#727 Bold Beginnings: Target Range

July 29, 2022Scott Benner

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.

+ Click for EPISODE TRANSCRIPT

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 727 of the Juicebox Podcast.

Welcome back to another episode of bold beginnings today, Jenny Smith and I will talk about the target that you're trying to keep your blood sugar in that range that we're all hoping to stay in. While you're listening. Please remember 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. Hey, can I bother you to please go to T one D exchange.org. Forward slash juice box join the registry, take the survey, that's all takes fewer than 10 minutes. You just need to be a US resident who has type one diabetes, whereas the caregiver of someone with type one head over there today. It's completely anonymous, absolutely HIPAA compliant, and all you need to do is complete the survey to help people living with type one diabetes. The bold beginning series began back on episode 698. And there is a complete list of episodes available on my private Facebook page called Juicebox Podcast type one diabetes, it's up in the featured section should go take a look

if you're enjoying this series, you probably should head over to the defining diabetes series and the diabetes Pro Tip series to learn more. This episode of The Juicebox Podcast is sponsored by Ian pen from Medtronic diabetes. And you can learn more about the in pen right now at in pen today.com

Jennifer Smith, CDE 1:55
thanks sorry, I was late. I was changing a screaming pad.

Scott Benner 1:58
So it's no trouble at all. The fun stuff life. We we were recording so cool. Ardens Dexcom has been expiring at 11:30pm for like, seven months right? Like we just I don't know what happened. You know, we ended up changing it

Jennifer Smith, CDE 2:16
like that like the ad hour like you let it go and or is that like the empty hour or

Scott Benner 2:22
the Dexcom? Dexcom. Not to CGM is Dexcom. Not okay. Now I see. Yeah. So we ride that thing right to it like right till the end. Yeah, I am, too. And every, every time we've changed it over the last six, eight months, however long it's been I might have lost track. I walked to her, she texts me whatever. And we look at each other bleary eyed, so tired. And I realize like, Oh God, I'm up for at least two more hours now. Right? And I look at her and go, the next time this is done. We're just going to change it a few hours earlier. She goes That's a good idea. We should definitely do that. Right. Yeah. This time. I set an alarm. I like told my phone basically. Hey, Siri, in nine days, and blah, blah, blah, hours remind me to chase. So yesterday afternoon, it goes off when I Oh, cool. We're gonna finally do this. And then we forgot.

Jennifer Smith, CDE 3:15
Because you turn the alarm off, right? I do that I turn the alarm off. And then like, Oh, what was that? Again? This was due four hours ago. We

Scott Benner 3:22
had a whole conversation about it yesterday. And I said, Listen, let's change it around five o'clock. That's a good idea. We'll do that. And then next time, we can adjust it into the three if we want her to the seven if we want we'll decide, right? And she's, she's like, Yeah, 1030 Last night, I texted her, I feel bad. I just texted her the F word. She's like, what's wrong? And I was like, we didn't change that. Thanks, God. So we ended up doing it like 1030 Last night.

Jennifer Smith, CDE 3:49
Well, let's do was an hour earlier.

Scott Benner 3:51
You're trying to make me feel better. But that's not

Jennifer Smith, CDE 3:53
ours better than you know. i You try.

Scott Benner 3:56
I'm old. I can't be up that late anymore. It's not good for me. So anyway, today, for the bulk beginning series, we're going to record the topic of range. So, so far, Jenny, I know it doesn't seem like it has been together is so delightful that it doesn't feel like time has passed at all. But we've recorded honeymoon, being diagnosed as an adult terminology would end which ended up being two episodes because it was long. There was lots in there there was we've recorded highs and lows, which basically is fear of insulin. We've recorded the 1515 rule, long acting insulin, and today we're going to do range and maybe we can sneak in food choices if we have enough time. Oh, that puts us only 1-234-567-8910 1112 just 14 more topics away from buttoning the series right up so we're doing terrific. I know as

Jennifer Smith, CDE 4:56
you said the the other than not that today his tactic but the food choices in my head right away flashed this like this like dangerous.

Scott Benner 5:08
We're gonna make people hate us. It's like Oh Please don't hate me. We I think in one of the the fear of insulin we we drifted into it for five seconds and even if we were talking about there I thought some of them's not gonna like hearing this but whatever. But for right now, yeah, range is a nice easy one. Great Yeah, no one's gonna be mad at us for talking about this probably. Okay, so again this series is for people who are newly diagnosed. And the way it began was we reached out to the Facebook group and said to them, what do you wish you knew in the beginning? And here are some of the responses that fit in this topic. What range to be, or to shoot for was really hard to understand. I would have been, it would have been easier to explain that they want him to run on the high side. So let's see right away. This is interesting, because we're getting a look into what doctors say, right? Apparently, they wanted the kid to be higher. But the mom found the online world pretty quickly and decided that wasn't a good thing. So what did she say here? Okay, they wanted him to run higher as his body adjusts for a few weeks was what she initially found out is what they meant.

Jennifer Smith, CDE 6:33
As they said, it probably wasn't explained that way.

Scott Benner 6:35
No, she's like, clearly what was going on is they wanted to figure out the doses. But none of that was communicated whatsoever.

Jennifer Smith, CDE 6:44
Correct. It was a poor communication. See bad pod? Sorry, my noises are going.

Scott Benner 6:50
even heard that one in a while? No, I

Jennifer Smith, CDE 6:53
know, my my high alarm, which isn't really I mean, it's not high. My high alarm is set for 130. Really not high. But it's just telling me clearly. Anyway. Yeah. So you know, initially, she should have been told, Hey, this is what we're aiming for. Here. Because of these pieces, we aren't quite sure how sensitive your child is going to be once we introduce insulin. And as the body starts having like more normal looking blood sugars, the body starts responding or coming out of DKA or whatever, right? And then we're going to transition down to a healthier target range, right. But that's it's not usually clearly explained.

Scott Benner 7:37
And obviously not because the very next statement is someone said, I wish they would have told me that being 200 for a few weeks was okay as the body adjusted, but that we were going to taper down to a more realistic and healthy range. That it may take a while to normalize blood sugars. So yeah, you're right. This is this is the thing that people don't get told. So let's kind of break that apart for a little bit. So I mean, you're diagnosed, I'm assuming most people are diagnosed with a higher blood sugar that's probably been higher for a while. And they even though they get you down in the hospital, you know, it's funny, I say that, like, that's the norm. But how many people have I talked to who go to a hospital or sent home right away, or were diagnosed during COVID and weren't even allowed in the hospital? Right? So what happens is there? I mean, obviously, you don't walk into the hospital with a 700 blood sugar, and they're like, we'll just fix that right now. Like there's a very slow type titration that takes place in the hospital, if you're if you're there is that for safety reasons.

Jennifer Smith, CDE 8:39
It is for safety reasons. You know, if you adjust the body from the idea that you're not quite sure how long blood sugars have been so elevated, right? For kids, it's probably not been that long of a time. It happens very quickly that turnover or that transition. But there is a slow progression of beta cell loss. I mean, if you look at the research in the development of type one, there is this progressive nature to actual diagnosis. But the high blood sugar's aren't really until that very end point near diagnosis, but you still need to be very careful about bringing those blood sugar's down. Because the body adapts pretty quickly to its new set range. And if you've been running at 300 Plus for a week or two weeks or three weeks, that needs to be certainly brought down slowly not to the point of you're waiting eight weeks to bring those high blood sugar's down but in the hospital if you have had a chance to have an inpatient stay, or a closely followed outpatient, you know, diagnosis and, you know, collaborative work with a with a health care team. They will still try to really bring things down slowly because again, once you add insulin into the picture via injection, whatever betas may be left, actually, they get a little bit of a rest, and then that we've talked about honeymoon already, that honeymoon could kind of come back into the picture. So they do have to be very careful.

Scott Benner 10:15
Yeah. And I'm assuming that the wider range is because of that partially. And because of also partially, they're not sure if you're going to get home and get a little, you know, rejuvenation out of those beta cells and suddenly went down. They don't want to tell you, it's one unit for 10 carbs, and then get you home and find out that, you know, it's a half unit for 10 carbs, because you're getting some help on your pancreas. Right? That's, that's, that's the one half of the reason why they would show you a wider range with a higher ceiling. But the other one could be, they just don't know yet. Right? Like, they're not sure what's going to happen. And Correct, right. And so this person here says, one of the most useful things that I learned from the from the podcast was that I didn't have to accept these out of range spikes at meals, just because she had diabetes, that I can make adjustments to flatten those lines, etc. So I'm going to hold hold the half of her thought there. So that's the next part that I think is important, because you said it a moment ago, if it's not communicated to you, well, this is a completely new thing for you. And they could tell you, I don't want your blood sugar to be under 100. Or, and but it's okay. If it goes up to 200. After meals, they might say something like that. I say this all the time. Like if you don't give more context, your statements in the beginning, when you're teaching something to somebody, they're going to assume that's the rule for forever. And that is what I see with people is that they don't think the people who don't make it online, the people who don't find somebody to talk to just assume, Oh, it's 100 to 200. And these are people you will hear from that have had diabetes for three or four years who are treating low blood sugars, you know, air quotes at 110. Because they're trying not to go under 100. And, and it just skews your way of thinking about it forever.

Jennifer Smith, CDE 12:06
Absolutely. In what you learn, in many things, not just diabetes, but it definitely makes sense when I'm talking about a health condition that's so dramatically impacting right now. And kind of forever. What you teach in those beginning stages, becomes almost a very hard rule that it's very hard to clear out of your brain. I kind of think of it almost like when my little one was starting to ride a bike. My husband, and he, he disconnected the front brake. And he taught my son. The reason was because he didn't want him squeezing as hard as he was. And he was like four years old, right? And like any explained, I don't want you flipping over the front. Well, now he doesn't he still doesn't like that front brake connected, because he was taught that he could have an accident in which he flies over. First, right. That was what he learned initially. And it's hard to unteach

Scott Benner 13:04
I also think that with people with diabetes, you see that with where they where their devices, like the the first place they put it is the place they think it belongs, you know, and that happens to kids a lot too. It still happens to Arden I moved Arden's Dexcom for her yesterday's we were talking about in the beginning, which I think will be in the episode. And she wears them on her hips. That's it. And I put it on and she goes, That's too high. And I'm looking I'm like, it looks fine to me. You don't I mean, and if it was higher than the last time it was there, it was by a half an inch, you know what I mean? But she acted like, and she's pretty reasonable. She's like that, like it

Jennifer Smith, CDE 13:42
was on her forehead instead of like,

Scott Benner 13:44
what are you doing? It's under my arm, you know, like, like it was. So it's just in her head. That's where it goes, I think. Okay, so back to this lady's point about I wish I would have known that the blood sugar's don't have to spike up after meal. She also says on the flip side, I would have liked to have known that we that lows weren't a thing that happened. Her main message here is she left the hospital believing spikes and lows were part of it.

Jennifer Smith, CDE 14:13
And we're going to be what she should see.

Scott Benner 14:16
Yeah, yeah. It's funny her description. It's not well written, I'm sorry to the person who wrote it. But But because so reading, it's not going to help you much. It's why I'm picking through it. But the intent of this statement is, it's almost like she's in a bad relationship. But somebody told her this is what it's like to be married. So you just have to deal with it. Like, right? Yeah, it's, um,

Jennifer Smith, CDE 14:38
it's interesting. That's too bad.

Scott Benner 14:40
Yeah. Right. Like, I mean, you know, way back in the Pro Tip series. You know, I said all the time, and I haven't said it enough lately, but it's my least favorite part about diabetes is when people get caught in a situation where they find themselves saying, well, that's just diabetes. That's how it happens. You can't avoid that. And you can and she's like, I wish someone would have told me that it was possible, even if even if I wouldn't have been able to do it right away the knowledge that it was on the horizon would have been a nice idea. Right? Absolutely. Now, I think the reason people don't get told that is that many times, they're with physicians who don't know how to stop spikes and highs and, and that's why you don't get told it's possible to fix.

Jennifer Smith, CDE 15:23
Well, and I think when you're talking about range to range is something that will evolve, so to speak, as you become more comfortable, and comfort comes from learning more, and experimenting more and paying attention to what happens for yourself or your child or the person that you're helping to care for. So that range may tighten, and be different than when you were first diagnosed, or even different than when you were six months out from diagnosis, right. And they may shift through life or through each variable, you might have different ranges that you're aiming for. So I don't think that there's a, there's not a hard and fast range.

Scott Benner 16:10
No, I imagine that you probably talk to people who are older, elderly people, you probably start shooting for a wider range. And, and that makes sense to and younger kids who I don't know run around a lot during the day and you know, get bursts of exercise that you don't expect, you might have a different range for them. But none of that changes. The goal, right should be the goal range, and the places you have to adjust that range for your specific situation. Again, I just think the biggest problem with this, this this piece is that is it, nobody tells you the first numbers I said out loud are not the thing you're going to be doing your whole life. There's some other statements here from people. I wish someone would have told me that everything seems to affect my blood sugar. So the I think the variable series does a good job of shining a light on that if you want to know about some things that that that can impact your blood sugar that no one at the hospital or a doctor's office might bring up. This, the next statement is I would have liked to known what main factors can increase or decrease the need for insulin. And then you know what I mean? So food

Jennifer Smith, CDE 17:19
again, there's variables, that's certainly relative to the variables too.

Scott Benner 17:23
But I think I think that it also it shines a light on the, you know, all carbs aren't created equal idea. Yes. Because the in the beginning, in the beginning, when you you're told that formula, which is what the next statements about them trying to lead into that. And then it you know, one day eat, I don't know, doesn't matter have french fries, the next day, you eat a salad that has some carbs in it, and it doesn't work out the same way. It fries your brain. You're just like, Wait, yeah, it was 12 carbs, they were both 12 carbs. Right? And then you start saying silly things like I did the exact same thing today that I did yesterday. And it didn't work except you didn't see all the variables, and it really wasn't the exact same thing. You know. So this, this person says, What did those numbers and that correction formula even mean? My son was diagnosed, and we were sent home with a mathematical formula. We're told to follow it daily. But I still don't know what the numbers are even referring to. And John, Jenny, as you know, that feeling is what spawned my blog in this podcast. So do you know what formula she's talking about?

So you're using multiple daily injections for an insulin pen, and you want more, but you don't want to move to an insulin pump. That's okay, because the option of the in pen from Medtronic diabetes might be the perfect solution for you. The in pen is an insulin pen. But it does more because it connects to the app that gives you your current glucose readings, meal history, dose history, activity, log dosing calculator, active insulin remaining glucose history and reports for you or your doctors to look at. Doesn't that sound like a lot of good information to have right there on your smartphone? I think it is, too. So how do you get started with the M pen you go to in pen today.com. When you get there, you're going to be able to see everything that I've already told you about and more. Not only that, but if you'd like to talk to somebody about the M pen, right? If you'd like to schedule an online health care provider visit, you can actually do that at my link. And you can also just get started in pen today.com. If you'd like to see how the dosing calculator works, there's a video there. You can click on it and watch it. I just clicked on it now, but I'm not going to watch it because I've seen it already. Plus, you wouldn't be able to see it. Anyway, to go learn More about the dosing calculator dosing reminders, card counting support, and the digital logbook, head over there and watch the videos. You may even be eligible, right? It's possible. And this means here's what this means. There's like a little disclaimer here. This offer is available to people with commercial insurance, and Terms and Conditions apply, but you may pay as little as $35. For the embed, go check it out. There's so much on that link, you can't go wrong in Penn today.com. In Penn requires a prescription and settings from your healthcare provider, you must use proper settings and follow the instructions as directed, or you could experience high or low glucose levels. For more safety information visit, you guessed it in Penn today.com. Hey, this isn't an ad, this is for the podcast, I'm gonna put this in here, I don't usually do this. But if you're listening to the bold beginnings episodes, when they're over, you might want to move up to the defining diabetes episodes and the diabetes Pro Tip series just like I was talking about earlier in the episode, you can find all of them at diabetes pro tip.com, or juicebox podcast.com. When you get there, you're gonna see something that says type one diabetes Pro Tip series from the Juicebox Podcast. And there's a little introduction there from me. And basically what it says is, look, my daughter has had an A one C between five, two and six two since 2014. With zero diet restrictions. This information works for children, adults, and for the newly diagnosed. And for those who have struggled for years, I believe that anyone living with type one diabetes can use these simple concepts to stabilize their blood glucose levels, lower agency and improve glycemic variability. Again, with zero diet restrictions, check out those episodes, diabetes pro tip.com, or juicebox podcast.com. And of course, they're right there all the episodes in a podcast player of your choice, whether you're on an iPhone, or an Android. And please keep this in mind too. All of the content within the Juicebox Podcast is free. And it's always going to be there's no need to pay for this information. I just want you guys to be as healthy as possible, support the podcast in any way you can through the advertisers filling out the survey at the T one day Exchange, or just telling somebody else about the show, will you support the show, the content keeps coming and it stays free

Jennifer Smith, CDE 22:37
I would expect they were sent home with a little bit more of a specific or a precise, I wouldn't necessarily call this a sliding scale that's more of a hard and fast if your blood sugar's in this range, take this many units of insulin right. Where this gives a little bit more precision because that formula gives you a way to calculate a dose just for correction insulin When blood sugar is high. So they may they will give you a target blood sugar. So your formula should say current blood sugar meaning where it is right now whether it's from a finger stick are from your CGM, your current value right now. And then you're going to subtract from that target your target. So if they told you to target 150, great, you're going to subtract your current 250 blood sugar. And then you're going to take away the 150 target, which leaves you 100. Right. But that number looks odd until you factor in what they've given you. And it's called a correction factor. That correction factor is how many points one unit of insulin or for some little kids, they might have said how many points or half a unit of insulin may drop your blood sugar, right. So let's say your correction factor that you've given been given in this formula. Target blood sugar 150 correction factor is 100. So, so we're going to take 100

Scott Benner 24:17
If you had a 300 blood sugar, you would subtract 150, which is your target which would leave you with 150 Correct but in your in your thing you need but

Jennifer Smith, CDE 24:27
and then you have to divide that value by the correction factor they

Scott Benner 24:31
gave you to use. In this example, we're using a correction factor of 100, which means we're assuming all unit of insulin is going to bring your blood sugar down by 100 points. So 150 divided by 100 gives you how many units to take. And that would be 1.5 1.5 units exactly based on all of that and then the problem is that all seems so like specific. And then when that when it doesn't work, you're like, it's impossible. I've got this mathematical formula that gave me all the people in the white coats for like, here's what you do. And they explain it hopefully the way Jenny did, which was very clear. But they don't tell you something in this example, like, when your blood sugar's really elevated, you may need more need more insulin, right? Right. And then you could

Jennifer Smith, CDE 25:23
or if it's right after you finish playing three hours of soccer in, you know the field with your child during a tournament, and now you're correcting a blood sugar that's too high. Well, activity is the variable in the picture now. So you may use this formula. And you may see a really dramatic drop in blood sugar and think, Well, gosh, it usually works. Maybe something's changed and nothing's changed. It's the fact that there's no exercise in the picture that makes the insulin work better. So these formulas are a place to start. Right. And they do need some adjustment. Pretty soon after initial diagnosis.

Scott Benner 26:02
I've also found over the years that having a CGM Arden has the Dexcom that it takes away. I don't think about the the range as much anymore. As soon as I think about, like rolling. Like gentle lines. Yes. Right. That's more how that's more how my brain thinks about it. Now, instead of like, I'm trying to stay under this number or stay over that number. I just think I'm really trying for there not too many sharp falls, or sharp peaks. And they, you know, I don't know like, I don't even think of them as numbers, I think them as lines. Right?

Jennifer Smith, CDE 26:42
It's exactly it's almost like the sky and sort of the ground, if you will, and you have this range that you're trying to fly like a glider plane through, and you want this nice, gentle rolling effect rather than these big JJ like roller coasters is not what you want. It's also

Scott Benner 27:02
really interesting how a visual representation of it changes your feeling about it. Because you know, if your high alarm just went off at 130 Arden's high alarm is 130 on her phone. And it's i It's 120 on mine, so I can react a little quicker to if I guess I have to find or somewhere or something. But it's funny that when you look at it visually, you're like, Oh, my God, what's this crazy spike here. And then you go back and realize it went up to 120. Right, because it visually looks like a crazy spike. But that almost trains your mind to work within the range that you've set up. Anyway, if you're lucky enough to get a CGM, you'll, you'll see what I mean. Last thing here for range, someone says the quicker that you can learn about your glycemic sensitivity and insulin sensitivity, the quicker you can use that information to make broader changes. And this does really affect your time and range. So I'm guessing we've already talked about this, right? But they probably were eating some foods that hit a lot harder than than the ratios, their insulin ratios could handle. Right? All right. So find that in an episode called food choices. That's either out now or will be out very soon, depending on when you're hearing this. Yay. All right, Jenny, take a deep breath. We're gonna do the food choices. Fantastic. So much here too.

Jennifer Smith, CDE 28:28
I am quite sure you got the gamut from one side to the other. And in some of it, I think it's interesting what you texted to me the other day because some people are so quick to latch on to one nutrient being the the the end all be all of this is what solved it for me.

Scott Benner 29:01
Jenny and I are going to continue that conversation in the next bowl beginnings episode called food choices. But for now I'd like to thank in pen from Medtronic diabetes, and remind you to go to in pen today.com To get started right now with an insulin pen that talks to an app on your smartphone, giving you much of the functionality that people have come to expect from insulin pumps. If you'd like to check Jenny out, she works at a place called integrated diabetes.com. Her services are for hire. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.