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Scott Benner 0:00
Hello friends and welcome to episode 648 of the Juicebox Podcast.

Today I come to you with another in the defining diabetes series. Today Jenny Smith and I are going to define insulin on board the notorious I O B. Please remember while you're listening 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 or becoming bold with insulin. This show is sponsored today by the glucagon that my daughter carries G voc hypo pen. Find out more at G voc glucagon.com. Forward slash juicebox. If you're a US citizen who has type one diabetes or is the caregiver of someone with type one, please go to T one D exchange.org Ford slash juicebox. Join the T one D exchange registry fill out the survey support people with type one diabetes T one D exchange.org Ford slash juicebox.

G voc hypo penne has no visible needle, and it's the first premixed autoinjector of glucagon for very low blood sugar in adults and kids with diabetes ages two and above. Not only is G voc hypo pen simple to administer, but it's simple to learn more about all you have to do is go to G voc glucagon.com Ford slash juicebox. G voc shouldn't be used in patients with insulinoma or pheochromocytoma. Visit G voc glucagon.com/risk.

Jennifer Smith, CDE 2:04
Insulin on board is an interesting topic it is

Scott Benner 2:08
and I think it's going to become more interesting as more people use algorithms to Yeah, because you're going to start thinking about it a little differently. But insulin on board is a measurement. I'm making air quotes about how much insulin is in your body that is yet to have done its job is how I think people think of it. Do you think of it? How do you think of it?

Jennifer Smith, CDE 2:34
True. And I think in in another way to define it. It's kind of like the expected it's the expected decay or action time over a defined period. So you know you've got this many units of insulin, your insulin action time is defined as four hours let's say you had four units taken 50% should be done by two hours after you Bolus if you have a four hour action window of that insulin right. But that's like the nutshell. Right? of insulin on board. I think insulin on board individually is very ill defined. It is not individualized unless you really test it out.

Scott Benner 3:29
And I so Kenny comes on and I and I think you know Kenny actually can yes on and talks about loop a lot. And if I'm not mistaken, his child's insulin action time he has set pretty short a prior to any kind of algorithm. I had Arden's insulin action time set at like two hours, two hours, I never remember, I never didn't want the pump to suggest insulin. Right. So I so I wanted that, you know, the way I talked about it with people is that there's a setting inside of your pump. And you just get to say, how long your insulin lasts for right, your insulin action time is one hour, two hours, three hours, four hours, five hours. If you use loop has an algorithm, it measures it as six, right?

Jennifer Smith, CDE 4:17
A five to six hours. If you use one particular like action, you know, profile, you can choose from multiple there's a child base, there's a adult based, then there's one that you can adjust the hours within, for the people who are doing some of their own coding and whatnot. They can also self adjust within their code, what they have their insulin action time kind of set for. But yes, each pump, whether it's algorithm driven or just conventional pump, loop pump or not. It is something that each pump has built into it. And again, I don't think that it's very well defined for people even just starting a base Conventional pump in an office clinical training, it's something that gets set, and is less than a minute in explanation as to why it's set for three hours or four hours or five hours. It's set that for three hours, and then you move on to like the next setting. Never go back to it. And they never come back to it. And I don't know how many people in a first visit, when I chat with them, we look at their active insulin time. I'm like, Well, why is your active insulin type set like this? Well, what is that? What does that mean? And where do I find that? Like, that's let's start over from insulin.

Scott Benner 5:41
Because if it because it's a it's a dummy setting, in the in a pump in a regular pump. By that I just mean, if you tell it three hours is your insulin action time, right, then it and you Bolus, I don't know 10 unit new gear at noon, two hours in the insulin on board is still going to indicate is probably being like a third of the Bolus though, correct, right? Yes. And but having said that, if you if that insulin action time was set at four hours, then it would think you had insulin on board of 4%. Right? If you said two hours, it would think it was more like 30%. And my point is, is that this, this number that gets put into your pump by a doctor who just is like I don't know, most people's is like three, and they just dial it up to three or maybe four, or maybe they're thinking I don't want you to over do it. So I'll make it five. None of that has anything to do with the impact of the food and your use of your insulin. It's it's it's a nice thing. But I think we're kind of beyond that now with technology. And you shouldn't be guessing at your insulin action time. Because it impacts insulin on board. And then what happens in real life is you eat some food. You don't do a great job of Bolus going for it for whatever reason, it's two hours after you've eaten your blood sugar's 270, you're indicating you're still going up. And then you look at the pump and go, Oh, we still has insulin on board. I don't want to do anything about this. And or

Jennifer Smith, CDE 7:09
it's recommending point two units, or like point two units. That's like a drop in the ocean. Like what point two is like nothing that's like, that's like, why would I even take it there's no purpose to just do it. And that's where people get frustrated. They're like, Darn it. That's where range Bolus came from 2.2 units, I'm going to take two units instead. And then it becomes like this willy nilly management of, well, I know the pump is wrong. Why is it wrong, though, right. And I think you made a really good sort of like comment that I think leads into insulin action was formulated to cover carbohydrate. That's how insulin rapid acting insulin was formulated to cover the expected in and out effect of carbohydrate. It's why we are very carb centric in diabetes education. Everything's about carbs. It's about counting the carbs, it's about insulin to carb ratios, right. But when we start having more than the typical well portioned, mixed meal, broccoli, grilled chicken and maybe you know, blueberries on the side, or whatever it is. Once it becomes heavier, in those other macronutrients, insulin action time, isn't wrong. But the reason that it doesn't look like your blood sugar is where it's supposed to be. Once insulin is done working, is because the other pieces of that meal weren't covered the way that they should have that. So it I mean, there's a lot of mix within evaluating insulin action time. How long does your one Bolus really stretch out and work for you? Is it getting you to where you want to get blood sugar wise? And then when you bring in pizza, versus the chicken and broccoli? What happens? Right now I'm stuck high and my pump is recommending point two units. I know I need more. We don't need more because your active insulin time is wrong. You need more because there's something else in the picture that wasn't covered. And it needs to

Scott Benner 9:30
be Yeah. So at a basic level these these measurements were set it for perfect world situations, not for the situation you find yourself in right away. There is a world where if you send your if you set your you know, your insulin action time at three hours, your insulin on board will probably reasonably be right if you're always eating the way you described. But the minute you elongate a meal impact by adding fat to it or protein or something that starts hitting You know, an hour and a half later, after you've eaten it, these are these are new impacts on your blood sugar that this, this simple, simplified formulas not thinking about. And I understand, right? Like, you can't explain all the stuff we talked about in the podcast if somebody's in a five minute doctor's visit, right? Right. And so, but the problem ends up being is you set the settings somewhere, and then you tell people, well, this is it. Insulin on board, if you have insulin on board don't Bolus, it's a, it's a generic thing to say. And you might be right sometimes, and and that might be wrong sometimes. But people get into this situation where they're in their home. And they know they should do something. And what rings in their head is the doctor told me not to correct before three hours. And I don't know if you've ever taken 24 divided by three. But there's only so many three hour segments in the day. And that's how you make yourself crazy. So waiting three hours feeling the pressure of this blood sugar's high, I don't want to do the wrong thing. The doctor said I have insulin on board still, it's sort of comes down to there's another epic defining diabetes episode that I think is called. I don't know if it crushed it and catch it. When I probably where I probably say something like, it's not stalking if you need it. You know? Yes, yes, you could stack insulin, do it wrong, make yourself very low. But it's not stalking if you need it, meaning that one meet and

Jennifer Smith, CDE 11:30
if, if you need it, you may want to go to the variables that we hash through in like very, I think really good detail, right? Because those variables are some of the reasons for saying, I'm not stalking, I'm taking extra insulin now. Because this variable is in the picture. And I know that I need it. My pump isn't recommending, but my pump doesn't have my brain. It's it's like a locked, I see this, you only need this. You are in real world. You know, you know what's going on.

Scott Benner 12:06
You need to understand I play there. Sometimes I think I say the same thing a lot. But you need to understand that 10 carbs of rice is going to impact you differently than 10 carbs of grapes than 10 carbs of pizza. And the Bolus that probably works well for the grapes, let's say doesn't work for the rice definitely doesn't work for the pizza. And so you take the insulin you think you're supposed to have you get high, take it again, a doctor would call that stalking. But I would say that if we're talking about the pizza, you just didn't understand how to Bolus for the pizza to begin with. Right? Right, or you used more insulin, or you would have timed it differently. This is the point where I've never really said this before in a defining episode. But if you tuned in to hear about insulin on board, and you're like they talked about insulin action time a lot. I think that if you really want to understand insulin on board, you should just go find the other pro tips and the other defining episodes and educate yourself about the big picture. And then I don't think you think about insulin on board anymore.

Jennifer Smith, CDE 13:11
Well, and I think the other thing, as you mentioned earlier is we become we've become in the past, I would say even three to five years of a lot of these algorithm driven pumps that people are using, I think with learning more about why is the system doing what it's doing. Why does it seem to work better than my conventional pump did? And some people get locked into the well, my system isn't giving me more insulin. I think it needs to be, but it's not giving me more. It's not helping me more? Well, our, our algorithm driven pumps have much more, I guess, a lot longer insulin on board or insulin action times, right. They're much extended comparative to what you may have had set in your conventional pump. I noticed that difference very early, going from conventional pumping to loop I did. And it was also a question for me. I was like, Well, I see it's giving me more and on my conventional pump, I probably would have given myself more with a I've got this much like hindsight that I know I need this much more, and I feel safe doing it and I can do it. But my pump wouldn't have recommended it. These systems are following blood sugar in a way that a conventional pump wasn't. And it's taking into consideration the glucose shift, where again, a conventional pump is not it's locked into one point of data that you're giving it to get back a suggestion. Whereas the algorithm driven pumps they're adjusting based on our rate of change, and the more information you feed it, the better can decide what to give you? And how long to look for that along with gets drawn out active insulin time.

Scott Benner 15:06
Yeah, it's important to know that what if you're experiencing, you know, a rise that you that you don't expect, it's not always just change your meal ratio, because your meal ratio might work really well, for a lot of things, it just doesn't work well for Chinese food, right. So you don't want to change your ratios in the pump, you want to change the way you think about that specific food. And I mean, that's a, that's a trial and error situation. But you you have to be able to look and go, my ratios work most of the time, they don't work for these foods, I have to figure out how to Bolus for these foods better. And and the other thing that what you just said made me want to talk about was, I guess I do actually still pay attention to insulin on board. But it's more about during a fall. So if I'm managing a high blood sugar down, or I have a real steady, lower blood sugar, and I want to know if it's going to drop, that's where active insulin makes is important more concerning to me than it is while I'm bolusing for food, crackers, one bolusing for food, I can see what's happening, I can see the big jump, I can see. Well, I mean, listen, I'm not into bolusing perfectly every time I don't think you should be that way. But if your blood sugar's one at a half an hour, after you ate, you didn't Bolus right. You know, like there was a way to do that better. There, that's easy to deal with. But when you find yourself at 180, or 200, and you start attacking it, and now you're dropping down. Now it's important for me to know how much active insulin is here because I can look at the act of insulin and decide how much juice as an example, would, would right counteract that act of insulin. So almost thinking of it as correcting a high blood sugar was almost like Pre-Bolus thing for the juice. And now put the juice in so they can do their job. And then the rest of it is just putting it in in a place where you kind of come in for a smooth. Yes, yeah. So you don't do it too soon or too late. And it is a lot like trying to land a plane apparently. So. Correct. You don't want to you don't want to fly off into the horizon and you don't want to crash into the ground. So good comparison. Yes. Great. I've never flown a plane in my life. And I never I flown a plane. Have you

Jennifer Smith, CDE 17:20
really? I have. Yeah, like a little, you know, like, a four seater. It's not like it was a huge plane or anything, obviously. But it was fun.

Scott Benner 17:29
Or and Lieberman was on here once and he offered to take me out. His parents live near me. And he was living in he was the CNN CORRESPONDENT Israel when I spoke to him, but I think he's back in the States now. And I was like, No, I'm not getting a small. He's like, we could fly down to here and get a sandwich. And I'm like, No, I don't know.

Jennifer Smith, CDE 17:50
It's it was it's really noisy. I mean, really, really noisy. But it was super fun.

Scott Benner 17:57
All right, so yeah, maybe I would do it. Six parachutes strapped in my face. Thank you very much for talking about it. Yes. On board with me, of course.

A huge thank you to one of today's sponsors, G voc. Glucagon. Find out more about Chivo Kibo pen at G Vogue glucagon.com forward slash juicebox. you spell that GVOKEGLUC AG o n.com. Forward slash juice box. If you'd like to hire Jenny Smith, she works at integrated diabetes.com. And she does this for a living, you should check her out. And don't forget that T one D exchange.org. Forward slash juice box link, go fill out that survey, please.

I want to thank you very much for listening. I want to thank you for sharing the show with other people. I want to thank you for the wonderful reviews and ratings that you leave. I would like to invite you to come check out the Juicebox Podcast Facebook page. It's called Juicebox Podcast type one diabetes, it's completely it's a private group is the words I was looking for. So about 23,000 people in there now they all have diabetes, great conversations going on. You can jump into one of them or just sit back and watch. I'd also like to remind you that today's defining diabetes episode was the latest in a long line of defining diabetes episodes. You can find them at juicebox podcast.com diabetes protip.com, or right there in your podcast player just search for defining diabetes juicebox they'll pop right up in your podcast player. There are so many I can't list them for you right now. And if you like the series, let me tell you about The rest of them. You know what I'm going to come back to this one diabetes pro tips, they begin at episode 210 and cover a bevy of topics. Those are also with Jenny Smith. There's the diabetes variable series also with Jenny variables that impact your type one care Quickstart episodes, how we eat everything from vegan carnivore, low carb flexitarian, intermittent fasting episodes for how we eat popular request episodes, stuff like what's in your go bag, switching to an insulin pump, how to split long acting insulin, bolusing, insulin for fat, all kinds of stuff there. What else we got? There's a great mental wellness series all about type one everything from sneaking food to hard questions to kids ask about type one. In a number of those episodes, I'll be joined by Erica Forsythe. She is a therapist who also has type one, there's a ton of Scott and Jenny episodes, so many to choose from their how to Bolus for fat and protein. We have a number of episodes about that. I have a great four part series about pregnancy with type one diabetes, and a ton more about pregnancy. Some in the defining diabetes episode, some in the pro tip episodes. Just so many we've done so many great conversations with pregnant type ones. And mothers who recount their pregnancies, ton of great stuff. I said ton a lot. I appreciate that. You're letting me go on that. But about algorithm pumping. Like if you're using a loop or any other algorithm actually don't miss the fox and the loop House series or any of the others. We just finished up the defining thyroid series which is really well received by people. And after dark so many afterdark episodes living with bipolar psychedelics, heroin addiction, we sex, divorce, sex workers, disordered eating from male and female perspectives. They're all there in the afterdark series. And last but not least, I told you I wasn't going to list the defining diabetes episodes but you know what Dammit, I'm going to you're ready. I'm gonna hammer through this. So today we did insulin on board. But going all the way back to Episode 236 When the series began, we have defined Bolus Basal honeymoon a one see time and range standard deviation extended Bolus algorithm, noncompliant glycemic index and load Pre-Bolus Trust will happen low before high brittle diabetes stop the arrows, ketones insulin resistance and over Bolus feeding insulin bumping nudge rage Bolus compression low and interstitial fluid, fat and protein rise. Dawn phenomenon smudgy effect feed on the floor insulin sensitivity factor adrenaline highs, insulin deficit growth hormone stacking insulin hydration, a lot of diabetes, moody diabetes, crush it and catch it see peptide and beta cell and of course today's insulin on board and there will be more. You can't use the tools if you don't understand what the tools are. Again, if you want to see those lists, join the Facebook page Juicebox Podcast type one diabetes, go right up to the top of the page where it says featured. And there is a post in there with lists of all of these episodes. And honestly, these are just a fraction of the episodes that are available in the Juicebox Podcast. So if you're not already subscribed, please do subscribe in the audio player that you prefer. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.