#423 Defining Diabetes: Insulin Deficit

December 27, 2020Scott Benner

Scott and Jenny Smith define diabetes terms

In this Defining Diabetes episode, Scott and Jenny explain Insulin Deficit.

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Scott Benner 0:06
Hello, everyone, and welcome to Episode 423 of the Juicebox Podcast. On today's episode of defining diabetes, Jenny Smith and I are going to define insulin deficit. Today's episode is part of the defining diabetes series, which lives here inside of the Juicebox Podcast. It's where Jenny Smith and I take terms from your life with type one diabetes, and explain them in ways that we hope make them useful, and understandable. Myself friend, Jenny Smith has had Type One Diabetes since she was a child, I think for over 31 years now. Jenny holds a bachelor's degree in human nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian and certified diabetes educator and a certified trainer on most makes and models of insulin pumps, and continuous glucose monitoring systems. And she used to be one of Santa's elves. Please remember, as you listen that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan are becoming bold with insulin. Now the music will build to a crescendo and we will begin.

This is going to be probably a pretty simple one. And it might not take a lot of talking. But I do want to I do want to give it its own space. Define insulin deficit? How do you think of it? If I say those words,

Jennifer Smith, CDE 1:42
I think it could be defined in a couple of different settings. And insulin deficit is easy to decide to eat whatever you're going to eat, you just don't take insulin for it. So there's a deficit of insulin nearly right. There could also be an insulin deficit. And this one, I think, is harder to determine how much insulin you need to correct and right, the situation of insulin loss is when you have someone using a pump, and the pump site has failed. But you don't quite know that that's what's happened. You're like doing all these extra things, your bolusing extra you're trying to like fix the high blood sugar. And finally, you realize, Oh, my pump site is all wet, or I smell insulin or Oh, look at that my pump site was like kinked instead of you know, when I took it out, that's a harder deficit to repair. Because you're not quite sure. How long is the deficit been going on? How much of the Bolus two hours ago actually went in? Did any of it go in the my blood sugar is here. So that one's I think, a little harder to take care of. But a deficit I mean, it's you're just you're missing insulin Bri has to do with like figuring out where you didn't get insulin.

Unknown Speaker 2:57
That's the reason we're

Scott Benner 2:58
in the situation scenario when your pump site goes bad. I sort of just looked back on as the Dexcom. So it's easier, but I sort of look back at where I start seeing that drift up and up. And if I think to myself, well, that was two hours ago, and she's 225 right now. I just act like none of that insulin that I thought I gave her exists. And I go pretty hard at it and and just try to start over again. I am such a big fan of like, crush it. Stop it start over again. Because I think it's time saving. Yeah, you know, and I and I don't like the idea of I don't know, I know, this is probably completely backwards from what most people get told. But if you have a 300 blood sugar, and it takes you six hours to bring it down. I don't know. That just seems

Jennifer Smith, CDE 3:45
that's a long time of feeling like crud. Yeah,

Scott Benner 3:47
yeah, that doesn't seem right to me. And I don't make a habit of dropping Arden's blood sugar like a stone. I'm not I'm not saying that. And I don't think that's good, either. I'm just saying that if I see that drift up, and it's been an hour, well, then I think all right, an hour ago, she stopped having enough insulin. But the truth is, though, is that I have the comfort in my head to know that her insulin is being used correctly, or it's been set up correctly, so that at any sort of a drift up. I don't think of as an anomaly, I think of it as something went wrong in the process. But that's because I have the confidence to know that the process is going to go the way it's going to go. It's tougher for people who are who are still getting things right or chasing things around. That's a horror that I have trouble putting into words like what does it feel like when something's happening inside of your body and you don't know what it is? Correct. And how do you make the next step? And I do see how people get to while Just wait.

Unknown Speaker 4:50
Right? You know,

Unknown Speaker 4:50
right. So,

Jennifer Smith, CDE 4:52
I mean, that's a really valid point to bring up is, if you're going to be as you coined the wonderful term, if you're going to be with insulin, know how your body responds to it, you can start to learn that, because you have things for art. And so well set that you can say, she wouldn't be drifting like this, I know that there's something not right here, I can add this much more insulin, I can attack it, I can avoid being 300. And if you do it with the pump and the pump site, she just keeps going up. Well, you're going to change that out, you're going to stop it again before and you might like me, I usually just do an injection. I'm not going to wait around for a pump site to start absorbing. Well, I give an injection and I take care of it. Yes. Who, like you said who wants to sit at 300 for six hours,

Scott Benner 5:37
right? You have some sort of a deficit fix. The issue is you can come in inject a correction I always like do like a Temp Basal increase to to kind of get the site moving. And then you're on your way again, I don't think we've experienced a site change high blood sugar in a very long time, because I don't even bat an eye. Now last night we changed Arden's pod and her blood sugar was like 85. And I Bolus the half a unit just because we changed the sight. And and didn't think anything of it. But but but to dig in farther for insulin deficit, like you can have a deficit at a meal, right? Like you could need four units us three, three units, that'd be a deficit of your meal Bolus. I see people whose basil rates are sometimes really steady. Like their their lines are steady, but they're higher, like oh, look how steady I am. But I'm always 140 That to me is a basil deficit. You don't have enough basil, unless you meant for your blood sugar to be at 148. And then even with corrections, you know, like we talked about earlier with, you know, with your with your ISF for your correction factor, you if you You're too late there, but when you're missing in all of those places, these deficits have different impacts, right, like so your basil depth, your basil deficit keeps your raised higher. If your meal deficit, if you have a meal deficit, then you're going to shoot up after you eat. And if you have a correction deficit, you're going to stay up longer, once you're up there and, and all of those things are really just to say that you have to use the right amount of insulin at the right time. And if your blood sugar is high, you probably don't have enough insulin. But a lot of people have deficits. I don't know if this is the right place to talk about this or not. But in the last month or so, since I talked to you last. I've helped to people with control IQ. And I did it blindly. Meaning that I have never seen the settings on control IQ. I don't know what the menu looks like, I have no idea. But I followed their Dexcom. And I said I'm going to talk to you, in my words. And we'll translate them to what you see there. And I was able to get two people's graphs level lower. Yeah. So it was all I almost just did it for fun, which I think says something weird about me. I was like, I wonder if I could do this. And I started with the one I said to the wrong one. I'm like, I have no idea what I'm doing. I'm like, I'm happy to like be a sounding board for you. But just remember that everything I say is going to be a gas, I have no idea. But in the end, it didn't matter. It was all the same. You know what I mean? Like it just you need more insulin here lessons on here. You don't Pre-Bolus you have to Pre-Bolus it was all the same stuff. Right?

Jennifer Smith, CDE 8:25
I think something too. And you bring in like good point about like, Where did the deficit kind of start and you know, with your initial if you're sitting nice and stable, but at a blood sugar 140 or even 150 or whatever, and you're flat and stable at it. What I always recommend to people is, was it flattened stable at a lower number and then you ate and then you got to the 140 or 150. And it never came down after that. Yeah, because that's the not necessarily relative to the basil. That's the Bolus problem. Right? Right. So sometimes it takes like, you have to take a couple steps back to look at where does it look like the deficit kind of got going? Because somebody might think in the scenario of Oh, it's 140, but it's flattened. I'd rather it be at you know, 102 and flat. I'm going to dump more insulin in here. Well, what if you start at 102 then and that basil hike that you popped in? isn't quite right, it's too much but you didn't realize you needed the insulin before that. So

Scott Benner 9:25
yeah, I will probably this will just end up being a different kind of an episode than I thought but I'm so where I go when I see somebody grant for the first I listen, you show me a 24 hour graph. I can fix your blood sugar in about four hours. Like that's how it is right so but the first thing I look at, if I see a graph that's kind of up and down my first question is always are you feeding insulin or stopping highs? Right? If you're feeding insulin I it makes me leap to your base was too strong. If you're always stopping highs, and everything's else faded away from where I where I want it to be. And I'm thinking about 85. When I'm looking at it, then I think, okay, where we'll start is, we're going to pick one basil rate, yep, I'm going to bring everything down, try to get it flat. And then we'll identify spots on the graph where maybe you need less or more overnight or etc, that kind of a thing for basil. And then once I've got that, then we figure out the Pre-Bolus time, you know, and yeah, and I'm, like, Look, you have to Pre-Bolus it's just not going to work. Otherwise, after you've got the Pre-Bolus time, then we work on understanding like the glycemic loads of different foods, and then you're kind of done. Like, I don't I listen, we're stretching this podcast out.

Unknown Speaker 10:43
It doesn't need to be rocket science,

Scott Benner 10:45
get your basil right. Pre-Bolus your meals, understand the impacts of foods, go live your life with diabetes. Right? Right. Like it kind of is like that. But it's fascinating to have that conversation. And you know, just as well having a conversation with a person and watching them have all their different aha moments. And, and they see all the things that they thought they were seeing that weren't right. And you're right, they can they never seem to be able to step back far enough away to see the whole, the whole picture, you know, right. It's really interesting. Okay, do you do it? Similarly, you do it, you do it like

Jennifer Smith, CDE 11:18
I do? Well, we do, actually. I mean, you're you do it kind of, really in the same scenario that we essentially we look for, we look for the lows, we always want to get rid of lows to begin with. Because if you're constantly feeding extra insulin, you're creating a lot more of the roller up and down, because you're constantly adding, and then you might be correcting, and then it's dumping you off, and then you're feeding that incorrect. It's just this never ending cycle. So we avoid the lowest first, even if it means adjusting things to a little bit higher to begin with, to get rid of the lows, and then we can bring that down. Once it's more stable, you can easily bring that down once you're not adding in all this extra food that you didn't really need.

Scott Benner 12:02
Do you find that it's harder to talk people into believing that their Basal is too low? If they're experiencing lows? Yes, like, like when you say to somebody, Hey, your Basal needs to be higher, they're like, No, I'm low all the time. Like if you're low all the time, because your base was too low, or over bolusing for food and you're crashing for the foods out of your system, and then they're gone, then their minds are like, Oh, you know, like, No, no, we're gonna make the basil higher, so that stable times are lower so that meals aren't as impactful on your system, you'll see and it that's a hard thing to talk people into believing it is it that's that's always interesting.

Jennifer Smith, CDE 12:40
It kind of it kind of goes right along with like, it's not really insulin deficit, but it you know, in a way, it's sort of robbing Peter to pay Paul, insulin in one place for insulin and another one place is wrong. And the other one, you're compensating and feeding with more insulin because the other place doesn't have enough of it. So if you get it smoothed out, yeah, then you got this nice, like, you know, but because

Scott Benner 13:06
we need to librium when you do that, when you have it unbalanced like that. To me, the biggest problem it causes is extra Bolus that's still available after food is digested constantly Yeah. And then you're crashing, and then you're feeding the you feed that insulin, and then you fly back up again, then you're correct and crash and then and it's just, it's fascinating to watch people. It makes me better at it to watch to watch it go wrong for people. Because the more that I can look at it, and just say like, Oh, just do this, this and this. It's it's great practice for me every time like, like my wife has said to me one time, she's like, the podcast reaches so many people at this point. She's like, Why are you like, you're giving a lot of time talking to like, one person at a time. Like, no, I'm learning. Like, they're getting help. That's what they get. I'm like, but I'm getting better at it. Like, right, like, by doing you learn? Yeah. So it's Yeah, it is really interesting.

Jennifer Smith, CDE 14:02
Yeah, I think it's, um, it's the way that and that's why I always bring up people's graphs when I'm talking them through adjustment, and why do I see the things the way that I am seeing them, because going forward, I want you to have that tool. I mean, as much as I love all the people that I work with, I want you to be able to have these tools in your own toolbox and go on your merry way. And

Scott Benner 14:24
Jenny can't sit in the matrix and just with a thing plugged into her telling you all how to take care of your ledger for the rest of your life. So it's funny. What I do notice, too, that some people are just in general. So like, I don't, I can never tell if it's they're scared or they're so sure that the things that they figured out are right. But I end up saying to people a lot of times privately, listen, I appreciate what you're thinking here is like but you're just wrong. And you got to let it go. You know, because you just you're fighting and you're wrong. Like I just try this once and see what happens. Yeah. I think

Jennifer Smith, CDE 15:00
it's many of the people that I see that more so in are those that have some pretty significant like hypo anxiety, they're very, very, very worried about having a low and many for good reason they've had a very significant problematic event happen, or, you know, EMTs coming to their house or,

Scott Benner 15:26
you know, be that's a good reason to be scared treated

Jennifer Smith, CDE 15:27
with it, right. I mean, there are a lot of reasons to be scared. But I think I see that a lot more with that group of people with diabetes. Well, I'm talking

Scott Benner 15:39
about that. And I mean this with love, but the Type A lunatics that are just trying to control like everything. And I'm like, Yeah, like you're trying to control six things you don't understand, which is, you know, who's particularly. And I mean, this again, would love particularly bad at this, nurses. I'm not a nurse, nurses and nurses who have kids with diabetes, are particularly thrown by diabetes. It's really interesting. Like, like, I listened had it happen once, twice, three times, I'd say, okay, maybe I'll make it up. I'm on my 30 100th nurse who all react exactly the same way. Like, I think that they're so accustomed to this, the order that they follow at the hospital, not really realizing that that hospital orders just really in place as somebody doesn't drop dead or get too low. It's not really about managing diabetes day to day. But yeah, they're they're the hardest to break free. But once they break free, boom, then they've got it like because then they can use that order that they that they're accustomed to in the right way. It's interesting. It really is interesting how different people react differently. If you'd like to learn more about what Jenny does it integrated diabetes, go to integrated diabetes.com.

The podcast has a private Facebook group that you can find, you know, on Facebook, it's called Juicebox Podcast, and then there's a colon and then it's type one diabetes. There's also a public page called bold with insulin. I'm on Instagram to just hit 10,000 followers there. It was kind of cool because I'm not very good at Instagram.

What a salesman I am. Hey, would you like to see an Instagram page? That's probably not good. Go to Instagram. Juicebox Podcast is sponsored by the Dexcom g six continuous glucose monitor and you can learn more@dexcom.com forward slash juicebox. We're also sponsored by the Contour Next One blood glucose meter. Check it out at Contour Next one.com forward slash juicebox. Want to get a free no obligation demo of the Omni pod tubeless insulin pumps sent right to your home. You can do that at my Omni pod.com forward slash juice box. Learn more about g vo Kibo pen at G Vogue glucagon.com forward slash juice box support my favorite type one diabetes organization at touched by type one.org and follow them on Instagram, and Facebook. And if you'd like to support type one diabetes research that makes a real difference. Check out T one d exchange.org. forward slash juice box. Let me do a little bit of talking for the podcast itself here at the end. As the year winds to a close there's one more episode left. But if you want those diabetes pro tip episodes, go to diabetes pro tip comm or head back to Episode 210. Your podcast player that's where it starts. Diabetes pro tip newly diagnosed we're starting over Don't miss the after dark series. Any of the episodes that are titled after dark and then something else. They're incredibly interesting and topics that people don't talk about very often. More recently, we have type ones who've experienced heroin addiction, believe me it depression, bipolar disorder, divorce. They talk about having sex with diabetes, smoking weed drinking, look for those episodes in your podcast player there after dark. And then you know other words. If you're interested in algorithm pumping, I have a whole series on it. Episode 227 is where it starts with diabetes concierge from there 250 to 304. And then the great three parter Fox in the loop house episodes 312 313 and 420 with Kenny Fox. We even have an episode about the mini med 670 G. Jenny and I talked about that Episode 326 and the blog looks pretty great too. You should check it out at Juicebox Podcast comm or anything else? Oh, no, I don't want to tell you about that yet. How about this juicebox Doc's dot com Have a great endocrinologist or diabetes practitioner or need one juicebox docs.com. Alright, that's it. One more episode left in 2020. It's kind of a relaxed conversation between Jenny and I, I started the year with Jenny. I wanted to end it with her

without them, without the talking overtop of the add music, you can see how incredibly repetitive it is. Isn't that weird?

But if you just talk over top of it, it's kind of handy. Learn more at my omnipod.com forward slash juicebox. See, then it really comes in, then it really does the job. promise that now you want to just chill with me. We'll do the end here. Change this here a little bit. I can tell something's gonna happen. I'll be back soon with another episode. Thanks so much for listening, for sharing the show for leaving great reviews. Wherever you listen. And if you're listening online, find yourself a nice podcast app and subscribe to Juicebox Podcast is available everywhere you get your audio