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Scott Benner 0:00
Hello and welcome to the fourth installment of my series entitled diabetes pro tip. In this episode, we talked about something so important it gets its own episode, and what could be that important Pre-Bolus thing. Today I'll be joined again by Jennifer Smith. Jennifer has been living with Type One Diabetes since she was a child. She also holds a bachelor's degree in human nutrition and biology from the University of Wisconsin. Jenny 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 monitors. And I love the way she thinks about type one diabetes. If you'd like to get one on one coaching with Jenny, you can go to integrated diabetes.com. To find out more. Before we get started, I'd like to thank the sponsors of the Juicebox Podcast. Today we're going to be talking about Dexcom on the pod and dancing for diabetes, you can find out more about the sponsors and about Jenny, in the shownotes of your podcast app or at Juicebox podcast.com.

Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And always consult a physician before becoming bold with insulin or making any changes to your health care plan. Now let's talk about the most important of important things, making sure your insulin is well timed with your meals.

In the episode about insulin, I told you that that my nurse practitioner CDA told us that fear of insulin was the biggest sticking point for people making good decisions with their diabetes, right. And after I got past my fear of insulin, the next hurdle I had to get past was Pre-Bolus. And I am now years and years later at a time where I will tell you that if you do not Pre-Bolus a meal, the likelihood of success is near zero. And if you have success without Pre-Bolus, saying.

All that means is that you gave yourself too much insulin prior to that. And it's just catching up now. And so this is it. We're going to talk about Pre-Bolus. And we're going to talk about how about insulin action, right the action of the insulin and how to balance it against the impact of the carbs or your body function. So tell me, let's go over the part that people aren't going to find comforting at first, right, which is, the amount of time it takes insulin to begin working in a person varies person to person and insulin to insulin. Is that pretty fair to say?

Jennifer Smith, CDE 2:58
It's pretty fair to say yes. And insulin to insulin. I would definitely say most of the rapids on the market should be fairly similar. The rapid acting influence on the market and their time of action should be fairly similar now. person to person. Yeah, that may vary situation to situation as well, creation to situation, it may vary. But again, that's the learning part of it.

Scott Benner 3:27
Okay, so person, the person could end up meaning just your body chemistry could mean where your infusion set is, right, you know, or your injections, right? Absolutely, yeah, you're a person who gets stuck on, I always injected my belly in the same place, that spot might not be as reactive to the insulin as if you would just try a new spot. If I went to a new spot, it might work quicker than it has been in your old spot. Right? If you're wearing an infusion set, it could and we alluded to it before you could get better action from your insulin on day one than you do on day three or better on day two, then, you know, two hours after you've put it on, there's a lot of different variables. But we're speaking generally here to you, you'll apply them to your variables later. Now, if you've heard this podcast before, you'll know that I have alluded to how insulin works in a number of different ways. So I'm gonna give my kind of cartoony description of it, and then we're gonna let Jenny talk about it for real,

Jennifer Smith, CDE 4:24
or 2d might be better as

Scott Benner 4:25
we'll see. So here's how I pictured my head a couple of different ways. The first way is I think of a tug of war. And I imagine a rope with a with a flag hanging in the middle of it. And on one side of this tug of war rope is insulin. And on the other side is your carbs and your body function. It could be adrenaline, it could be fear, it could be anxiety, whatever it helps to drive your blood sugar up. That stuff's on one side of the rope. The insolence on the other side. Unlike a tug of war in a school yard, our goal is not for one side to win. Our goal is for them both to pull and pull and pull until they get it exhausted, they both go, I can't do this anymore, and they drop the rope and our flag still in the center. That flag represents the blood sugar. You start at when the impact of the carbs begins in my mind. So I'll explain a little more. If you let them both start pulling at the same time, the carbs are generally speaking going to gain power and momentum before the insulin begins to work. So now your rope is going towards a high blood sugar and you're starting to head up. Now suddenly, you're 50 points higher. And what if you started with 150 blood sugar, now you're at 200. And now these carbs have momentum, they have speed, they're pulling your blood sugar up. Now, all of a sudden, 15 2030 minutes later, the insolence like, Oh, no, wait, I have a job to do. I remember and it kind of comes online. But now it's pulling, it can overpower the the momentum that the carbs have created. Plus, you now have another hundred points of blood sugar to contend with. And all you have is the insulin that you counted your carbs for. So even if you counted your carbs perfectly, and realize that this meal is five units, once the momentum of the carbs is rocketing your blood sugar up, once you have a number that is higher than you started with those five units, are not even going to begin to cover what's happening, let alone the food that you've put in. But if you put the insulin in first, and let the insulin come online slowly and begin to pull down and create the momentum in the other way, then you flip the script. And now the carbs are fighting. So instead of having a fight at 180, blood sugar, you're having a fight at an 80 blood sugar. And instead of your blood sugar falling at 80, it's being the attempt is that it's now trying to be pulled up by the carbs. And that's how when you see people with a stable graph, that's how they're doing it. And so for me, in a perfect situation, for me, my daughter's blood sugar is diagonal down when I give her most foods. Mm hmm. There's differences, you know, food to food, situation to situation, but in a perfect world. To me, that's it, you want your insulin working, your blood sugar trending down, creating some momentum down, when you allow the carbs to begin to pull up. Now, you explain that in a technical way that sounds

Jennifer Smith, CDE 7:28
and in most in most settings, yes, that's 100% I mean, insulin, our rapid, I've always thought that rapid is such a misnomer, honestly, rapid indicates like now rapid is like, you know, click, click, click lights with design, it's working. And it's, you know, still education is take your insulin and start to eat. I mean, even from most endo offices, it's take your insulin and start to eat, it's going to be working very, very quickly. That's not the case. And anybody who has been taking insulin long enough, and you've seen the spikes, and you've seen the issue is despite counting your carbs as precisely and weighing them and everything, and you're still seeing these issues. It's the mismatch of insulin timing, it is so rapid take anywhere between about 15 to 30 minutes to really get that active peak, not peak, but that active phase where then when you start putting your carbs in. They will match as you said that carb digestion will start to match with the insulin, you'll get a nice gentle curve up. And it should then start to curve back down. There is a lot of there's a lot of education that also focuses on, as you mentioned, watching for that curve down, watching for the curve down to start so that you know the insulin is already moving thing. Yep.

Scott Benner 9:04
Yeah. And to give you some context, the person I spoke about in a previous episode, who was having trouble, told me but what am I gonna do, I'm gonna be scared. I said, Well try it a little bit this time, and then a little more next time and a little more next time and go forward. And, and so I always tell this story somewhere. And I think here's the right place to tell it prior to glucose sensing technology being a thing that anyone knew about, but prior to, you know, Dexcom, I was again in the office and the CD says to me, hey, you're going to get one of those Dexcom things and I thought, I don't know what that is, you know, and she starts telling me it's it's a continuous glucose monitor. And I'm like, I again, don't know. And then she tells me this simple story. There's a 17 year old boy in our practice, who loves candy, certain kinds of candy and he can't figure out how to bowl with it. So he gets a dexcom whatever the first one was, I don't even remember anymore. His whole goal was to eat this candy without a spike. So it goes out to the store. And he buys like little grab bags of these candies and a number of them enough for a week and every day starts on this experiment first day, just like you said, eats, gives himself as his insulin, just like he'd been told his whole life, blood sugar goes up to 20, something like that sits there forever. Eventually, he has to give himself more insulin to bring it back down again. Next day, he tries a little sooner, give himself a few minutes, 510 minutes gets a little less of a rise. So the next day, he goes even sooner. And then before you know it, it's a little sooner, a little more, and he starts adjusting it back and forth a little more, a little sooner, a little later, until one day, he eats the candy. And his blood sugar never moves. And she tells me that story. And I thought immediately Wow, that means it's possible. Yeah, that was the first time I thought I was like, if that kid can do it with candy. I can do it with anything. Like anything, right? And so yes, give me that CGM. Please. And I got it. And I and I started, you know, dispense with my fear. And I started learning about it. There were hiccups along the way, right? I've given her insulin, and she's gotten lower than I meant to for two when she's eating. But you know, once twice, I'll go back to this over and over again, when something goes wrong. It's not a mistake. It's a learning experience. It's data for next time, right? Right. So I put the insulin in, and she goes down to 70 and sits at 70. While she's eating. It's beautiful. You know, like, there she goes that and then and then then a spike. Even if I really messed up on the amount of insulin I used a spike takes you to 120. Right, right, right. It's not right. It's just, it's all about that timing and amount. And I repeated over and over again, that you all the things you and I are going to speak about all the things that people hear about on this podcast, if you want to know how to use your insulin, at its core, the very first step is timing and amount. If you get used the right amount at the wrong time, you can use the wrong amount at the right time, that it's too much if the right amount of insulin at the right time, you have to balance the action of the insulin against the impact of the carbs. If you do that, I don't want to say it's easy, because that's insulting to people. But let me just say I don't think about diabetes that much anymore. It's easier, it's much easier if you do that. It is easier. Absolutely. And it's a lot more.

Jennifer Smith, CDE 12:26
It gives you a lot more visual than to understand. Because it's not so much of an unknown well, gosh, I counted the carbs, I took the right amount of insulin and this is always happening to me. Why. And if you can start to put those pieces together, it's not a y anymore. It's like turning the light bulb on. Here's how I explain what Jenny just said.

Scott Benner 12:53
The dexcom g six continuous glucose monitor gives you a complete picture of your glucose showing you where it's going and how fast it's getting there. There can be nothing more important. The dexcom g six also eliminates finger sticks for calibration, diabetes treatment decisions, and diabetes management. It also has an automatic inserter. Like it just you know, you stick it on and you push the button and the next thing you know you're wearing it. Now you can use the dexcom receiver to get the information from your transmitter. But for those of you who enjoy using your cell phone, it works great with iPhone and Android as well. The last little thing about Dexcom isn't so little. How about the share and follow features also for Android and iPhone, your loved ones can follow your blood sugar anywhere in the world. And if you're the parent or a caregiver of someone with Type One Diabetes, you can be watching their blood sugar as well. You want to know what Arden's blood sugar is right now. It's 82 just glanced up and saw it just like that. Now my results are mine and yours may vary. But my daughter's a one C has been between 5.2 and 6.2. for over five solid years. The decisions we make about how to give my daughter insulin and when to give it to her come directly from the data that comes from the dexcom g six. And I don't know if you know this or not, but my daughter does not have one dietary restriction. Those numbers are accomplished through waffles, just as well as through salads, through burgers, just as well as through zucchini. It doesn't matter anything that impacts my daughter's blood sugar. That impact is shown to me by the dexcom g sex and then I make good decisions. You want to make some good decisions, go to dexcom.com forward slash juice box and get started today. That's the best decision you're ever gonna make. This is a short episode and I don't want you to have to have to add breaks. So hang on for me for one more second. Let's talk about Omnipod. This past week I visited the AMI pod headquarters in Massachusetts where they've just moved their production facility. It's about to go live and I got to tour the floor where you're on the pod You're going to be made from now on, right here in America, right in Massachusetts, I want you to know that what I witnessed in Massachusetts on that assembly line, it didn't just renew my excitement about on the pod, it shot me over the moon, the accomplishment of bringing a production like that into one facility, putting it under your roof, that showed me a real commitment to the people living with Type One Diabetes. Right? This isn't being made overseas somewhere or you know, a bunch of different factories. It's all right there at the Omnipod headquarters, and it's state of the art is absolutely stunning. This is a company who is behind you for the long haul. I believe that before but I believe it even more. Now, here's what you want to do, go to my omnipod.com Ford slash juicebox. Or click on the links in your show notes or Juicebox podcast.com. When you get there request a free experience kit. That's right, a pack a pod experience kit on the pod is gonna send you a pod that is an exact replica of the one you'll get when you start using the product for real, but this one's non functioning. And so it's safe to wear for you to try out, you'll be able to find out if you like it, where you want to wear it. And you'll notice how after you've had it on for a little while you don't even remember that it's there. Miami pod.com forward slash juice boxes links show notes at Juicebox podcast.com.

Last thing, don't forget dancing for diabetes that's dancing the number four diabetes.com. It's the little organization that does a ton of good for a lot of people living with type one, they're on Facebook and Instagram, and it dancing the number four diabetes.com check them out. Here's how I explain what Jenny just said. I think of it as this equation that it's a mathematical equation that doesn't have any math in it. I did this. That happened. So next time, I'll do more or less sooner, you know, a little less a little more, that kind of thing. And I always just I always just keep looking at it like that. I did this. And that happened. It's the idea of being in a fistfight. And you want to hit first because now you have caused an effect. Right? And if you and so now, you know, I've done something. And that's what happened next. Now I can make a good decision about what what I do next, instead of waiting for diabetes to do something to you. And then you're just covering up your face hoping not to get knocked out. Right? Like because you don't know what's happening. You don't know why it's happening, you have no context for what's going on. But when you make the first move, you can be sure that what happens next was impacted by what you did, I put insulin in 10 minutes before you ate 10 minutes before I ate. And my blood sugar went to 150. So the next time I'm going to try 15 minutes. And if it goes to 130 I might try 20 minutes. And you know, if I get low, then later I might say okay, I might need a little more a little less. Now here's where people always say, Well, how much Scott How long? You know, give me the time, give me the amount? That answer for me is always going to be I don't know, figure it out for yourself. Okay, you have to

Jennifer Smith, CDE 18:13
this is the starting place.

Scott Benner 18:15
Yes. This is

Jennifer Smith, CDE 18:15
where to start. This is how to start. You have to do your own. I mean, diabetes as a science experiment, it's a daily, I feel like every day you're almost given like this new petri dish. And you're told, keep the dots growing purple today. Okay, let's work on keeping the dots growing proponents of something green pops in. And then these like little horny pink things pop on, you're like, Ah, you know, but it is it's like, it's a science experiment that for the most part, when you figure out what does work, the timing around the most typical foods that you eat and whatnot, it takes a lot less thinking out of the equation.

Scott Benner 18:55
Yeah. And while this isn't about Pre-Bolus, and we'll come up later. But it's important for me to say because I think this is impactful when you really stop and think about your, your habits around food. They're pretty similar. Right? Right. So you know, you're not I always say like this, like, if you're a person who gets a pizza on a Friday night and has two slices. You don't suddenly next Friday have seven slices. You don't go from being a two slice person to a seven slice person, right? Like Yeah, and so, so you can start making these decisions about how much insulin and when. And you can make them based on historical knowledge about what's going yeah,

Jennifer Smith, CDE 19:33
I usually tell people as the Pre-Bolus piece you've got most people have about 20 to 25 foods that are the most common for you to eat regularly. Yeah, that's at least 80% of your control there at least. So if you can nail the Bolus timing around those and figure it out, for the most part, you know, variations in setting will happen. Whatever Ever Yeah, but for the most part, if you've figured that out, you're also much more likely to be able to figure out food that isn't your norm, because of the similarities to what you've chosen. And what you're usually eating,

Scott Benner 20:18
because you can stay flexible, I call it 60 fluid, right? So here's, here's where I'll tell people this, don't get mad. I don't count carbs. I actually think about it a little backwards from maybe how most of you think about it. I don't look at the food and say, you know, weigh it or measured and say, Okay, well, that's 25 carbs. And my pump says that, I get one unit for every 10. So that's two and a half units. In honesty, there is no accurate insulin to carb ratio set up in Arden's pump. We don't even I don't even pay attention to that. I look at a plate and I say to myself, that's seven units. I think that if she's gonna sit down and gorge herself on nachos and cheese, the last time that happened, it took 10 units. I think of it as insulin, not as carbs. And of course, that takes a little practice, right? It does, it does. And it is a little contingent on you having a CGM, I'm not gonna lie about that, right, because I start with a healthy Pre-Bolus. And healthy would mean in amount and time. And then I watch her CGM, and I don't really watch it, I have her tolerances set tightly enough that if she leaves that range, I find out about it. So as an example, if I were to give Arden something incredibly carb heavy, I might use a Temp Basal increase, and a Pre-Bolus to try to spread out the action of the insulin across this timeline where there's going to be these carbs, right? If I make a bolus, and 30 minutes after I do it, she's 121 30 diagonal up. I look at that line. And it tells me something based on my previous knowledge, it's that I say to myself, ooh, this I missed, like, this isn't enough insulin, and I will give her more I will bump it and nudge it back. It's not a ton more, it's enough to stop the arrows.

Jennifer Smith, CDE 22:16
Right? And the arrows are very important to bring up in this in this as well. Because if you are using a CGM does arrows do indicate a rate of change? And again, that's not something that most people realize. They don't understand that and not understand.

Scott Benner 22:33
Don't tell us that

Jennifer Smith, CDE 22:34
it's that they've not been told they've not been told, hey, these arrows tell you that you're increasing by 30 to 60 points in the next 30 minutes. Okay. If that's the case, and I know what my kind of correction factor is, or whatever, I can say, Okay, I'm going to need this much more insulin, because if I don't correct my rising 130 blood sugar in the next 30 minutes, I could be 30 to 60 points higher. I could be as high as 190. I don't want to be 190 I've obviously miscalculated someplace, I can throw in a bit more insulin to counter that expected and stabilize it. Yes.

Scott Benner 23:11
Yeah. It very much. Yeah, it very much is remembering to, like I guess the way I usually say it is that you have to trust that what you know is going to happen is going to happen. Right? Yeah. You see, and and i think that the least important aspect of what the Dexcom does is the number. It's the direction and the speed, direction and hundred percent.

Jennifer Smith, CDE 23:40
I wish more please say that, again, is the direction it's the trend, it is not

Scott Benner 23:46
just the number, the numbers nice, like don't get me wrong, it's a starting point. But you know, if you're 60 and stable, and you haven't had insulin for three hours, you have had food for three hours, well, maybe you could get away with like a Temp Basal decrease of 100% for a half an hour, maybe you'll rise to 90, right. But if you're 60 and you're falling well, then you don't have enough time because as we've now discussed over and over again, insulin doesn't begin working right away. Also temp basals are insulin. It's funny how people think of bolusing and bazel is different. But once you're on a pump, it's the same thing. You can't just turn your bazel off and it starts happening right away,

Jennifer Smith, CDE 24:26
takes about 60 minutes for circulating insulin level to be different.

Scott Benner 24:29
And I always write and I always try to think of it a little bit as like Arden's Pre-Bolus time like if Arden's Pre-Bolus time is 20 minutes, well then setting a Temp Basal is not really going to start working for at least 20 minutes plus, it's a fraction of the bazel rate if if you're getting a unit an hour, and I say to it, okay, let's double it. Let's double it to two units an hour. That impact of that doesn't begin for 20 minutes or so plus, it's not the whole unit extra. It's the it's the fraction of it. So right when we talk about bazel We'll get to that. But so Pre-Bolus thing is really just the idea of balancing, again, the action of the insulin against the impact of the carbs, giving yourself a chance, not letting the carbs wash you away. Because here's what happens when the carbs wash you away. Count your carbs exactly right, you put your insulin in, you spike up the 200. When that happens, that insulin was only for the food. It wasn't for the 200 blood sugar, and it wasn't for the momentum of the rise. And so when I see that, like, I guess an easier way to say this, when when I don't have time for Pre-Bolus and Pre-Bolus. And to me is never about the number, you can Pre-Bolus a 65 blood sugar, you know, you can Pre-Bolus at 90 blood sugar, because still no matter what, if you're stable at 65, the insulin you put in is not going to start working until it starts working. So you have and so don't get me wrong. If I see a 65 blood sugar and I and Arden needs 10 units for what she's eating. I don't put all 10 units in at a 65 I might do an extended bolus which we'll talk about an extended boluses. But I get some insulin moving, I make sure the insulin is on the winning side of this tug of war to start. But in a situation where I can't Pre-Bolus let's say I know the meal is five units, hundred percent certain it's five units. But for whatever reason life, let's call it I can't Pre-Bolus and ardens. You know, I'm going to start eating right now. I'll give her seven units. Mm hmm. Because I Bolus for the food, the five units for the food I knew. And I pre buy. And I'm Pre-Bolus seeing the rise, I know is coming. And the and the number I know is coming. So I'm already treating a high blood sugar that hasn't happened yet. Because I know it's going to happen. Because I didn't Pre-Bolus

Jennifer Smith, CDE 26:54
right. JOHN Walsh goes into detail about what you're doing in a little bit of a different way. He calls it super Bolus,

Scott Benner 27:01
I call it over bolusing.

Jennifer Smith, CDE 27:02
Yeah. And he calls it super Bolus in the way that you take that five units, let's say in your example, and let's say your bazel behind that meal for the next two hours is one unit an hour, you actually take your bazel running for the next two hours, and you add it into the Bolus for the meal and you take it all up front. And then to decrease the chance of being too low later. Because of so much upfront action and the blood sugar staying normal, you actually set a temporary basal decrease, he recommends starting with 100% because you've loaded that onto the front to avoid a low but on the back end. Some people find though that attempt B is 100% off is too much. They only need a 50% they still call the spike and prevent it. But in the back end, they're not having a low then. So similar kind of concept.

Scott Benner 27:58
Yeah, I consider that trading Bolus for Basal. So so you know, say 120 diagnol, up 3040 minutes after a meal and I go, Oh, geez, I gotta stop that arrow. How much do I Bolus to stop the arrow? I usually Bolus an hour's worth of a baby of basal insulin. That way, if the arrow stops, and I stay steady, and she doesn't go down, I say okay, well, obviously, I was just wrong on the initial amount. But in those situations where you push the button, you know the unit and a half goes in, and five seconds later the error goes from 120. to diagnose the flat you go, Oh, I didn't need that. Right Temp Basal off a half hour. All I've done is trade the Basal for the Bolus. Absolutely. Here's a good place to say this. And we'll say this in each of these little vignettes. Never suspend your bazel it's always temporary basals. When you suspend you're shutting your pump off when you shut your pump off. It does not.

Jennifer Smith, CDE 28:52
You have to remember to turn it back on. Yes,

Scott Benner 28:54
yep. It's always temporary, because you can set at Temp Basal for a half an hour, an hour, two hours, but at the end of that time, it was that it'll go back on and start delivering your Basal it's always temporary Basal is not not don't suspend your pump. Okay, so I think do you think we covered Pre-Bolus? there?

Jennifer Smith, CDE 29:11
I think that's pretty good. Good. Yeah, that's awesome.

Scott Benner 29:16
Don't forget that you can work with Jenny yourself. If you want just go to integrated diabetes.com to find out how. Let's also take a moment to thank our sponsors Dexcom on the pod and dancing for diabetes. There are links in the show notes of your podcast player app, or Juicebox podcast.com. But you can always go to dexcom.com forward slash juicebox. My omnipod.com forward slash juicebox or dancing the number four diabetes.com. I hope you're enjoying the pro tip series. This was Episode Four where we talked about Pre-Bolus. And don't forget that episode one is for those starting over or just being diagnosed. Episode Two was all about multiple daily injections. Episode Three. We talked all about insulin. today of course Pre-Bolus Singh. In the next episode, Temp Basal rates huge and important and then after that insulin pumping, they're designed to be listened to an order, trust me, listen to them in order. I have just a little bit of music left here. So let me thank everyone for the great reviews and ratings on iTunes. very much appreciated.