle. That's a straight line on a CGM. And she said, I'm following and I was like, Oh, good, because I was nervous. I was literally making it up as I was going along, right. And I said to her, I'm like, so just try to imagine this. You know, when you eat food, your blood sugar starts to go up pretty quickly. You know, in the first couple of minutes, you can see it on the CGM. But when you Bolus for insulin, it doesn't, like the insulin goes in. And it just, you know, sometimes can sit there for 1520 minutes, depending on the situation and, and where your blood sugar is, at the time, could go longer and longer before you see an impact and the pulling down from the insulin. So what I want you to do is, I want you to cheat a little, I want you to tell the insulin, it's allowed to pull first. And then right when the insolence kind of picking up steam, and that flag is starting to move off center towards the insulin. So let's go ahead and eat. Right. And so now you'll eat and a few minutes later, just as that flag is really starting to move towards the insulin side, or, you know, down, the food kicks in and starts to pull up. And I was like, and now we're in a tug of war. And if we've timed that insulin correctly, and use the nerf, and if your Basal is right, and all the other things, neither side is going to win that tug of war. And the flag is going to stay right in the middle, minute after minute off into the future. And you're going to have a nice stable line. And that's doable when you're eating anything. Like it's not easy, but it's doable. That's it. That's what I said to her. And she was like, okay, I'm good. And she was on her way. What about that? Did you like when you heard it?

Jennifer Smith, CDE 7:34
I just liked that there was something that was easy to put in the mind that is of a tug of war game, knowing what the pull is and the fact of a difference in a real tug of war game, you want one side to win, right? We want insulin to win, but we also want the food to win. Right? So your explanation also goes along with a CGM line, which allows us to see that flag just little bits of movement as each side gets their pull in, but overall keeps it fairly nice and stable. You might have a little bit of a rise, the insulin really gets moving because you timed it well and it smooths it out on the back end. It's just a really easy mental kind of picture to paint for people who are much more I think visual learners in a way okay. It just yeah, it made it was just a really nice a really nice description.

Scott Benner 8:29
I sometimes I you'll hear me talk about, like football with like blockers. And there's times when I think about it my head like, like the point in time on the CGM line like the.is, almost like a drunk running between two lines of people with pillows. And as they wobble back and forth, the people with the pillows reach out and shove them back to the center again. And I don't know another way to say that when I'm watching Arden's graph, and I see it rising. In my mind, I imagine the insulin on top of it, trying to push it back down again. And the same way as treating a low. When I see that going down, and the carbs go in, in my mind, I'm like, okay, the carbs are underneath there like a floor jack now trying to lift it back up again. And it helps me a lot when I'm considering the insulin to picture it that way. Because the math of it doesn't help me in that moment. Like I'm not comforted by we use the right amount, or I know her carb ratios good. Like that kind of stuff. Like I look at that graph. And I imagine what's happening carbs, fat, digestion, insulin, Basil specifically, and you'll and I find the addendum to this story. Now that algorithms exist. And you can see basil getting like ramped up yeah. Right, it almost feels like we can't protect the quarterback with our five offensive linemen. So I've kept the tight end and to block, which is a very specific idea if you don't understand football, but like, here's more like, hey, this rise is happening. I know your basil of one unit an hour usually handles this, but the algorithm says it's not working. Here's 1.3 units for the next 10 minutes or something like that. I'm gonna I'm gonna leave the tight end back to block a little longer. Yep. And those little like, picture grams are a big part of how I taught myself to understand the algorithm. And yeah, and graphs on the CGM. So I

Jennifer Smith, CDE 10:39
think it goes along with and we have, we use bump and nudge which are also terms that you brought in, we use them kind of opposite. Mine is opposite of what cuz you say what for bump what is bumped do

Scott Benner 10:53
to me bump brings you up and nudge brings you down. And you think of nudges nudging up, you nudge with carbs, and you bump with insulin, correct and I bumped with carbs and I nudge with insulin, but it doesn't matter as long as matter

Jennifer Smith, CDE 11:09
as long as you understand which is which for you

Scott Benner 11:11
as long as you understand, which is wait, don't start randomly going bump and meaning one thing and everything. But even that like it's it's still that you've heard me say before, and this gets a little bit away from tug of war. But at the same time, I think it helps add to the idea. When you learn to drive, one of the hardest things in the beginning is to learn not to overcorrect. Right, like you don't want to like see that yellow line. You're like, Oh my God. And then the next thing you know, you're across the yellow line and you're out into the weeds or you're crossed into the other lane. I think that when you when I stopped and thought about when you're drifting off the road, the amount you turn the steering wheel to bring yourself back is almost imperceivable to your eye. You're barely moving it. Right. And that's how I kind of think about the insulin in non emergency situations. Like I'm not saying if you're 60 straight down, you should have two gummy bears and see what happens. But because what's gonna happen is you're gonna wake up with the EMTs there and gummi bears in your mouth. But if you're drifting at the end of a Bolus, and it's five hours in and you see an ad become a seven da become a 76. I'm like, I wonder what a gummy bear would do right here. I wonder what's two Skittles might accomplish? Like, can I just bump this back up a little bit. And then the same. And I know we've talked about it so many times. But it really does fit here. The same thing with a slowly drifting up blood sugar, my 95 has become 105 has become this. Like instead of staring at it for the next three hours until it's 180 and bolusing. Like see what point one does. You know what I mean? Like what would Temp Basal for 15 minutes accomplish here like that kind of stuff?

Jennifer Smith, CDE 12:54
I think that's maybe why we consider it like I've always been conservative with nudging. I've always been concerned nudge and bump in terms of me, a nudge is a little light, gentle. And a bump is a little bit more of a. Right. So my nudge to my blood sugar is if I'm lower. I've always been really conservative with what I use to treat. And so I consider that more of like a little gentle. Like, I might need one or two grams of carbs, a little nudge. Whereas if my blood sugar is going up, or it is high for some reason, I consider that bump this thing, man.

Scott Benner 13:39
So you use the words as strength. And I use the misdirection. Yeah. Oh, isn't that interesting? I

Jennifer Smith, CDE 13:46
use that because I've always like I said, bump and nudge are a little like a little nudge is like, it's more like friendly, where the bump is like, Man Get out of my way. Like, whoa,

Scott Benner 13:56
I gotcha. I understand. Okay, no, this is wonderful. No, I love this conversation.

Jennifer Smith, CDE 14:01
I am a visual learner i That's how I think of things to which I think is the reason that I really liked your example of the tug of war. Yeah, because in my mind, I probably had thought about it, almost like that. But I didn't really define

Scott Benner 14:14
words to it. I literally speak and picture sometimes. I know my wife whose brain does not work like that. You should see her and I tried to tell each other how to get to somewhere in our car. It's fascinating. I lay it out. And she goes, I don't know what you're talking about. That she tells me and I'm like, I can't follow what you're saying. Yeah, it really is fascinating. Yeah. So tug of war, to me is, you know, you're going to be inclined to think of it as a meal Bolus, but I apply it to everything I applied to basil. I applied to meal Bolus is corrections. Anytime you're using insulin, there is a tug of war at play. Hmm, that's it. Okay. Thank you. I appreciate that.

Unknown Speaker 14:55
Absolutely. That was good. All right.

Scott Benner 14:57
So I think And because we only have a couple of minutes left,

Jennifer Smith, CDE 15:02
are you the direction giver like I am, that's like, The Red House three blocks from here, take a right. And then when you get a little further, where there's the gas station that used to be, but now it's all burned down. Now you take a left, those are my directions. My husband's the one who taught me to read a map, right? Like, yes. And even still, when I do maps, I still expand it. And I'm like, is there like a McDonald's or something? Like, what should I look at? Where are the arches? Or where is the gas station? Like, where is it on the map? So I can see that where I'm turning? Oh, yes, this is an identifiable building. And that's how I know where I'm going. Yeah, I

Scott Benner 15:40
don't know, directions at all. Like, if I'm driving south or north, I have no idea. Like, it's not important to me, like, you know, and I don't know, like, I'm like drive, like, you know, for a couple of minutes, and then make a left here. And then and she's very specific about it. Like, like, it's really interesting, although, I don't know if it matters now. My son's 24. He doesn't almost drive anywhere without his nav on. Oh, really? Yeah. I'm like, Do you know where you're at? And he's like, the thing knows, and I'm like, okay, art is completely different art. No getting a car at like, seven at night. She'll be like, I'm gonna go drive around. And then she'll come home at like, 11. And she'd be like, there's a house. And she'll like, have dug deep into the town and found a place and been very like, like learning the the landscape of it. I don't think Cole would go for a ride for fun, ever. It's interesting. How they think about it differently. Yeah, I don't even I can't even tell you how I give directions because obviously, I'm just doing it the right way.

Jennifer Smith, CDE 16:38
Yeah, I give directions just like I told you. Yeah, I tell people what to look for. What's there, the big red tree that's got half of it missing? that's those are bytes that's

Scott Benner 16:49
viable. Yeah. What if I don't see the tree though.

Jennifer Smith, CDE 16:52
You're you were not using your eyeballs. Yeah, should have been paying attention.

Scott Benner 16:55
And now you're in Minnesota. I think we're kind of done for today, to be perfectly honest with you, I'm just gonna leave you go.

diabetes diagnosis comes with a lot of new terms, and you're not going to understand most of them. That's why we made the finding diabetes, go to juicebox podcast.com, up into the menu and click on the finding diabetes, to find the series that will tell you what all of those words mean. Short, fun and informative. That's the finding diabetes, the diabetes variable series from the Juicebox Podcast goes over all the little things that affect your diabetes that you might not think about travel and exercise the hydration and even trampolines, juicebox podcast.com, go up in the menu and click on diabetes variables. And now my full conversation with Medtronic champion, Mark. Mark, how old were you when you were diagnosed with type one diabetes? I was 2828. How old are you now? 4747. So just about 20 years?

David 18:09
Yeah, 19 years?

Scott Benner 18:11
What was your management style when you were diagnosed?

David 18:13
I use injections for about six months. And then my endocrinologist at a navy recommended a pump.

Scott Benner 18:19
How long had you been in the Navy? See eight years up to that point? Eight years? Yeah. I've interviewed a number of people who have been diagnosed during service and most of the time they're discharged. What happened to you?

David 18:31
I was medically discharged. Yeah, six months after my diagnosis.

Scott Benner 18:35
I don't understand the whole system. Is that like, honorable? Yeah.

David 18:38
I mean, essentially, if you get a medical discharge, you get a commensurate honorable discharge. I guess there could be cases where something other than that, but that's that's really how it happened. So it's an honorably discharged with but because of medical reasons,

Scott Benner 18:50
and that still gives you access to the VA for the rest of your life. Right?

David 18:53
Correct. Yeah, exactly.

Scott Benner 18:54
Do you use the VA for your management?

David 18:56
I used to up until a few years ago, when we moved to North Carolina, it just became untenable, just the rigmarole and process to kind of get all the things I needed. You know, for diabetes management, it was far easier just to go through a private practice.

Scott Benner 19:10
Was it your goal to stay in the Navy for your whole life, your career? It was? Yeah,

David 19:13
yeah. In fact, I think a few months before my diagnosis, my wife and I had that discussion about, you know, staying in for the long term. And, you know, we made the decision despite all the hardships and time away from home, that was what we love the most. So that's what made it that much more difficult

Scott Benner 19:30
was the Navy a, like a lifetime goal of yours or something you came to as an adult?

David 19:34
lifetime goal. I mean, as my earliest childhood memories were flying being a fighter pilot and specifically being, you know, flying on and off aircraft carriers. So, you know, watching Top Gun in the 80s certainly was a catalyst

Scott Benner 19:47
for that you've taken off and landed a jet on an aircraft carrier 100 times. Is there anything in life as exhilarating as that? No, but

David 19:56
there there's a roller coaster I rode at Uh, I think it was at Cedar Rapids up in Cleveland Sandusky, and they've got this roller coaster rotation from zero to like It's like 80 or something, you go up a big hill and you come right back down. So the acceleration is pretty similar I would say to catapult shot, I'm

Scott Benner 20:14
gonna guess you own a Tesla.

David 20:17
I don't I I'm a boring guy, I got a hybrid rav4 I get made fun of I get called, you know, my, my wife says I drive like a grandpa. I'm a five miles per hour over the speed limit person. And no more than that. So yeah, in the car. I'm boring Scott. So

Scott Benner 20:31
you've never felt a need to try to replace that with something else.

David 20:35
You can't replace it. It's irreplaceable. That's what I thought. So up until the point where someone you know, buys me an F 18 or allows me to get inside a two seater and fly it you can't replace it? How did

Scott Benner 20:45
it make you feel when you saw or maybe you haven't seen? gentleman named Pietro has his large aircraft license. He's flying for a major carrier. Now he has type one diabetes. Does that feel hopeful to you?

David 20:56
Yeah, it does. You know, when I when I was diagnosed, that wasn't a possibility. The FAA prohibited commercial pilots who had type one diabetes, but I think it was 2017 when they changed their rules to allow type one diabetics to be commercial pilots. And part of the reason they did that was because of the technology advancements, specifically in pump therapy and pump management. So I don't have any aspirations of going to the commercial airlines. But one of my sons who has type one diabetes very much wants to be a commercial pilot. So, you know, in that respect, I'm very hopeful and thankful. Yeah.

Scott Benner 21:28
Do you fly privately now for pleasure?

David 21:31
I do. Yeah, one of my favorite things to do is fly my kids to the different soccer tournaments they have all over the southeast us. So last week, my wife and I and two of our boys flipped to Richmond for their soccer tournaments up there. And Charlie, who's my middle child has type one diabetes. So you know if I can combine flying family and football and one weekend to me that's I think I've just achieved Valhalla.

Scott Benner 21:55
So then it sounds to me like this diagnosis was a significant course correction for you. Can you tell me how it affected your dream?

David 22:02
Well, I you know, if I guess three words come to mind first, it was devastating. Everything I had done in life, everything I'd worked up to up to that point was just taken away in an instant. And I was not prepared for that at all. The second emotion was, it was scary. I hadn't thought much about life outside the Navy, certainly not life as anything else, but a fighter pilot. And Heather and I were getting ready to move to France, I was going to do an exchange tour with with the French naval air force. So we're taking French classes. So pretty quickly, I had to reinvent myself. And then probably the most important thing at the same time that all that was going on, I had to learn how to deal with type one diabetes, and how to manage it effectively. The third thing that pops into my mind, I guess, is challenging, you know, new daily routines, I had to establish first with injections, and then eventually, you know, through pump management, and then learning how to count carbs and recognize highs and lows, how my body reacts to blood sugar trends based on exercise and stress and those types of things. And my goal at that time, and it still is today is to leverage technology and make sure my habit patterns are effective so that I take diabetes management from the forefront to the background.

Scott Benner 23:09
Have you had success with that? Do you feel like you've made the transition? Well,

David 23:13
I have I mean, I believe in continuous improvement. So there's always more to do. I will say the technology since I was diagnosed specifically with pump management, it's just, it's just incredible. It takes less of me intervening. And it's really done by the pump itself and by the algorithms through the CGM EMS. And to me again, that that should be the goal for everybody is to not have to focus so much on the daily aspects of type one, diabetes management, you know, we should let technology do that for us.

Scott Benner 23:42
What else have you found valuable? I've spoken to 1000s of people with type one diabetes, the one thing that took me by surprise, because I don't have type one, myself, and my daughter was very young when she was diagnosed. I didn't really understand until I launched this podcast, and then it grew into this kind of big Facebook presence. I heard people say, I don't know anybody else who has type one diabetes. I wish I knew more people. But until I saw them come together, I didn't recognize how important it was. Yeah,

David 24:11
I think similarly, I didn't know anyone with type one diabetes growing up as an adult up until when I was diagnosed. And then all the sudden people just came out of the woodwork. And when CGM is first hit the market, certainly within the last five years. It's amazing to me and my family, how many people we've noticed with type one diabetes simply because you can see the CGM on their arm. I mean, I would say a month does not go by where we don't run into someone at a restaurant or an amusement park or a sporting event or somewhere where we see somebody else with type one diabetes. And the other surprising aspect of that is just how quickly you make friends. And I'll give you an example. We're at a soccer tournament up in Raleigh, this past Saturday and Sunday, and the referee came over to me My son Charlie at the end of the game and said, Hey, I noticed you're wearing pomp. And he lifted up a shirt and showed his pump as well and said, I've had type one diabetes since I was nine years old. I played soccer in college, I'm sure that's your aspiration. And I just want to tell you don't let type one diabetes ever stop you from achieving your dreams of what you want to do. And it's the other man was probably in his late 50s, or 60s. So just having that connection and seeing, you know, the outreach and people's willingness to share their experiences. It just means the world to us and just makes us feel like we're part of a strong community. Yeah.

Scott Benner 25:31
So would you say that the most important things are strong technology tools, understanding how to manage yourself and a connection to others? Yeah,

David 25:40
technology for sure. And knowing how to leverage it, and then the community and that community is your friends, your family, caregivers, you know, for me, the Medtronic champions community, you know, all those resources that are out there to, you know, help guide the way but then help help you keep abreast on you know, the new things that are coming down the pike, and to give you hope for eventually, you know, that we can find a cure, you

Scott Benner 26:02
mentioned that your son wanted to be a pilot, he also has type one diabetes, how old was he when he was diagnosed,

David 26:08
so Henry was diagnosed when he was 12 years old. That was just at the start of COVID, we are actually visiting my in laws in Tennessee, we woke up in the morning, and he had his bed. And several years before that, we had all four of our boys tested for trial net. So you know, predictor of whether or not they're going to develop type one diabetes, and whether or Henry and one of his brothers tested positive for a lot of the indicators. So we always kind of had an inclination that there was a high degree of possibility he would develop it. But we always had at the back of our mind as well. And so when that event happened, at the beginning of COVID, we had him take his blood sugar on my glucometer. And it was over 400. And so right away, we knew that without even being diagnosed properly, by endocrinologist that he was a type one diabetic, so we hurried home, to get him properly diagnosed in Charlottesville. And then we just started the process, first grieving, but then acceptance, and, you know, his eventual, becoming part of the team that nobody wants to join,

Unknown Speaker 27:11
how old is he now?

David 27:12
He's 15 years old. Now,

Scott Benner 27:14
when's the first time he came to you? And said, Is this going to stop me from flying almost

David 27:20
immediately. So like me, he always had aspirations of flying. In fact, he out of all four boys wanted to be in the military, that was a difficult part of the conversation, and maybe something that we don't talk about as a community. But there are some things you cannot do as a type one diabetic, and that's a hard fact of life. And unfortunately, joining the military is one of those hard and fast things you cannot be, you cannot join the military as a type one diabetic. So it was very difficult for him and for me and my wife to get over. Then we also started talking about being a commercial pilot. And so I saw that same excitement in his eyes because like me, you know, he can be an NFA teen or a 737 or a Cirrus SR 20 That I fly and be just as happy. So he still has that passion today and still very much plans to eventually become a commercial pilot.

Scott Benner 28:05
I appreciate your sharing that with me. Thank you. You have four children do any others have type one?

David 28:10
They do? My oldest twin Henry has type one diabetes, and my middle son Charlie has type one diabetes as well. The boys are twins. The oldest two are twins. One has type one diabetes. My middle son, who is not a twin has type one diabetes.

Scott Benner 28:24
I see. Is there any other autoimmune in your family? There isn't

David 28:27
I'm really the only person in my family or my wife's family that we know of with any sort of autoimmune disease, certainly type one diabetes. So unfortunately, I was the first to strike it rich and unfortunately pass it along to to my sons, but

Scott Benner 28:42
celiac thyroid, anything like that. Not at all, nothing. We're

David 28:46
really a pretty healthy family. So this came out of nowhere for myself and for my two sons. That's really

Scott Benner 28:52
something. I appreciate your time very much. I know I appreciate your sharing this with me. Thank you very much. Anytime Scott, learn more about the Medtronic champion community at Medtronic diabetes.com/juice box or by searching the hashtag Medtronic champion on your favorite social media platform. If you're not already subscribed, or following in your favorite audio app, please take the time now to do that. It really helps the show and get those automatic downloads set up so you never miss an episode. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com