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Scott Benner 0:00
Hello friends and welcome to Episode 440 of the Juicebox Podcast. Today's episode is the defining diabetes with a Jenny Smith.

Episode of defining diabetes is the 30th installment of the series. It goes all the way back to Episode 236 defining diabetes Bolus, and it leads right up to today, Episode 440. Defining diabetes stacking insulin. The defining diabetes series, which exists here inside of the Juicebox Podcast is me and my friend Jenny Smith. Jenny's had Type One Diabetes for over 30 years. She's a certified diabetes educator and an all around delightful person. Anyway, Jenny and I define the terms that you use in a life with diabetes. And we don't do it in some boring way. Like we're not reading to you out of it. That's not like oh, basil. Insulin is defined as we don't do it like that. You have a nice, interesting, reasonably lengthy conversation that will leave you with a full and firm grasp of the definition of the day. Please remember, while you're listening that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please always consult a physician before making any changes to your healthcare plan, or becoming bold with insulin.

At the end of this episode, I'll leave you contact information for Jenny in case you want to reach out to her where she works at integrated diabetes comm if you're a US resident who has type one diabetes, or is the caregiver to someone with type one, please consider checking out the T one D exchange. Your participation in the T one D exchange will take just a few moments, but the impact of your kindness will last forever. T one D exchanges looking for you type one adults and caregivers who are us residents to participate in a quick survey that can be completed in just a few minutes from your phone or computer. And after you've finished. And trust me, these are simple questions. I did the whole thing in about seven minutes, maybe you'll be contacted annually to update your information. And they may ask you further questions. This is 100% anonymous, completely HIPAA compliant, and it does not require you to ever see a doctor or go to a remote site. And you can opt out whenever you want. The T Wendy exchange began is a nonprofit organization focused on accelerating therapies and improving care for type one individuals. That mission emerged from a heartfelt desire to support a community in need. And the belief that the best way to do that was through a firm foundation of research and cross clinical collaborations from that foundation, the T one D exchange has become a robust Type One Diabetes data platform. And it uses that platform to drive meaningful research and innovation and treatment prevention and hopefully one day a cure. So check them out. T one d exchange.org. forward slash juicebox. So the idea of stalking insulin, I want to describe what it what it I want to describe what it is. And I want to talk about why doctors are so fervent about bringing up don't stack your insulin. And then I want to talk about using insulin in more targeted ways that I think mimics stalking to people who don't understand. Does that make sense? Okay, yeah. So So what is stalking influence something?

Jennifer Smith, CDE 3:40
Absolutely. 100%. That's the correct term. And I think it's one that crosses all everybody with diabetes, for the most part with using insulin, I think they've heard at least the term stalking. And I have not seen an endo that doesn't know what that term means. So it's an across the board understood, I hope.

Scott Benner 4:03
So and so at some point or another, a doctor is always going to tell you and I think very rightfully so. And I have to say I'm not against it. But they just say it like this, you can't stack your insulin, like you can't, because because if you do, you're gonna get super low later, and it's gonna be bad. And I don't that Listen, I purposefully stacked some insulin up on Arden last week. And I knew she was gonna get low later. And she did. But we just got into one of those weird situations where food was piled on top of a site that was bad, like so we were right at the end of a site. And everybody who uses a pump might know this, but you're like in that last, like 30 units that's in the pump. And you're like, this thing is working great. blood sugars are terrific. I can get through one more meal with this thing. And then it just doesn't work out for some reason. And you're like, Ah, so now you have this incredibly sticky blood sugar. It's higher, there's food and you're going up. You've just changed the site. So now you know there's a lag there and basil and everything and you just start like, you know, if you make a small Bolus, it just sits wherever it is 250 is still 250. And I don't want to do the like, little Bolus, little Bolus, little, but I don't stack like that, like, I'm just like, hit it hard. If nothing happens, hit it hard again, and we'll catch if we have to. But if you're not wearing a glucose monitor, or you're not aware that that's gonna happen, something bad on the other side,

Jennifer Smith, CDE 5:26
and I think you described kind of a good point, too, is that if you hit hard with some corrective, right now, you should see a faster turnaround, because you now have a larger amount of insulin to actually hit the issue, right? And then you're not saying, Okay, I'm gonna take four units right now, and then 20 minutes, if it's not moving, I'm gonna take another four units, right, that's not what you're advocating at all. It's, though, hit harder upfront, see if it's making impact, which that bigger amount should, and then you have less weight. Unfortunately, when you do these little micro pulse boluses. And for some, again, another piece to consider is sensitivity, I mean, three units for an adult who needs three units to correct a high blood sugar or a really resistant teen who might need that a little kid, I mean, that might be their whole dose and whole day, right. So you have to consider the person and sensitivity, but these little trickle boluses over like a three hour time period where you're hanging out high, and you keep adding, adding and adding, and some people get very aggressive with the adding in terms of how many, but the doses aren't very big. So you might do

Unknown Speaker 6:44
point 2.1

Unknown Speaker 6:48
out of every

Jennifer Smith, CDE 6:49
15 minutes, and you know, you can see everything in a download, obviously. But you're like, you're not gonna see any change from point one in 15 minutes, right? So but it leads to the stacking component, because the more you do these little incremental doses, now you have each of those little pulses of extra has its own timeline of finish into the future, and peaks. And that's important to understand, right?

Scott Benner 7:17
So if insulin has an initial impact, a peak and a tail, and you go making eight, Bolus is over two hours. There, all of these peaks impacts and tails happening all over you. And then once whatever's holding your blood sugar up there, abates, all these different things. Now, it's like you're being shot from 75 different angles, all of a sudden, you can't get away and blood sugar just starts falling. And then you get into that situation, where how much is going to stop this

Jennifer Smith, CDE 7:48
right? How much carb Do I need to intake now? Because how much is left? I mean, and with a pump, your pump has iob visual for you. But the stacking component makes it harder that i o b and the end effect of when is it really going to finish off? And how much do I need to take in to counter it? Is it a lot more? Is it a little bit? It it kind of is a throw your hands up in the air and just write Yes, which we don't really want to be. And

Scott Benner 8:18
so you don't want to stack and it's a it's just a bad idea if you're blind and you don't know what you're doing. And I want to say too, there's other worlds where you end up stacking and you don't mean it in a dehydrated body where you think, oh, the insolence not working. And so your stack, you know it's point, you know, like you said sensitivity could be point one for one person could be three units for another person, there could be a 250 pound adult doing three unit Bolus is every half an hour trying to change something, right. And if it's dehydrated, I don't understand obviously, the physiology of it. But that insolence in there, it's incapable of moving around, but it's still there. And then all of a sudden you get hydrated, and it all just comes at once that I've seen happen to and that's that can be frightening as well. And then again, you get that same position and people have a difficult time seeing my blood sugar's 250. I've now put in, you know, four boluses over the next over the last 90 minutes or so. And now my blood sugar's dropping like a stone, is it safe to count up those bonuses and figure out how many carbs to put in for that. That's basically what I would do minus maybe a little bit for the number, you know, so if I thought in a normal situation, it was going to take a unit to go from 250 to 90 and I ended up using four units and started falling I'd probably put carbs in for three of the units right leave the last unit to to do it. Yeah,

Jennifer Smith, CDE 9:41
we usually say about 50 to maybe 70 ish percent is for coverage. Okay. Yes. All right. I think another one in terms of stalking comes in for like sites that have been bad and you finally get it you're like okay, I obviously need to change this site will sometimes that site Like you just said it might have that depot of insolence still under the skin that didn't necessarily get absorbed the way you wanted. Thus, you've got a high blood sugar right now. But for some, when you remove that bad site, sometimes that depot of insulin leaks out, you can actually see it like physically coming out of the site when you take it out. And that you're like, Okay, well, I clearly didn't get any of that last Bolus. So I can definitely heavily correct this high blood sugar right now, because I obviously didn't get any, well, if it's not leaking at the site, you likely still have some of that insulin under the skin. And sometimes moving the site or removing that canula can for some get that kind of absorbing under the skin. And so now you've got this big amount that you've been adding for a higher climbing blood sugar, and now you've injected some or you've added a whole big bolus with your new pump site. So now you might have this like whopping drop lead, because you don't really know how much is there circulate. And that

Scott Benner 11:02
story makes me realize that stalking is a lot more scary in the beginning, before you have much time, because I remember that same thing, like, you know, when Arden was super small, we were using syringes, and I'm like eyeballing up, you know, a quarter of a unit, and, and you put it in, and you push it, and you take it out, and then you see a bubble, a big a big drop of insulin comes back out of the injection hole and you're like, ah, and then you're then used to freeze me. I was like, I now know, I have no idea what to do now. And it takes time for you to realize like, okay, and I mean, how often does the insulin leak out? But when it happens? Are you ever freaked out? I'm sure you haven't done this. But sometimes you have it. Sometimes I see people like they'll push the they get they're pushing the plunger before the before they're actually in like something out of the thing. So there's different ways and you're like, Oh, well, how much did I lose? What do I do now? It all can be confusing. And and it gives you this sort of paralysis where you know, I can't move.

Jennifer Smith, CDE 12:03
It's actually kind of one of them is kind of with topic, but sort of off topic is. I never used insulin pens. I've never wanted to

Unknown Speaker 12:11
we've never I

Jennifer Smith, CDE 12:13
don't. And I don't like them. I don't I mean, they work really well for many people. So it's this is not a don't use them. But my experience was always that I always had this background like did I get everything? Because I'd see even holding it in under the skin for 10 second count after you fully injected all blah, blah, blah. When I had tried one when they first came out on the market, I'd pull it out, I'd still have this like drop hanging from the tip of the pen. I'm like, Well, how much insulin Did I just missed? You know, what, what was the purpose of this? Now I might be a half a unit short or a whole unit short. So I think I used it for a couple weeks. And I was like, nope, so sorry, Doctor, I like my files and my insulin syringes back, please. Okay, so

Scott Benner 12:55
now the other side of it. And I've received a number of messages about this over the years, but one that just sticks in my head is from a guy who said when you said it's not stalking, if you need it, it changed my life. And so I say it's not stalking if you need it. But right what I kind of mean by that is, like, first of all, you have to be like things have to be dialed in, like your basil has to be right, your insulin to carb ratio has to be a known quantity, you have to be, you know, good at giving yourself insulin, right. But once you do that, if you Pre-Bolus for a meal, and you it's 40 carbs, and you finish it. And then 25 minutes later you reach across the table and grab a roll out of the basket while you're talking. Well, Bolus for that role, like but but there are plenty of people who would that would then think No, that's stalking insulin.

Jennifer Smith, CDE 13:53
Yeah, that's entirely not stalking. Right?

Scott Benner 13:55
Right. If you need it, it's not stalking. It's bolusing. It's you know, and so, there's, um, there's just something you have to wrap your head around there. And it seems like it's simple, but in the moment, it's not because because you could see, you could Bolus for your meal, right? And 45 minutes later, your blood sugar might be 75. And you're like, Okay, well, I'm gonna have another role, it's hard for people to then go I have to Bolus for this role because my blood sugar 75 maybe it'll be okay. And that's where you have to trust that what you know is going to happen is going to happen, which is that role is going to go in and it's gonna have its own timeline, its own life, and so will the insulin that you put in with it.

Jennifer Smith, CDE 14:35
And I think that's an important point, obviously, is that if the insulin is needed, you also should be knowledgeable enough to understand why it's needed. And along with that comes things like sensitivity, you know, your sensitivity, you know that you're not just blindly taking four units right now that this much typically brings you down by this much and if you do take extra Insulin, you should see this type of a change, if you're not seeing it, you know, taking some more, but again, not these little like pulse pulse pulse pulse.

Scott Benner 15:10
I think in the end I, I would want people to understand that the difference between just wildly throwing insulin at something hoping and purposefully using it in ways that you know, are needed. Those are two different ideas, but they both to an untrained eye or to somebody who's just trying to keep you from making a mistake, which is law. It's it's a laudable thing, but those two things can look the same. And they're not, those two things have nothing to do with each other.

Jennifer Smith, CDE 15:41
Right? So they're both stacking, right? But one is a, I'm stacking insulin, but I know how it should impact me. The other one is, I think, sort of along the same lines as like Rachel is saying, it's like, God, darn it, I

Unknown Speaker 15:58
pop it in and hope for the best.

Scott Benner 16:01
Here. Well, it's um, I think I see people it happens to people too, with new infusion sets with pumps too, because they put their pump on and they don't get, you just don't get the right reaction right away when pumps first on and then the creeping blood sugar and then the Bolus that doesn't work. And now it all feels slippery slope p but I don't I mean, when when we change ardens pump, I just put it in insulin right away. I just Bolus something depending on her situation. Right anywhere from I usually do anywhere from an hour's worth of basil to, you know, a correction with that, like, I just like to get something moving. And

Jennifer Smith, CDE 16:38
Yep, I usually say that same thing for a new site. kind of know what your basil is, at that time of the day. You know, if it's at point six, eight o'clock in the morning, it's but it's 1.2 at you know, eight o'clock at night. Clearly you're gonna Bolus a little bit different. Ours is always Bolus about an hour's worth of basil with the new site change.

Scott Benner 16:58
I mean, I'd say it all the time. I just like to have a little insulin on my side when I know something's coming. And we'll get we'll move on to another topic in a second. But Arden's You know, we've been messing with different birth control packs, trying to find her right dose. The first two months, I'm gonna have to do a whole episode about the first two months was hellish. And then this third month, this pack seems to be right for her. And it's it's going better. But aside from her blood sugars being incredibly difficult to get on top of her appetite was bizarre. It like at times, it was like she was pregnant. Like, you know, she's like, you know, can I get grapes and rice and like, you're like, wait, what, you know, she's mixing these weird things. And there were times where she'd say, I'm hungry. But I don't want to eat. But I know I'm going to eat and in that in that situation. I'm like, well, just Pre-Bolus 15 carbs, then why? And I don't know, like, I gotta get something moving here. I can't just have her because once she says, Oh, I know what I want. I don't want to slow that. Well, I don't want to slow the process down because it took her 20 minutes to figure out what she wanted. Like if I say okay, let's just Pre-Bolus she'll go Forget it. And that and that'll be the end of it, you know, right. So I just like having some insulin on my side.

Jennifer Smith, CDE 18:10
Well, and that's kind of a good strategy. And I also use that a lot for kids and teens, especially for like, their lunches at school, that they often don't know what they're going to choose and they get there and then there has been no Pre-Bolus time. And the worry is that always comes up is well if they Pre-Bolus and then they don't end up eating that amount. I'm like, just Pre-Bolus for the minimum that you know, your kid is going to eat 10 grams, 15 grams to me, if your kid constantly eats 100 grams at lunch. A 15 gram Bolus, I guarantee is just a juice box in case they decide not to eat, they're gonna

Scott Benner 18:43
be okay. That's exactly how I talk about pre bossing little kids just get some on your side and there's an amount that you know, you know, they're gonna eat, there's an amount you know, every kid's gonna eat. Okay. My friend Jennifer Smith has been living with Type One Diabetes for well over 30 years. She has first hand knowledge of the day to day events that affect diabetes and its management. And as you've heard time and again on this show, she really is a wealth of knowledge about type one. Jen, he holds a bachelor's degree in human nutrition and biology from the University of Wisconsin. She's 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. She's also the person who here with me on the diabetes pro tip episodes, and in all of the defining diabetes episodes, Jenny is just absolutely terrific. And if you'd like to meet up with her in a professional way, Jenny does coaching. You can find her at integrated diabetes.com Don't forget to add your name to the T one D exchange at T one d exchange.org. forward slash juice box every time you complete their survey. It benefits everyone living with Type One Diabetes and it helps out the show T one d exchange.org forward slash juice box. I'd like to also thank Dexcom Omnipod chivo Kibo pen touched by type one and the Contour Next One blood glucose meter for being long time advertisers on the Juicebox Podcast you can check out everyone that supports the show with their ads at Juicebox Podcast comm or right there in the shownotes of your podcast player. And when you support the sponsors, you're supporting the podcast and helping to keep it free.

If you're interested in hearing more of the defining diabetes episodes and can't find them in your podcast player, you can go to diabetes pro tip.com and scroll to the bottom where you'll find all the defining diabetes episodes. You'll also find all of the diabetes pro tip episodes in that same place, diabetes pro tip.com and for all of your other Juicebox Podcast needs Juicebox Podcast COMM And of course you can find us on Instagram at Juicebox Podcast on Facebook at bold with insulin or in that private Facebook group Juicebox Podcast Type One Diabetes