#711 Bold Beginnings: Terminology Part I

OmnipodJuicebox PodcastInterviewType 1 DiabetesBold Beginnings

Jul 1

Bold Beginnings will answer the questions that most people have after a type 1 diabetes diagnosis.

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Music - Google Play/Android - iHeart Radio - Radio Public, Amazon Alexa or wherever they get audio.

Bolus - Basal - Honeymoon - A1c - Time In Range - Standard Deviation - Extended Bolus - Algorithm - Non Compliant - Glycemic Index - Glycemic Load - Pre Bolus - Trust Will Happen - Low Before High - Brittle Diabetes - Stop The Arrows - Ketones - Insulin Resistance - Feeding Insulin

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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:00
Hello friends, and welcome to episode 711 of the Juicebox Podcast, a special two part episode that concludes on Episode 712, which is available right now to download

Welcome back to the bold beginning series with me and Jenny Smith. Today's two parter happens in Episode 711 and 712. This is bold beginnings terminology part one. In these two episodes, Jenny and I define every word that's available to you in the defining diabetes series. At the time of this recording, there were over 40 definitions. We did a quick definition for newly diagnosed people and left you the episode number. So you can go back and get a more complete definition. If you've just been diagnosed. Or if you're trying to figure things out, it is our estimation that this two part episode, part of the bowl beginning series will catch you up on terminology very quickly. If you're looking for the defining diabetes series, it's available at juicebox podcast.com diabetes protip.com. And in any audio app that you listen in, join the Facebook group Juicebox Podcast type one diabetes to find the lists of all the series in the featured section. This episode of The Juicebox Podcast is sponsored by Ian pen from Medtronic diabetes. And because of the format of this episode, I'm going to put the ad right here for you so that you don't have to take a break while you're powerless running through these definitions. Isn't that cool of impelled to let that happen? Thank you and pen, even though I didn't ask you, but I know you're listening. So just be cool. All right. All right, ready the pen. It's an insulin pen. But it's more than that. Because it's attached to an application on your iPhone or Android phone. This application is going to do many of the things you've heard about people getting from their insulin pumps, you'll be able to see your current glucose right on the screen, a dosing calculator, active insulin remaining meal history, dose history, glucose history, activity logs, and you can generate reports based on your data. Not only that, but you're getting a great insulin pen, everything you expect the cap the needle, the insulin cartridge holder, it's an insulin pen, just like you've come to expect. But it gives you more with this attached app. You can go right now to N pen today.com To find out more and get started. And I'm gonna tell you what terms and conditions apply, but you may pay as little as $35 for the in pen. Medtronic diabetes does not want costs to be a roadblock to you getting the therapy that you need. Within Penn's Access Program. You may pay as little as $35. Where will you find that out? At in Penn today.com. On this site, tons of frequently asked questions that you're going to be interested in just scroll to the bottom. What is the M pen? How much does it cost? Our insulin cartridges included? Does M pen work with long acting insulin? Can I pair more than one M pen to an app? You want to know the answers to those questions? Go right now to in pen today.com and get your answer if you're ready to try the M pen when you're at the link. Just follow the easy instructions it says ready to try you complete a short form. And just like that you're on your way. In pen today.com forward slash juicebox in pen requires a prescription and settings from your healthcare provider, you must use proper settings and follow the instructions as directed where you could experience high or low glucose levels. For more safety information visit in Penn today.com. Just this morning, I put up the conversation that you and I had about this series. So you're gonna Okay, you're gonna find out what it's called for. Right now for the first time. Yay. So what I want to do is I'm going to stay with the naming system. So like there's that defining diabetes, colon, you know, Bolus and there's diabetes, pro tip colon, you know, whatever that episodes about, right? So with for the, for the prefix for this one, I chose bold beginnings. And I went over a lot of things I wanted to Thursday's just like let's just call it newly diagnosed. And I thought, well, then people who aren't newly diagnosed might skip over it. And I think it would still be very valuable for you if you were, you know, diagnosed six months from now, you know, sometimes people are like, Oh, it was six months ago. We're not newly diagnosed. And I thought so I don't want to I don't want to push people away from the content with the name that makes them think this isn't for me. So in the beginning I I mean, when we asked for people, what do you wish someone would have told you when you when you were diagnosed? And that's the beginning, damage any, that's what I'm going with. So

Jennifer Smith, CDE 5:12
it is a beginning and we very much explain. I mean, the title of it is good in terms of the beginnings part of it, because obviously, somebody has who's even six months in who has not put any not that they haven't put work in, but they haven't put the kind of like, evaluate thing kind of work in yet. They need to know some of how to begin.

Scott Benner 5:35
Yeah, I mean, you have to start somewhere you need to, you know, it's so funny as I wanted to call it like, it's funny. I know, it would have been confusing, but a part of me wanted to call it basil, because of it being sort of like, you know, the base. And, and I was like, Oh, that'll be to

Jennifer Smith, CDE 5:52
foundation would be another good word. Yeah,

Scott Benner 5:54
I know. I thought that'll be too trippy. So let's just go with alliteration bold beginnings. Perfect. So today, we're going to talk about terminology. Great. And I have the list in front of me. Do you have it?

Jennifer Smith, CDE 6:08
Let me bring up my notes so that I can

Scott Benner 6:13
we have 14 pieces of feedback that are under the under the heading terminology. I'm going to about you're looking I'll give you the first one person says that all of the terms were so confusing. MDI carb ratio correction factor, Basal Bolus Pre-Bolus. And she says, I really thank God for the defining diabetes episodes. So that's nice. That's not a question. That's a bit of an answer. But we'll talk around terminology for a little bit. Okay, perfect. So what ends up happening, right, you get diagnosed, you're in a doctor's office. They use words, as a matter of course, we all have a friend who's in it, or, you know, a therapist, you know, buddy, and they everyone uses buzzwords. That to them are everyday words, it's, you know, to these people saying Bolus and basil is like you saying, you know, sunshine in the moon, we think, Oh, everybody understands this, right?

Jennifer Smith, CDE 7:11
Or what's very common now, especially with texting are all of the, you know, the three letter means three words of right, those acronyms? Sometimes I have to look it up. Like, I don't know what that was.

Scott Benner 7:24
My wife texted me yesterday. And I said, I will answer you as soon as you tell me what that emoji means. Right? I don't know. And I'm not in a position to find out. So you know, it's so it's gonna happen. You're in the doctor's office? You know, you know, for me, one of the things that I maintain is that when doctors try to tell you about glycemic index and glycemic load, I just think the words are off putting. And they are. And that's why I end up saying, you know, you have to understand the different foods impact you differently, because I don't know, it's just from my perspective, I heard glycemic index glycemic load sitting with the nutritionist at the children's hospital, I was like, this is the part I'm going to ignore.

Jennifer Smith, CDE 8:08
Because it wasn't, well, and I don't want to it's not. It's not saying it mean, but you needed it simpler, right? Those big words can be really scary when you've also just been introduced to something that can be scary, right? Right. So you bring in all of these big words like, what happens with this hyper or situation or this hypo situation, or whatever is going on. And all of a sudden, like, you get these like, this increase in your heart rate, and you're like, what, what, what, what is it?

Scott Benner 8:41
I don't know what I'm doing. And then and then it's juxtaposed against the pressure you feel, to figure it out, and to do it correctly. Because I mean, it's either you as an adult, and my goodness, then you're like, I'm on my own here. And if I don't understand this, there's no one else. Or it's the pressure of, I had it, I had the thought directly in my head, I'm gonna kill her. I know I'm going to make a mistake, and I'm going to kill Arden and that's how it felt when she was first diagnosed. You know, again, here, all the terminology was so confusing. One person said, I needed a way to remember the difference between Bolus and basil. She said she made flashcards for herself. That's not a bad idea,

Jennifer Smith, CDE 9:19
actually. Right. That's not a bad idea. No, not at all. I

Scott Benner 9:23
interviewed a woman the other day. She was wonderful. I enjoyed it so much diabetes for over 40 years. And when I asked her what her Basal insulin was, she told me the name of her meal and some 40 belly. Yeah, yeah. And so

Jennifer Smith, CDE 9:39
well, do you if from the Bolus Basal aspect Do you want to really know the reason for Bolus for food?

Scott Benner 9:47
So I was thinking, do you know it? Well, well, what I was thinking was let's run through these people's thoughts a little more here and the feedback that we got, and if the feedback sticks with just like, hey, I need to know the difference. Maybe we can Do a condensed speed version of defining diabetes and roll. Awesome. Sure. Okay. Okay, as dumb as it may sound, the difference between type one and type two is confusing to me. Another person said insulin resistance, how do I figure out what that is? What is the dawn phenomenon? I think in an episode for being newly diagnosed, it would be really helpful to use full terms for things rather than just acronyms and jargon. And we'll all eventually learn them. That's interesting, too. Okay,

Jennifer Smith, CDE 10:31
that's not a bad. Again, if somebody's asking anyway, and really wants to know, then they will be more informed the next time their clinician says a word. Yeah, they'll actually know what it means.

Scott Benner 10:43
And I think that, well, I think the way we listen, we didn't just make defining diabetes by mistake, like it really seemed the way to go. And people on the other end, have to be willing to listen to it to learn, and they have to know it's there, which is difficult. You know, it's funny, not to take too much of a sidebar here. But the other day, I saw a person talking about the bolusing, insulin for fat episode, and how life changing it was for them, and that they had been struggling for a really long time. And I thought, but that episodes been up for years. And then I remembered, just because I put it up, doesn't mean everybody see. But from my perspective, you're like, I did that already. So I take the

Jennifer Smith, CDE 11:27
especially if somebody's starting with Episode One, and just being very, like just moves through the episode, one episode took a long time to get to the other episodes,

Scott Benner 11:37
this person makes the point that a lot of the episodes feel pump specific, but that most people don't get pumps in the beginning. And it's funny. I want your opinion of it. I don't think the pro tips or pump specific, I think that you could listen to the pro tips and just apply it to a life with MDI. But maybe when people hear it described through pumping, they don't think it would be backwards compatible, maybe.

Jennifer Smith, CDE 12:07
Right? I think the biggest thing that you could learn from the pro tips, if you are using MDI are the strategies for especially bolusing remain pretty much the same in terms of understanding the timing of insulin. It's the delivery of how you would do it with an injection comparative to the fancy features of a pump that might you tell it to do something and then it continuously does it versus on MDI, you may have to feed a little insulin feed a little insulin feed a little insulin, it's the same concept. It's just you may have to do a couple more injections with MDI, to get the same impact. Yeah.

Scott Benner 12:48
Alright, so I'll tell you what I'm gonna do. Because I'm looking through everybody else's information here and overall, around terminology, it's Look, I need to know what this stuff means I need to know quickly and the one woman makes there's, I say, woman, by the way, like 75% of the people that listen to podcasts are women. So I'm just assuming they're women, I guess. But it could be a guy. The one thing that I'm seeing is I was overwhelmed. The default I found the defining diabetes episodes eventually, but it felt like a lot. And I didn't know what to listen to. So I think we're going to do exactly what I just said, Here, we are going to play a speed round of defining diabetes. To an eye, this is gonna be a fun test. Alright, so I have

Jennifer Smith, CDE 13:32
we make this into a game that we can, like, you know, put out there.

Scott Benner 13:36
Well, here's the, you know, we should first of all, and here's the thing, I'm looking at the list. It is. It's long, it's gotta be 40. Oh, my goodness, hold on. I'm gonna pull up Isabel's list. Do you know that every time I make a new episode, that fits on the list is about re does the list and says it's awesome. She's a pretty cool person. So our defining diabetes. Here it is. I wonder if I put it in this document? If you would see it? Does it update in your notes under the Dr. Jack's or diagnose January comment? If not, it's okay.

Jennifer Smith, CDE 14:26
I saw something pop into my notes.

Scott Benner 14:30
Well, I'm gonna I'm gonna look through it. Is it a image? Yeah. Is it an image? It's an image? Was it not coming in clearly yet?

Jennifer Smith, CDE 14:39
Let's see. Oh, there it is. It's under Yeah, it's the Juicebox Podcast defining diabetes series with all of the Yes. Okay,

Scott Benner 14:47
so, alright, so this is what we're going to do and there are 44 terms on this list. So right now the Define diabetes series begins at episode 236 and runs intermittently all the way up to 677 was the last defining we did. All right. Yes. You ready? What do you think? All right, so it's 11 o'clock now we have 30 minutes and 44 things that define.

Jennifer Smith, CDE 15:13
I could actually go a little beyond a little time between between people. So yes.

Scott Benner 15:19
Taking the fun away but I appreciate it. Yes, we

Jennifer Smith, CDE 15:22
will try 30 minutes. Go.

Scott Benner 15:25
Okay, Bolus. You go Bolus.

Jennifer Smith, CDE 15:30
Me to go we'll go. Bolus is the amount of insulin you take to cover food that you put in your body.

Scott Benner 15:37
And if somebody says What's your Bolus insulin, they mean your mealtime or your fast acting insulin? Correct. Some examples might be Novolog, a Piedra fiasco humor LOGG. Did I miss any little jab loom JEV. So those are insolence you use to correct high blood sugars or to cover meals. Correct. That's good. That's what that means. All right, that's what Bolus means Basil is a slower acting insulin. It's either injected for people with MDI. The way I always think of it, whether it's right or not, is that it kind of goes under the skin and a crystal form and then sort of melts away slowly over time, giving you a base level of Basal insulin Basal insulin is meant to control your, your blood sugar away from food. And it if it's dialed in correctly, it should hold your blood sugar fairly stable at a place Basal insulin shouldn't drive you down. It's not its job to overwhelm meals. It's a baseline of insulin if you're using it. Good.

Jennifer Smith, CDE 16:43
Oh, I was gonna say one. In fact, to add on to that once your Bolus is done working, your Basal should hold you where the Bolus left you. If the Basal is right,

Scott Benner 16:54
that's a great way to put it. So Basal insulin is let's see love a mirror Lantis. What are the new

Jennifer Smith, CDE 17:02
Jao? Trust Siba basic lar. I might be missing one

Scott Benner 17:11
you had to pick one if you were if you were giving a person on MDI a Basal insulin. Which one would you pick? I have an answer. What is yours?

Jennifer Smith, CDE 17:18
To in today's world, I would pick receba.

Scott Benner 17:21
Me too. And that's only based on feedback I see online from people.

Jennifer Smith, CDE 17:26
And that's based on my feedback that I see actually from the people that I get to work with. It seems to be much better and in from I know a lot of people probably say Well, is it good for age, you know, a specific age. I have kiddos using it and adults using it and it across the board seems like a very good true 24 hour insulin.

Scott Benner 17:50
Oh, you know what we should do while we're doing this? I'm glad I thought of it after only the second one Bolus. The defining diabetes episode for Bolus is episode 236. The defining diabetes episode for Basal is 238. The next defining diabetes is 241. Honeymoon. It's your turn. Awesome. Honeymoon. Yay. Wait, no, no, no, hold. I did that already. No, no, I tricked myself. Basal insulin in a pump is different. So if you're pumping, right, you don't inject Tresa are another thing. Your pump just takes the fast acting insulin, your NovaLogic for example. And it not only you know, can you tell your pump I just had 30 grams of carbs. And your pump might say to you, well, that's three units and you put it in, but you tell your pump I need 20 units of insulin every 24 hours for as a Basal insulin and it breaks those 20 units down into very small, tiny, like blip pulses. Yeah, like pulses. And so instead of injecting insulin, like you would with MDI, for your Basal, and letting it work on its own, the pump puts in a little bit a little bit a little bit constantly, it creates that baseline. Correct. Right. So

Jennifer Smith, CDE 19:03
and that is the beauty of a pump is also using only what we consider rapid acting insulin or Bolus insulin. Your body doesn't have to sort of figure out the action of two kinds of insulin right? A Basal injected insulin like to receive our Lantis and then a Bolus insulin like Novolog, for example. You should however, always make sure to keep Basal injected insulin in your refrigerator in case your pump fails, right. That's my little educator, thing for you appreciate that.

Scott Benner 19:37
One day, I will actually do that. Maybe when Arden least or college will be the first time we actually do that because that would be a good idea.

Jennifer Smith, CDE 19:45
So when your pharmacy isn't like two seconds away from your house, right?

Scott Benner 19:49
So then once you're in so when you're injecting insulin when you're MDI multiple daily injections, which we'll get to on this list at some point, Bolus is a thing. Like your Bolus insulin is that thing, your Basal insulin is a thing. But when you're pumping their concepts you Bolus because the pump just holds insulin and when you Bolus it puts in insulin, and it also creates a Basal level. I don't know if I'm saying that right. But do you really mean like that it's not as tangible when you talk about it in pumping their functions. And when you talk about an MDI, their vitals, does that mean I think

Jennifer Smith, CDE 20:25
it's because of the difference, as you just said, there's a defined Basal injected insulin. And that's a kind of insulin. It does the same thing as your drip, drip pulses of basil coming out of your pump. But you're right, I guess I never thought about it that way that, you know, pump. It's the same reason for using the insulin, even though you're using two different kinds of insulin to do the same thing. It's

Scott Benner 20:52
almost like the difference between writing on paper and typing on a computer. Like yeah, right. It's a thing is happening when you're on a pump. But when you're writing on paper, you're physically accomplishing it. Oh, I'm good with that one, episode. 241 honeymoon. Sorry, it's your turn. Already six minutes into it, we've only done so

Jennifer Smith, CDE 21:14
we're good. That's okay. Oh, is that phase after diagnosis, where your insulin needs may come down by how much is really, completely individual. It may happen soon after your diagnosis. It may happen a little bit later, like weeks after diagnosis. It may last for a short period of time, short being maybe a week, and it may last longer. Some people it could be an entire year of honeymooning. So it's something that happens essentially, once your body has enough insulin from injections, or maybe you've started a pump pretty quickly. It gives your beta cells a little bit of a break. And so you often get a little bit, outcome, or output I should say from those data's again, they start to help, because they're not as stressed as they were pre diagnosis where they couldn't keep up with such high blood sugar levels. And so you end up having this drop off in insulin need. Some people require only Basal insulin, they don't take any Bolus insulin for their meal coverage. At first, and then some people may take just really tiny amounts of both kinds of insulin, Basal and Bolus insulin.

Scott Benner 22:36
So the way you see it kind of in the real world is the doctor set you up with insulin, it feels like it's working. And then all of a sudden, you wake up one day, and it feels like you don't need as much of it or sometimes at all, or somewhere in that spectrum. The reason it's a term that people know about in diabetes is because it's incredibly frustrating and confusing. Because if you think about it, you've made the decision. I need insulin to cover this food. And then what happens if all of a sudden there's another entity also giving you insulin, your beta cells right now you've got twice as much as you need, your body doesn't see manmade insulin and go oh, no worries, we don't need it. So yeah, right. So two things are happening at once. Is it possible that someone never experiences a honeymoon? Yes, okay.

Jennifer Smith, CDE 23:26
All right, adores that it's so mild and things are not quite contained as much that it may not really

Scott Benner 23:33
notice. That is what I thought when I wrote down to people never Are there people who never experienced it. What I thought was, I wonder if they're just people who never notice it? Because maybe their management isn't even such like maybe put yourself in a scenario where your doctor is like shooting for a 200 blood sugar. Right? And maybe you're experiencing 150 blood sugar because of the honeymoon, you would never know that your pancreas was helping,

Jennifer Smith, CDE 23:57
right? Because you're not necessarily getting too low. So it's not worrisome. Right?

Scott Benner 24:01
Right. It's the outcome that makes you worried about it. Like if you have a if you have a great doc that sets you put your settings together where your blood sugar's 110 all the time. And then your pancreas kicks in and make sure 80 or 70 or 60 that you would notice. Absolutely, yeah. All right, honeymoon episode 241. Episode 243 is a one C. Say the real words. What do they mean?

Jennifer Smith, CDE 24:27
Well, a onesie is hemoglobin a one C.

Scott Benner 24:32
a 90 day that's it. The blood test can be done by a finger stick in the office or a blood draw gives you a 90 day average of what your blood sugar is or was correct. It's weighted differently though, right? Like if you had an average blood sugar of 150 in the first 45 days, but an average blood sugar of 80 and the last 45. It might show lower is that right?

Jennifer Smith, CDE 24:55
That's correct. It's weighted heavier to the more recent timeframe. And the reason is because of the cycle of red blood cell life, of which hemoglobin is a piece of that. And glucose has an affinity for hemoglobin. So the more glucose you have in your system, the more it gets stuck to the hemoglobin. And the life of the red blood cells essentially has a memory, if you will. So, older red blood cells will not be in as large of a concentration or percent as the ones that are closer to the time period where you got your blood drawn, or had the fingerstick done.

Scott Benner 25:37
Okay. Back in the day, once he was the only way that people using insulin could track their successes or or see where they might need adjustments. Today, we don't just talk about a one see their journey. What else do we talk about?

Jennifer Smith, CDE 25:52
We talk about time and rain, I'm in

Scott Benner 25:54
range, which by the way, as I'm looking at our defining diabetes series, we might not have defined. So really, it's possible we're gonna we are making more work on ourselves. So now I'm thinking, so, but But listen, here's why your agency can be fooled. And it's a great measurement. I'm not a person who says it's not a great measurement, I think it's a it's a reasonable way to see where you're at, except if your blood sugar is 400, for 12 hours of the day, and 50 for 12 hours of the day, your agency is going to look lower because of the average. But that is not healthy. And that is not the right way to achieve a seven a one C for example, you can get to a seven the right way or the wrong way. And that's and but but go to Episode 243 For a more complete description of a one C, but find the diabetes pro tip episodes eventually for an idea of how to keep stability so that you can trust the agency that you're seeing when you get it tested.

Jennifer Smith, CDE 26:57
Correct. And I think he was he was one of like the first episodes we did together, wasn't it?

Scott Benner 27:03
Yeah, it was, before we did any series, I asked you to come and talk about it. So there is a there is an all about a one C episode. That's just you. And like a young Jenny and Scott talking. This is a little embarrassing. But the next defining diabetes episode 245 Is time and I looked right past it on the list as I was like, I don't see it anywhere. Go ahead, give them time range.

Jennifer Smith, CDE 27:28
Yes, time and range is a, it's a good visual of a defined bottom and top value that you want to stay within the typical defined time, especially if you're using Dexcom, or many of the other continuous glucose monitors, they have a default of 70 to 180. So if you are looking at your CGM data, especially the amount of time that you spend between that bottom and top is going to be your time and range the time you you know, a percent of the total time in glucose overall, you'll also be given a time above that and a time below range to how much percent some some of the databases also do. Time wise, like how much time did you spend above this in hours or minutes? Which is kind of interesting to define it that way too. But yeah, time and range. I think also, it goes along with what do you want your target to be? So you have to define your target range to be able to then say, Oh, I spend, you know, 90% time in range? Well, that's great. What's your target that you're setting that for?

Scott Benner 28:44
So anyone see time and range, and the next defining diabetes episode, Episode 247, standard deviation, these are sort of the three things you use to measure your actual outcome. You can't just look at the A one C because as we said, it could be fooled. You can't just look at time and range. Because what if you set your range from 60 to 300? And you're like, I'm always in range. That doesn't count. Okay, that's not fair. You got it, you got to play you got to set up some rules, right. So for instance, Ardennes is well, I guess Ardens is 70 to 150. In her clarity report and clarity is just the software that that Dexcom uses to help give you a feedback. And so if Arden's 151, she's high out of range, if she's 69, she's low out of range, if we keep her between 7150 to 24 hours that would say that we were in range for 100% of the time, right so anyway, don't like don't lie to yourself, I guess like like set it up like and so you can see where you really are. I find it incredibly valuable to look at those numbers every other like few days I just pulled up on my phone real quick. I'm like alright, we're where we're at. I expect If it's B or G, something's happening, you know, right. Here's the thing. I'm embarrassed. I need you to explain standard deviation. Oh, because the math thing, I know what it is, I can't explain it. And you're, you're like what?

Jennifer Smith, CDE 30:17
Well, I also think that standard deviation, I mean, well, you can essentially explain it as a math thing. It's similar within diabetes, but you'll also see that value represented as milligrams per deciliter, or for those who are millimole as millimoles, and especially looking at your clarity reports, because they will give you a standard deviation. And really what that indicates is variance. Right? A deviation from, from your average, up and down. Correct? Yeah. So if you're saying, okay, my standard deviation is 60. That means that you're having a wide variance up and down from where your like stable midpoint is. If you have a standard deviation, that's 22, then you have a very small variance up and down from where you're kind of averaging.

Scott Benner 31:16
So smaller, the number of better you're doing,

Jennifer Smith, CDE 31:18
the smaller the number and another one that kind of goes along with it, which we don't have on our defining list. But people consider similarly is the coefficient of variance, right? This is that CV. I mean, that's located within there as well. I think many more people pay attention to standard deviation, though, to try to say, am I improving, and that kind of goes to goes along with that time and range, you know, defining your target range. And let's say you've had it set really high, you've had it set from 70 on the bottom to 250 on the top, and you're looking to improve, you're taking tips and things and you're learning more, bring that top number down, right? And compare time periods so that you can actually see, okay, I had this much time in range, but now I've tightened my, my range, am I actually doing better, even though I've tightened things up, and that's also where standard deviation should come in. Because if you've tightened things up, but your variance has not changed, it's gotten a little bit worse. That's not doing better than

Scott Benner 32:27
right. So that's an episode 247, where Jenny and I do a better job of explaining standard deviation than me just going I don't understand it. And if you want a bonus for that one, episode 343 is called standard deviation and her friends. It is a conversation that I had with a doctor who works for Dexcom, John Welsh, and we do a deep dive into standard deviation, coefficient of variation, a one C time and range and more like we really dig into it if you want to, like do a data geek diabetes. Deep Dive, it's episode 343 on

Jennifer Smith, CDE 33:02
I might have to listen to that. Oh, he was I don't think I've listened to that one. He

Scott Benner 33:05
was very interesting. Okay, Episode 249. To finding diabetes, extended Bolus, I can do this one. Awesome. Alright. So if you have a pump, and you know, you could kind of mimic it in a MDI. But if you have a pump, you could say to yourself, I'm eating pizza, which I think is going to be 60 carbs. But I know that when I eat pizza, I don't feel the impact of pizza in my blood sugar for an hour. Let's just say that that's your experience. It's probably longer than that. But okay, we'll say an hour for your experience. But I do know I need some insulin when I start to eat but not all of it. If I put in too much, I get low. So what I'd like to do is extend my Bolus. So this 60 carbs, I've decided this is let's just say your your ratio is one to 10. And you need six units, what you really want is for, I don't know three of the units to go in when you Bolus, but you'd like the other three units to get stretched out over an amount of time. So you can tell your pomp, I'm going to extend this to three now and do the other three over 90 minutes. And that it will take the remaining three units that didn't put in and stretch it out almost like a really heavily heavy Basal program, like we just discussed five minutes ago, how Basal on your pump is spread out little bits at a time little bits at a time constantly. In this scenario over those 90 minutes, it would take those three units, break them down over 90 minutes and put them out in small boluses over those 90 minutes, and that would be extending your Bolus. Is that fair? Is that fair? Not bad. All right. There's nothing to add to that. I did it.

Jennifer Smith, CDE 34:50
Right. No, you did it.

Scott Benner 34:52
Here's the thing. Perfect. Here's the caveat. They're not easy to figure out. Because if you extended over two hours and you really needed it Over an hour, then you're too weak. If you extend it over, you know, over an hour, and you really need to extend it over two hours, it's too strong. It is a to me it's a trial and error thing to learn how to do an extended Bolus. If you're on MDI, it's not the same, because you can't slowly stretch it out. But in the example of food that is going to cause a rise later, you can Bolus some up front and then inject again, a little later act almost Pre-Bolus thing the rise, which is sort of what you're doing with an extended Bolus as your Pre-Bolus in the next rise that you expect,

Jennifer Smith, CDE 35:36
correct. And a lot of that on MDI. I mean, along with pumping to it takes some analysis of some of the similar things that you've done over and over to see enough of a trend to say, Oh, well, this always happens when we have peanut butter and jelly at lunchtime. So we'll have to try an extended Bolus or we'll have to try a double Bolus sort of plan.

Scott Benner 35:57
Can I do the next one and then you can do the one after? Sure. 251 is algorithm you're going to hear people say algorithm you might think Oh, I hear people say all the time, Facebook algorithm algorithm, it computer program, think of it that way. Right? In terms of diabetes. Let's see on the pod has the Omnipod five tandem has control IQ Medtronic has the 670 G that right there all

Jennifer Smith, CDE 36:26
777 Their newest, and in Europe 780

Scott Benner 36:32
Do It Yourself versions loop. What's the APS one called a free

Jennifer Smith, CDE 36:38
APS, there's Android APs. I'm sure that open APS I'm sure that I'm that there are lots of the APS like little offshoots that I don't really know as much about honestly

Scott Benner 36:53
doesn't matter. The ones Jenny just ran through are literally do it yourself. Someone on the internet made it and made it available to somebody else. Some people choose to download them, you put it on your phone as a as a program, as an app, I guess would be what the young kids would say. And you're somehow this app, I'm not a computer person talks to your Dexcom CGM, for example, and to your pump, and it makes decisions about insulin dosing and handles those decisions, the algorithm is handling those decisions, whether it's on a do it yourself unit, like the loop which Arden uses, Jenny uses Jenny loops, or it's on the new AMI, pod five, or control IQ from tandem or any of the others the algorithm is just the computer, program app, whatever you want to think of it, taking in your data, making decisions and then telling your pump make your basil higher, make your basil lower, we need to Bolus here, that kind of stuff.

Jennifer Smith, CDE 37:54
Correct. And all the algorithms, they're a little bit different for each of the different system. Right? So swapping from one to another, you may have some reworking to do. And or that really starts with relearning this system versus the system that you're coming off. Yeah.

Scott Benner 38:14
All algorithms are settings based if your settings are bad algorithms are as useless as you not understanding where to Bolus if you're on MDI. But that's what algorithm means specifically, can you do episode 253 non compliant?

Jennifer Smith, CDE 38:29
Oh, this is such a word that I, I so hate this, this one. But yes, I can do it. So non compliant, if we look at it just as a simple non emotional, this is what non compliance specific to diabetes and or really any health condition means, right? You are intentionally neglecting your own care or your child's care, right? That you're really refusing to take good steps to do better to remain in the target that you've been given to aim for. That's non compliant, whether it means not taking your medications, just not appropriately managing and covering for food that you're eating, or you're missing your doses or whatever it is a I don't love the word non compliant. In fact, I really hate it. Because I don't think I don't think 99% of people are willfully choosing to do themselves harm, right? I don't that would

Scott Benner 39:40
be my that's my experience from talking to people. What I see mostly like, I'm not going to tell you there aren't some people who just have breakdowns and just like I'm not going to be diabetic anymore, which gets you to the hospital in a couple of days. But mostly most of the time what I see what happens is, the doctor gives orders to the patient The patient either doesn't understand them or understands them, and they're not good orders. And then you come back to see the doctor three months later, your numbers in close aren't where he expects him to be. So the or she so they make the assumption that you're not doing what you were told, and therefore they believe you to be non compliant. That's pretty rad. Yeah,

Jennifer Smith, CDE 40:20
exactly. And, and therein lies I think a big, big problem really is. There's a rabbit hole here. But in many office visits, there's a limited amount of time that can be spent in discussion, and really digging into what the data is showing. And when you only really look at data, and you don't ask more about what's happening in the person's life. You may certainly think that somebody is quote, unquote, non compliant. Yeah, well, maybe this big life, upheaval ended up happening. And that doesn't mean that the person doesn't want to take care of themselves. It just means that something has happened that is sort of taking over and they're trying to do their best. So yeah,

Scott Benner 41:07
here's, here's, what I would say is if somebody's calling you non compliant, and you and your heart are like, No, I'm really trying, you can express to them. I'm doing what I've been told it doesn't seem to be working. Can we try something different? You could run into a doctor who's like, yeah, great, let's make a change. You could run into an ego that says, oh, no, no, no, what I said to you was right, you must not be doing it. That's them. And that does happen, I'm sorry to say, but that's them, not knowing what to do next. So they just push it back on you. Correct. There are even people who will go listen to these defining diabetes episodes, they will listen to the Pro Tip series, they will show up with an A one C five, five, and the doctor might say to you, that's too low, and call your non compliance because they want you to be at six. There's a lot of self care in diabetes. And if you ever experienced any of these things, you're going to realize that you need to be the arbiter of what success is for you that you're not, you're not noncompliant if you're trying. Can we move on? Do you want to say more? Yes. Episode 255, the famous glycemic index and glycemic load. And by the way, by the way, Isabel, if you're listening, you have misspelled glycemic on my list. I want it fixed immediately.

Jennifer Smith, CDE 42:27
Because probably an honest little mistake. On the see on the keyboard right next to each other,

Scott Benner 42:34
fired, fired this lovely woman who makes these lists for free out of the goodness of her heart, she can't do it anymore. Episode 255, glycemic index glycemic load? Go ahead.

Jennifer Smith, CDE 42:45
Yes. So glycemic index is the first, glycemic load takes it a little bit further. But really, glycemic index tells us with diabetes, whether a carbohydrate containing food or not, how quickly it's going to raise your blood sugar. That's really it. So white rice versus green kale leaves, they both are carbohydrates, they both have a certain amount of carbohydrate in, you could eat the same amount of carbs in both of them. 10 grams, 15 grams of both, and they're going to have a different impact on your blood sugar in terms of a timeframe. Okay, so the slower or the lower glycemic sort of numbered foods are going to have a slower overall impact on your blood sugar in a defined time period of about two hours.

Scott Benner 43:39
Take off, take a bite of pizza, and it's three carbs of pizza, your blood sugar rises at one rate, take a spoonful of sugar that's three carbs or sugar, it will rise much quicker. Correct? Exactly super important to understand when you're boasting for your meals glycemic load is

Jennifer Smith, CDE 43:55
glycemic load is the amount of that food that you eat at a given time. So honestly, glycemic load is the bigger impact. In my opinion. If you look at portion, a good example is watermelon. Watermelon has a really high glycemic index somewhere in the 70s. Anything above 70 up to 100 is very high. So if you take a small half cup of watermelon, compared to four cups of watermelon, they have the same glycemic index. But the load effect of the smaller portion is going to downplay its impact on blood sugar comparative to the four cups of watermelon, which is going to have a very large impact on your blood sugar.

Scott Benner 44:45
Okay, so the the load kind of a way to think about it is so the glycemic index is how quickly it punches. The load is how much it hurts.

Jennifer Smith, CDE 44:57
Yes, yeah, yes. Okay. All right. Yeah. That's a good way to explain it. Yes, I like that.

Scott Benner 45:03
That's how I got the podcast. Okay, so that's 55 Pre-Bolus. I'll do 258 is Pre-Bolus. It's just the idea that man made insulin even though Jen Jenny hates if you call it fast acting insulin cuz she doesn't think it works fast enough. And she's right, it does not work quickly enough. But in, in, depending on your situation yourself, how hydrated you are in a million other things. Insulin begins to work slowly, right. So when you put it in, it's not like it's doing its full job. Immediately, it takes time to kind of ramp up the best way I can explain it very quickly. It's like watching a locomotive pull away. It's putting all of its energy into it, but it's not going 100 miles an hour, it takes it a half an hour to get up to speed this this locomotive I'm making up a number. I don't want to train people calling me going it takes a locomotive 23 You know what I mean? So you put,

Jennifer Smith, CDE 45:56
I'm sure that there are people with diabetes, who are locomotive drivers, who probably would know the direct answer. So

Scott Benner 46:02
it's occurred to me as I said it so. So you put the insulin in, you sort of let the Pre-Bolus you Bolus before the food, pre the food, so that when the food starts impacting when the glycemic index of the foods starts slamming into you, at the same time, the action of the insulin is also occurring. And that there's a great episode in the Pro Tip series that I'll talk about tug of war and all this stuff, and you will understand Pre-Bolus And when it's done, but as at the definition Pre-Bolus Is the idea of putting in your insulin before the food so that the impact of the food and the action of the insulin can happen at the same time. Correct? Right. I think I'm gonna have to do the next one.

Jennifer Smith, CDE 46:44
Next one. Because it's your

Scott Benner 46:47
term, yes, please do episode 260 is called trust will happen. And it exists because because at some point, you'll get to believe that what you know is going to happen is going to happen. And it's a big deal when you're using insulin, like we just talked about when you're putting something in your body or your kid's body that could make you so low that you could have a seizure. And you're trusting that the Bolus will start working when you think it will and that the food will hit when you start when you when you know it will. And even though you see it over and over again, it's it can be difficult to give yourself over to it. So I like to tell people that eventually you'll, you'll trust it and trust will happen. And what you know is going to happen will happen and it's a it's convoluted, but if you listen to it, it's a it's actually a big deal. Because otherwise, you can't do it. It's it's like I guess the simplest ideas. If you're parachuting, you can't jump out of the plane unless you believe the chute is going to open. Correct. Right. So trust will happen. All right, Episode 269. lobe Oh, Jenny, sorry, hold on. This is gonna be me talking for a while this is another episode 269 is called Low before high. Super simple. I'll give it to you in two sentences. When I wake up in the morning, every day, and I think about diabetes, I have a mantra, I would rather stop a low or falling blood sugar than fight with a high one. It is a staple of how I keep my daughter's blood sugar down. It's just a theory. It's a way to think the minute you start accepting the higher blood sugars, things get out of whack. So you're shooting for low understanding that the old make a mistake at some point. But fixing that mistake is far, far more palatable than fighting with a high one. Okay, and then the next one is episode 284. Jenny brittle diabetes.

Jennifer Smith, CDE 48:56
Yeah, that's another good thing. Like give me the nasty one. That's not very fair.

Scott Benner 49:04
This is like when you make the nurse give you you know how the doctors make the nurses do the shots and they leave the room. So the kids of course, yeah, I'm doing that with you right now.

Jennifer Smith, CDE 49:12
Right? Yes, exactly. That's not very fair. So brittle diabetes. Again, it's it's a term that is really an older term. In my professional opinion. It's meant to describe somebody who appears to really have very difficult to manage glucose numbers, where there are very severe swings up and down, and nothing seems to be able to contain them. And that essentially is Bertel diabetes. Yeah. Is it? Is it really a thing that is truly yet to be defined in terms of research urge, I mean, brutal diabetes, if it is truly happening, somebody should have worked through all of the pro tips. And said, I've, I've done all of these steps, I've gotten help from somebody who really has spent time with me. And I still have these time periods where I just don't know why it's not working. Right, right. And I think that many times brittle is being it's defined in a clinical setting, to somebody who hasn't had the greatest

Scott Benner 50:40
assistance whose blood sugar's look very variable for no reason. Correct. Right. But I generally believe there's a reason you just don't know what it is.

Jennifer Smith, CDE 50:51
I generally really, really, really Yes, believe that there is a reason and some of the meat the some of the reason may also be undiagnosed other conditions, that nobody's taken the time to ask enough questions to the person to say, Well, hey, this is happening. And it started happening about here, let's take some lab work. Let's look at your digestion. Let's you know all of these other pieces that could actually be creating this variability. I would say 9.9 times out of 10. You don't have brittle diabetes, right? There's, there's something that needs more assessment. Yeah.

Scott Benner 51:29
So if I was I, at some point, in these episodes, you'll hear me just say, you know, the worst thing I think you can do is just throw your hands up and go, Oh, that's just diabetes, you know, my blood sugar falls out of nowhere. It's what happens. Usually, it's because you didn't Bolus for a meal correctly. You got your insulin out of balance with the food you drop really quickly. And then doctors look at that, you know, think about 20 years ago, versus now even you still have trouble getting people understanding how insulin works, even at the physician level, but 20 years from now, they're like, I don't know, you're fertile. Like it just it to me, it seems like an answer out of the 1940s. You know what I mean? Like, like, Absolutely. Like, like, I don't know, like, like, put yourself back in that time. Right. And, yeah, there's a man and a woman and they're married, and the man does something terrible and the lady gets upset, and they go, Oh, she's, that's how she gets, you know, they mean, like, you know, it must be her time of the month, like just these general throwaway bullshit answers. I didn't mean to curse during this, that that are, the way I hear them is I don't know what's going on. So I'm just going to say that this is something unforeseen and uncontrollable. And it's just the way of the world but might not be the truth. Someone's calling you brittle at this day and age. Go listen to the Pro Tip series. Oh, okay. Here's another one for me. Episode 286. Stop the arrows. Again. It's just a theoretical thing if you have a CGM. I prefer to say that sometimes we all get stuck wondering what's happening, instead of just stopping the arrows, right? Like, well, my blood sugar's jumping way up. I don't know what and then the people sit back and they go, Well, I guess I Bolus that this time for this while you're talking to yourself, your blood sugar is shooting up, right? Just stop the arrow. Again, in much more detail in the episode, we don't need to spend a lot of time with it. I'll talk about like keeping your car in a lane and stuff like that. You'll love it. It's going to be great fun for you. So 288 ketones, not as easy as it sounds, Jenny. So I'll give it to you. Again. Nice, hard one.

Jennifer Smith, CDE 53:33
Yes, no and ketones specific to diabetes now, right? Because that's what we're talking about. They are chemicals, if you will, that the body makes when it breaks down fat to use for energy. So could you have ketones and could they not be dangerous? Yes. You could, in fact, have any people wake in the morning in a fasting state and have what are overnight sort of fasting ketones, right? Those are not the dangerous ketones that we think of when you get diagnosed and you're told all about all of these things. And one of them is ketones. Watch out for keto.

Scott Benner 54:23
You're in DKA, diabetic keto ketosis, right. So, right.

Jennifer Smith, CDE 54:29
So I mean, DKA, those types of ketones are very different ketones and those are not the ketones that you want. Obviously, that is a very serious complication. That occurs essentially, when your body has a very high glucose levels and not enough insulin. Then you could very easily move from high ketone levels into diabetic ketone. acidosis which

Scott Benner 55:00
is life threatening, so it's a big deal. Yes. But it doesn't stop it from being true that if you eat a low carb lifestyle, you might see some ketones. Correct? Yeah. Okay.

Jennifer Smith, CDE 55:11
So and that's actually a good point to make in terms of like a little clarity, I should say. The level of ketones very much defines DKA versus nutritional ketosis, which is really what if you're on a low carb or a ketogenic diet? It's really what you're aiming for. Your goal is to get your body burning fat for energy instead of carbohydrates. Okay,

Scott Benner 55:37
yeah. So, alright, Episode 295. And by the way, there's a really deep dive ketone talk in the defining and in other places in the podcast, so it'll get explained much more episode 295 is called insulin resistance and over Bolus, now these two things aren't the same thing. It's just, we set out to make a defining series about insulin resistance, and we started talking about something else, so much so that it belonged in the title, but let's just stick with insulin resistance here. I'm going to ask you to do that one, too, because it's a term I rub up against, and then I get on a soapbox, so I'm just going to let you do it.

Jennifer Smith, CDE 56:16
Sure. I mean, insulin resistance really is the body's inability to utilize insulin at a silly cellular level. At a certain amount, so you need more insulin to overcome the cell's inability to recognize and allow insulin to work. Okay, and there are many, many reasons for insulin resistance to happen. So, I mean, I don't know how much more Yeah, we can't sanative definition.

Scott Benner 56:52
Go listen to the episode, because you're gonna hear it like, if you have type two diabetes, insulin resistance is different than if you have type one diabetes. Right? It's not different. But structurally,

Jennifer Smith, CDE 57:06
it's the same reasoning. I mean, if you have insulin resistance, whether you're type one or type two, insulin resistance is there because your body is just not using insulin the right way? Quite honestly. Could you be? Could you be a lean individual and have insulin resistance? Yes, you could. So I think that's a hard one, especially in terms of defining between type one and type two. Insulin resistance is just you need more insulin to overcome your body's inability to use what it should metabolically be able to use. At a lower amount.

Scott Benner 57:41
I think you should listen to the episode because the words can be used as a crutch with bad settings. So Correct. Yeah, insulin resistance is exactly what Jenny said. But what if you're your ratio, carb ratio, right? Your one unit per 10, carbs should really be one unit per five carbs, and then your blood sugar goes up, and then you correct and your correction ratio is not right, you won't come down, the doctor sees that and goes, Oh, you're insulin resistant. You're not insulin resistant, you're not using enough insulin. So right, so anyway, there you go. episodes, yes, Episode 344 is called feeding insulin. And in my recollection, you have two minutes, I have two minutes. In my, my recollection, that is about when people have too heavy of a Basal profile. And you find yourself constantly feeding the insulin, meaning you're getting low, and you have to keep putting in food to bring it back up. So you don't want to be feeding your insulin. You want the insulin to be set at a place where it works without needing to be offset with carbohydrates.

Jennifer Smith, CDE 58:44
Correct. And you could also feed Bolus insulin. I mean, the first idea is evaluate basil. Absolutely. Especially if you are without insulin on board and you're constantly nibbling to keep your blood sugar up. That's a first analysis Basal. Absolutely. But if you're feeding yourself and snacking, without having to Bolus again, after you've Bolus for a meal, and there is insulin on board, then you're probably feeding your rapid insulin or your Bolus insulin. And that would be an analysis point

Scott Benner 59:18
don't want to feature so So Jenny, we're gonna stop here. The next time we record we're going to pick back up with 347 Bumping nudge. I've loved this. I think this is terrific. So we got through a number in we got through about half of them wasn't Yeah, it did a good job. There was a couple of times I was like, we're just getting chatty. But but but we didn't. We kept we kept it really short. I think this will end up being an episode about an hour and a half long. That will do exactly what all of those people who talked about terminology wanted. So right, excellent. All right. I'm sorry, go live your life and you know,

Jennifer Smith, CDE 59:49
that's okay. I've just got a patient I have to get run. And so anyway, I'll see you next time. Awesome. Thanks. Bye.

Scott Benner 1:00:00
are a huge thanks to Ian pen from Medtronic diabetes for sponsoring this episode of The Juicebox Podcast. Head over now to in pen today.com To get started. And while you're doing that, go download episode 712. To hear the second half of this conversation, Jenny and I pick this conversation right back up the next day, and we finish strong. Hope you're enjoying the bold beginning series. If you are gonna look for other episodes that you think you might also enjoy. Jenny Smith works at integrated diabetes.com In case you want to hire her, and I'm gonna leave you a little bit of information there for the music, about how you can find out more about the podcast, subscribe, and other such things. Alright, some quick stuff you'll want to know. The private Facebook group now has 26,000 people in it Juicebox Podcast type one diabetes, people using insulin, you can hang out, watch what they're saying talk, ask questions, pick brains, or just lurk whatever you need. It's there. Juicebox Podcast type one diabetes, including lists like the bowl beginning series, defining diabetes, the diabetes protip episodes, diabetes variables, all listed in the feature section of the Facebook page Juicebox Podcast, type one diabetes, it's a private group, so you'll have to answer just a few questions so that we know you're a real person. Everything else you need to know about the podcast can be found at juicebox podcast.com or diabetes protip.com. If you're looking for a great endocrinologist, we have a list at juicebox Doc's dot com. It's curated by the listeners, doctors who are down with how people who listen to the podcast they care their type one. You want that part to be easy to write juicebox docs.com completely free. Everything is free by the way, find me on Instagram, find me on Facebook, find me somewhere. If you're enjoying the show, please leave a beautiful rating and review in whatever app you're listening in. Like five stars. This is amazing. And then give a really great description. So the next person who sees your review will know that it's worth listening to. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast and don't forget that episode 712 The second half of this episode is available right now in your podcast player or at juicebox podcast.com.