#1225 Defining Diabetes: Duration of Insulin Action

June 17, 2024Scott Benner

Scott and Jenny Smith define diabetes terms In this Defining Diabetes episode we define duration of insulin action.

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Scott Benner 0:00
Hello friends and welcome to episode 1225 of the Juicebox Podcast.

Today on defining diabetes Jenny Smith and I are going to define duration of insulin action. 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. Jenny, let's define duration of insulin action. That's the I A is that right? Yes. All right. People want to know how to figure it out, depending on different insulin types impacts on boluses, manual pumps versus algorithms, etc, and so on. So first of all, duration of insulin action, is it something that is it's not quantifiable specifically to the insulin? It's got to do with you as well, right?

Jennifer Smith, CDE 2:34
Yes, it could, because in terms of, as you said quantifiable to the insulin, anybody who opens up those little paper packets inside of your insulin, which nobody does, that all goes in the garbage, right, you'll actually see what the, you know, the manufacturer has in terms of the duration of insulin action, its profile, it's sort of a bell curve of action, right? And that's tested and true. But that's coming out of a lab that's not in the individual body. And as everybody in the diabetes community knows your diabetes may vary. And that includes how long insulin may act in your body. We're talking about rapid insulin here, right?

Scott Benner 3:15
Yep. So, okay, so it's not as easy just to say, I pulled out the package insert for FY ASP, and it says it peaks here and it dissipates here and blah, blah, blah. And that's gonna work the same for everyone. That's not the case.

Jennifer Smith, CDE 3:29
It's a guidepost. It's a guide. Right. That's the starting place.

Scott Benner 3:33
So I don't want to freak everybody out. But could the duration of insulin action for you change from day to day, week to week? Not necessarily, not

Jennifer Smith, CDE 3:42
necessarily, I wouldn't say that I would say person to person is much more the case that it could be a little bit longer here or a little bit shorter there. I think scenario also changes things. Again, working with a lot of women in pregnancy, we find that not only is insulin need increased as pregnancy progresses, especially into the third trimester, but also that the clearance of insulin is faster in pregnancy. So it kind of it goes in a bit slower in action to begin with from a resistance factor, but the end effect kind of has almost a clearing effect a bit faster. Okay. I mean, a lot of that has to do with right, we're taking insulin by injection or by a pump, and whatever in that. There are sort of pieces of that that get moved out by the kidneys, and they get kind of flushed by the body. Right? So there are parts in that end of action time that could change but it again is based on scenario or where you are not on day to day. Today. It works for three hours tomorrow. I don't know it looks like it worked for five

Scott Benner 4:53
hours. So if you're having a bad experience, very likely you've not used enough insulin or timed it well or something to that effect. Correct. Okay. But in the is it this specific case of pregnancy? Or like? Are there other spots that can like chew it up and there are other spots,

Jennifer Smith, CDE 5:09
those who have any sort of degrees of kidney disease, okay, that can also change insulin action time. All right. So those are some of the very specifics that could change in one person. But again, it's not a night and day change, or it's not an hour to hour kind of, Oh, it's here. Now tonight, I have to consider it's three hours instead of five hours. Gotcha.

Scott Benner 5:36
For most people, once they see it, I injected it here, I pushed the button here, it started to work. 20 minutes later, it really started to pick up steam, 30 minutes in 45 minutes, it felt like it was at its full power. hour and a half later, I felt like it was trailing off whatever those numbers are, once you start seeing it, you should see it with some consistency.

Jennifer Smith, CDE 5:55
You should okay. And that's again, there are always some variables in the picture. One has your Basal insulin bend evaluated, right, because if it has, then wherever a Bolus of rapid acting insulin leaves you, your basil should hold you nice and stable in that time period, after you expect that that rapid has stopped working, right. But if your basil hasn't been tested, then you can't really test the duration of insulin action for your rapid dose. Because the Basal might be pulling or not giving enough strength in that latent part. If that makes sense.

Scott Benner 6:36
You have to hold this in two different places in your mind. Yeah, the insulin action works as it works. But the result you see could be different if your Basal is not correct. And other factors.

Jennifer Smith, CDE 6:49
Yeah, the other one would be fat, right? Okay, your high fat intake or a high protein type of meal. Those are not the meals if you're going into understanding this term, so to speak, you're really not going to test this out in a scenario where you sit down to, you know, a 12 ounce steak with butter all over your potato.

Scott Benner 7:14
Potato journey with some sea salt on it, maybe and some craft pepper, you're hungry. I mean, now that you're talking like this. Sorry, no, no. So that's important because, yes, alright, let's let's talk about it specifically, like I once heard somebody who really, really understood loop as an example, who told me insulin action is six hours in loop. Uh huh. Right. We're sure we see it so many times bah, bah, blah. And I thought and then somebody else would come along, go, I have my insulin action set the four hours and loop. But that's all just about like wanting the algorithm to be more aggressive. There, you're kind of falsely manipulating the insulin action to talk the algorithm into believing that the insulin is gone. Is that right? Correct.

Jennifer Smith, CDE 8:00
And that is ages old, even years ago, with no algorithm types of pumps. People realize that what the pump was calculating as I OB or insulin on board, which is another term that kind of goes along with this duration of insulin action, right? So people would say, well, by two hours after a meal, I'm still high. Why is the pump not suggesting anything? Well, if your duration of insulin action is set for four hours, the pump thinks that at noon, you're four units, two hours later, there's still two units left, right, you've got two hours before the rest of that finishes, it's not going to offer you anything. So those who were smart, were thinking I can I can fiddle with this system, I can set my duration of insulin action at two hours, because then at two hours if I'm high, now the pump will give me more insulin and ooh, this definitely is what I want to do. But all you're really doing is you're tinkering

Scott Benner 9:00
you're talking to Bolus calculator into believing there's no insulin there so that it will suggest more insulin based on the on the blood sugar. Yeah, I during my most aggressive times, just using a manual Omni pod with Arden. I think I had her insulin action set it three hours at one point because no matter what I wanted the Bolus calculator considering the carbs that were there and no matter because I knew our settings were good. And that wouldn't be stalking if I did that. Yeah, I hope people understand. What we're saying here is that that insulin on board in your pump is really just a calculation made based on what you tell. The pump your insulin action time is now some of the algorithms I would imagine you can't manipulate that nominee pod five for example. It believes what it what it believes. Yeah.

Jennifer Smith, CDE 9:51
Omnipod five is interesting tandems control like you. It's a hard set five hours with the algorithm enabled. Okay. Omnipod five has an allowance for duration of insulin action to be adjustable by the user. Okay, it's only going to reflect boluses that the user drives. So if I take via Omnipod, five suggestion to units right now for the food that I'm going to eat, that has, with a calculation, let's say I have my duration of insulin action set in the system at two and a half hours. So at noon today, two units, two and a half hours later, by 230, I should technically have no iob left from this driven Bolus. However, as we know, algorithms have their own output. So at 230 in the afternoon, maybe I was higher, and the system accommodated and gave me a little extra nudge of insulin. There might at 230 still be iob. Coming from what the system is driving out, but no longer from that nude Bolus. Does that make sense? Yes, it does. They are manipulatable in some of the poems. So

Scott Benner 11:05
if you don't want to get into all of this, and you just want to understand duration of insulin action? Are they different from like is Novolog and a Piedra? Are they different? Or do you you don't think about that you just think of faster acting as faster acting right? Right,

Jennifer Smith, CDE 11:19
rapid acting, the Nova log, the Piedra and the human log, those three which are all classified, just normal, rapid acting's, they do have a similar enough profile of starts here, peaks here finish action by about, they say three to five hours, which is, I mean, two hours is a good difference in time, right? But by about five hours later, the expectation is that those are cleared from the system, the more rapid acting insulins, like fee ASP and the loom job, those tend to have not only a faster onset, but because so they end up having when I used to be asked by loved it, it had a really nice, flat, complete, very visible finish. There wasn't this little trickle action, kind of nearing to the end, when it was done. It was done, it was very easy to see, in terms of a P dry No, their initial when they came to market, their big thing was that you could really, it seemed to be almost like they were saying it was a much more rapid insulin, because you could take it either at the start of the meal or 20 minutes into the meal. And you'd have the same blood sugar management. Now there.

Scott Benner 12:25
I tried that. Yeah. Arden you said I don't I don't find that to be Charles now. Yeah. I mean, in fairness, if you mean and knock over 200 It does that pretty well, you know. Sure. Right, right. The way I've always described a pager is that it's very consistent and stable. Throughout the Bolus. I don't see any like crazy hot moments where it's burning, like extra unit. I mean, like is like, Wow, it's really working right now. Like it just it starts to work. And it continues to work like that. And I don't have any trouble bolusing then for the next thing, and seeing some crazy, like hot flash where it makes you super low out of nowhere. It's very consistent and stable for Arden. Yeah,

Jennifer Smith, CDE 13:08
I was gonna say and it was the complete opposite when it came to market. I really wanted to try it was not that way for me at all. Funny, it seemed to work well, initially, but if I used it at I was using a lot of extended boluses. It did not work well in extended Bolus is for me at all. That's interesting. It almost it was like the extended portion that was getting dripped in had not the right amount of action. I gotcha. Compared to my long term used homologue. So again, person to person

Scott Benner 13:39
person, but yeah, okay. But we understand what duration of insulin action is. Did we miss anything there was well defined. I mean, I feel like we talked way more about it than most people do.

Jennifer Smith, CDE 13:51
One thing people are probably considering it, we talked about some of the variables were you wouldn't really want to expect to need to change it, right. But one way to test it out if you're kind of curious, because our rapid insulin is really meant to cover what, what macronutrient carbohydrates. That's it? Yeah. So if you really wanted to test and see with a known nice Basal setting, you could certainly just eat the way out, get a 15 gram portion or a 10 gram portion of carbohydrate, take whatever the dose is supposed to be for that expect by about 90 minutes, you're probably going to be peaking. insulin action should have kind of a bell curve where your blood sugar goes up, you peak at a certain place my plateau for about 30 minutes and then it should curve back down to get you close to where you started. Before you ate whatever it was. That's a good way to kind of see where does it finish? And does it stay stable then Right.

Scott Benner 14:47
Okay. Very nice. Thank you. Yes, excellent.

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 15:56
Yeah, 19 years?

Scott Benner 15:58
What was your management style when you were diagnosed?

David 16:00
I use injections for about six months. And then my endocrinologist at a navy recommended a pump.

Scott Benner 16:06
How long had you been in the Navy?

David 16:08
See eight years up to that point?

Scott Benner 16:10
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 16:18
I was medically discharged. Yeah, six months after my diagnosis.

Scott Benner 16:22
I don't understand the whole system. Is that like, honorable? Yeah.

David 16:25
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

Scott Benner 16:37
reasons, and that still gives you access to the VA for the rest of your life. Right?

David 16:40
Correct. Yeah, exactly.

Scott Benner 16:41
Do you use the VA for your management? Yeah,

David 16:43
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 16:57
Was it your goal to stay in the Navy for your whole life, your career? It was? Yeah, yeah.

David 17:01
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 loved the most. So that's what made it that much more difficult

Scott Benner 17:17
was the Navy, like a lifetime goal of yours or something you came to as an adult,

David 17:21
lifetime goal. I mean, as my earliest childhood memories were flying being a fighter pilot and specifically being flying on and off aircraft carriers. So you know, watching Top Gun in the ad, certainly a

Scott Benner 17:34
weight was a catalyst for that you've taken off and landed a jet on an aircraft carrier,

David 17:38
hundreds of times.

Scott Benner 17:39
Is there anything in life as exhilarating as that? No, but

David 17:43
there there's a roller coaster I wrote at, I think it was it's 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 18:01
gonna guess you own a Tesla.

David 18:04
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 wife says I drive like a grandpa on the five miles per hour over the speed limit person. No more than that. So yeah, in the car. I'm boring Scott. So

Scott Benner 18:18
you've never felt a need to try to replace that with something else.

David 18:22
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 18:32
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 18:42
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 I 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 19:15
Do you fly privately now for pleasure?

David 19:18
I do. Yeah. One of my favorite things to do is fly my kids to the different soccer tournaments I 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 19:42
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 19:49
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 were 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 20:56
Have you had success with that? Do you feel like you've made the transition? Well,

David 21:00
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 comes in 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 21:29
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 21:58
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 of a 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 an example. We're at a soccer tournament up in Raleigh, this past Saturday and Sunday. And the referee came over to my son Charlie at the end of the game and said, Hey, I noticed you're wearing pomp. And he lifted up his 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 this gentleman 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.

Scott Benner 23:18
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 23:27
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 to 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 23:49
mentioned that your son wanted to be a pilot. He also has type one diabetes, how old was he when he was diagnosed,

David 23:55
so Henry was diagnosed when he was 12 years old. That was just at the start at COVID. We were 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. How old is he now? He's 15 years old now,

Scott Benner 25:01
when's the first time he came to you? And said, Is this going to stop me from flying? Almost

David 25:07
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. So I saw that same excitement in his eyes because like me, you know, he can be an F 18, 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 25:52
I appreciate your sharing that with me. Thank you. You have four children, do any others have type one?

David 25:57
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 26:11
I see. Is there any other autoimmune in your family? There isn't I'm really the

David 26:15
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 with celiac, thyroid, anything like that. Not at all. Nothing. We're really a pretty healthy family. So this came out of nowhere for myself and for my two sons.

Scott Benner 26:38
That's really something. I appreciate your time very much. 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