#735 Bold Beginnings: Pre Bolus

August 16, 2022Scott Benner

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

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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 735 of the Juicebox Podcast.

On today's episode of bold beginnings, Jenny Smith and I are going to be talking about Pre-Bolus simple concept that not many people learn about. Don't forget the bold beginnings series is all about things that listeners of the Juicebox Podcast wish they would have known in the beginning. While you're listening today, don't forget 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. If you enjoy Jenny Smith and you'd like to hire her, she works at integrated diabetes.com. If you're liking what you're hearing in the bulb beginning series and want to expound learn more, you're looking for the defining diabetes episodes, and the diabetes pro tip episodes. There are lists of them at the Facebook page Juicebox Podcast type one diabetes. In the featured tab that's a private group with over 27,000 members. If you're not on Facebook, check out juicebox podcast.com or just search in your favorite audio app.

This episode of The Juicebox Podcast is sponsored by in pen from Medtronic diabetes, take the right insulin dose at the right time. The right pen is a reusable smart insulin pen that uses Bluetooth technology to send dose information to your mobile app. Offering dose calculations and tracking in pen helps take some of the mental math out of your diabetes management. You can get started right now within pen at in pen today.com. Or perhaps you're ready to talk to a healthcare provider about m pen. Again, in pen today.com. Head over there now to hear about the app that has current glucose on it meal history, dosing history and much more like dosing reminders, carb counting support and that digital logbook, lighten your diabetes management load with in pen from Medtronic diabetes seriously, in pen today.com. Just head over now and check it out. impendent is an insulin pen that you may pay as little as $35 for offers available to people with commercial insurance terms and conditions apply. But $35 for an insulin pen that talks to an app on your phone and keeps track of things. Not unlike an insulin pump. This sounds like something you want to learn more about in Penn requires your prescription and settings from your healthcare provider. You must use proper settings and follow the instructions as directed. Or you could experience higher low glucose levels for more safety information visit in Penn today.com. And just like that, I've gotten the ads out of the way for you. So you can listen straight through to Jenny and I talk about Pre-Bolus. Jenny, our bowl beginning series is going along well. We are making our way through so far we have recorded and put up honeymoon being diagnosed as an adult terminology which came out in two parts. Fear of insulin, the 1515 rule, long acting insulin, time and range like what range is shooting for and food choices. today. We're going to talk about Pre-Bolus Oh, yes. So I hope you're ready. I'm gonna scroll down to people's,

Jennifer Smith, CDE 3:43
I'm always ready. I never know what we're topic going to kind of address here like here, this is today.

Scott Benner 3:50
Like you're like You're like a member of my gang. You're like we can do it. Let's just go out right now. Always ready.

Unknown Speaker 3:56
What's the plan?

Scott Benner 3:58
Nevermind. We'll figure it out as we go. So the first person just says, I wish we had been told about Pre-Bolus Ng and I'll have to tell you, I'm reasonably astonished when I see people who for days, weeks, months, and sometimes years of their lives using insulin, run into the idea of Pre-Bolus in one day, and they just go I've never heard of this before.

Jennifer Smith, CDE 4:21
Correct. I've gotten multiple comments like that. And the assessments that come in for the people that I get to work with. That's one of the big things there like I had somebody just told me about this, or the emails that I get, you know, asking about, like working together. Nobody had told me about Pre-Bolus thing I've been you know, I've had type one for 40 years and nobody told me

Scott Benner 4:44
like, I talked to somebody recently diabetes for 50 years. And I said how do you handle your meals? You're like, you know, I just sit down and I Bolus the night. And I was like it was like like a Pre-Bolus No, I mean, just you know, just do it at the same time. Why do you not do it earlier? Why would I do that? Right? Well, what about this? And they're like, Oh, that makes sense.

Jennifer Smith, CDE 5:06
Well, and usually, I think the first piece of that comes with the rapid acting that we have had around for a number of years already has the idea that rapid means rapid. So when it's prescribed to them in terms of what the doctor or educator has given them an information it's take the insulin, start to eat your food, this is a rapid acting insulin. But we've talked about for rapid is not rapid, I think still needs time,

Scott Benner 5:39
especially for people who've never used to CGM or worn one, that you can't really see how food impacts blood sugar, and how long it takes for it to start moving. And you can't see the differences between different types of carbs. And so if like, you're saying, if somebody says, well, it's rapid, I couldn't take my rapid insulin 15 minutes before I eat, because sounds like I would be in trouble. I don't want to get low, and they've probably seen themselves get low at some point. And then it then some, you know, probably not for the same reason. But then anecdotally, they believe I couldn't possibly ever do that. So the next person says, it would have been nice, if someone would just would have explained the importance of Pre-Bolus thing. So I think we should. So if you're newly diagnosed, someone's giving you insulin, and they're telling you probably count your carbs, you know, this formula will tell you how many you know how much insulin for this for this amount of carbs. The thing you need to understand different, I think, big picture is that the impact of the carbs happens over its own timeline, just as the impact of the insulin kind of happens over its own timeline. So if you just sort of like picture in your head, you know, a flat line going along your blood sugar at any number, it doesn't matter where 8590 110 200 Wherever you start eating at, you have like some stability, and then all the sudden the food starts to push your blood sugar up. There's sort of a bell curve that happens, they're going up yep, at the same time, the insulin tries to push your blood sugar down. So there's a bell curve going down, you need to line up the the impact of the carbs and the action of the insulin so that they're fighting with each other instead of just working unencumbered, I guess it's correct way to say, All right,

Jennifer Smith, CDE 7:22
yeah, you want to time them appropriately. And I think they're in brings, I think, brings in another piece, potentially, to timing, from initial diagnosis. Most people are told, you don't have to change a thing that you're eating, you don't have to change a thing that you're going to feed your child or your teenager, just remember, you have to take insulin for whatever is eaten. Yeah, well, if if that's the case, then in they're not really transitioning at all from what they had been eating, which may be very high carb or very high glycemic types of foods. But you're also told rapid insulin, just take it before you start eating. As you just said, the timeline there of action is going to be very displaced. And you want to, you want to line those up or overlap them, almost overlay them so that the insulin and the foods start to work better together.

Scott Benner 8:20
I also think that it's possible that the statement from a doctor, you're not gonna have to change how you eat is true. But if they don't give you more context about how insulin works, that's not going to be very helpful, because it will seem like you have to change how you eat. My point is that I believe, I believe that if a doctor says you don't have to change how you eat, and here's how you use insulin to make that true. That's one statement. But you are also going to run into doctors who are trying to soothe your soul with with that, right, you know, they're, they're just trying to they're trying to say, Look, I know that you've just found out that you or your kid has diabetes, this is all very shocking. We're talking about insulin for food. But don't worry, you don't have to change how you eat like, you know what I mean? Like that's more it makes

Jennifer Smith, CDE 9:06
it it makes it easier, right? Like, there's one easy piece it's a comfort to know, well, I can keep eating, you know, Froot Loops for breakfast.

Scott Benner 9:15
Well, and that's the other thing is they don't ask you how you eat, you know, they just like don't worry, you won't have to change your over and they're like, Wow, this is great, because I eat Popeyes for lunch. And I have this and I love it crispy chicken sandwich. Oh, it's gonna be like, and so it's a lovely thing to say to somebody and I happen to believe it. You know, I think you can manage insulin for different eating styles. But you can't just tell somebody, oh, don't worry. You don't have to you don't have to change how you eat, but not give them any more context than that so correct that Pre-Bolus thing. I mean, I guess the last thing I'm going to say before I move on to my next thought is that we did the these episodes are in an order for a reason honeymooning happened first because Pre-Bolus thing if you're honeymooning This is gonna look different than if you had diabetes for a while to, you know, so you have to be careful about that. Because you might have, I mean, you see people worrying about it all the time, go back to the honeymoon episode if you don't know what we're talking about. But if your pancreas is still making some insulin, you don't want to like, be out ahead of the charge, don't like, Don't worry, I'll take care of it too. Now we got everybody trying to get your blood sugar

Jennifer Smith, CDE 10:21
down. And the reason that concept of Pre-Bolus in comes after we've talked about the impact of food becomes even more beneficial than it sort of adds a layer to understanding, oh, I guess this discussion around like nutrition intake or food intake. Looks like I really do have to pay attention to insulin, and oh, look, Pre-Bolus is the next thing to really bring into the picture along with what I choose to eat. So

Scott Benner 10:47
yeah, I mean, there's, listen, there's a level of of proficiency, you need to Bolus for more difficult foods, right. And yours. And Pre-Bolus thing is a big part of it. This person says here, I was really confused on whether I should Bolus before or after a meal. It's interesting. She says, they made this sound like a preference and not what would work best. It took me five years into diagnosis to learn about Pre-Bolus Singh. And I only learned because of the podcast. So no one, no one really told me about told me that insulin doesn't work immediately that it has a lag time, whether I'm injecting it or pumping it,

Jennifer Smith, CDE 11:28
which is really interesting, because it Pre-Bolus thing is not it's not a new concept, by any means. When I was initially diagnosed, and I was using our insulin, regular insulin, which is short acting, takes a longer time to get moving in your system that was told to my parents and explained very well from the beginning. If you're going to eat at noon, Jenny needs to have her insulin by 1130. At the latest in order to make sure that it's moving along with the food. So this concept of Pre-Bolus is certainly not. It's not just because we have rapid acting insulin. And we it's it's been around for a long time. But it seems like there's a disconnect in terms of who teaches about it, or who doesn't.

Scott Benner 12:21
I think you're you've I mean, for all of time, you're you've been trying to balance the action of the insulin against the impact of the food, it's just that the amount of time that it takes for insulin to begin working has changed over the years change. Right. Right. And so it's the same game. It's just different parameters. Right? Yeah. It's just It's fascinating that I mean, it's somebody could get five years into this and have to find a podcast to learn about it. Because guess what they fall into is that, well, this is just diabetes. This is what diabetes is I eat my blood sugar goes to 250. It stays there for a couple of hours. I mean, it comes down rap, and it comes back down again. Yeah. And that must be what this is, because it happens every day. And so that's that. Here's a great, but yeah,

Jennifer Smith, CDE 13:06
and those are also the people that ended up getting sort of hand slapped at visits with the doctor, for why are your blood sugars not like more contained, let's add more insulin probably in the wrong place? Because of the mismanagement of insulin specific to food. That's unfortunate. Yeah,

Scott Benner 13:27
it's that concept of Listen, I'm not trying to be funny here. But if you're married, you know the concept of moving the goalposts, right. Yeah, yeah. You're told that the goal is here. And then you start working towards that goal, and someone comes in and goes, none of the goals over here now. So no, no information about Pre-Bolus thing. And then it's your fault. Your blood sugar's high. Well, what are you doing? What are you eating? This, you know, and when you start getting questions like that, my opinion is you're either with an under skilled clinician, or a lazy one, one or the other, who's putting it back on you. They either don't know or they don't want to try. It's one or the other. Because if you knew how to use insulin, your blood sugar would knock up to 50. FDA correct. Just wouldn't tip here from this person Pre-Bolus thing ahead of time, like when I'm finishing cooking, so that it doesn't feel like I'm waiting forever to eat. So this is a big part about Pre-Bolus thing that we never talked about. There's a little beautiful post this cute little like cherub face girl on my Facebook page the other day, she's like four years old. And the moms video is showing us a video of her and this girl is just like, I don't want to wait.

Jennifer Smith, CDE 14:44
That's so cute. It's cute, but it's sad.

Scott Benner 14:48
It's both things. And so it kind of sucks because yes, you do sort of have to Pre-Bolus ahead of time and think about it like when you're driving to the restaurant is That time, or is it when I get out with a car at the restaurant? Or is it when I order you know, because I don't know how long it's going to take for the food to come. And that's one problem. And when you're cooking at home, it's one busy cooking. And so I don't I didn't remember to do this. Now what am I gonna sit and watch the food get cold? I'm not going to you do have to think ahead. I'll tell you. There's all kinds of strategies if, if we're on our way to a restaurant, and Arden's blood sugar's terrific. Then I don't nothing right heart, right. But when we pull up, I know the restaurant a little bit. I know we're going to be eating 20 minutes from now, or 30 minutes from now, and about what she's going to eat. What are we gonna have? I might be like, Hey, why don't you Bolus like five carbs 10 carbs now then after she eats, we check again, put in a little more, I'll tell you with that strategy. We went to a place the other day, Arden had her period. I haven't said Arden had her period in the podcast for a while. So I think it was about time. We're going into this diner kind of place where she is going to get something not good. Like, like, quality wise, this is going to be a French toast and real syrup. And or a macaroni and cheese situation. She's just juggling the possibilities in her head on the way to the place. Right. And on top of that she had a little ice cream while we were waiting to leave. And so she missed on her ice. I said did you Pre-Bolus This ice cream? She goes look at my graph. Does it look like I did? I said no, it doesn't. So heading up 141 50 We're trying to Bolus it. And we roll into the place where already bolusing in the in the parking lot because this one, it's 170. Now like she totally just booted the the ice cream, and her blood sugar leveled out at 200. But still, with all that Pre-Bolus thing, we she ate a massive, I'm just gonna call it a pile of macaroni and cheese like all kinds of cheese. And within a two hour window, she went from not Pre-Bolus and ice cream to eating macaroni and cheese to back to 95. Right. And it's because of where we thought to put the insulin correct nothing else. It's I mean, well, and

Jennifer Smith, CDE 17:10
where to put the insulin with a little bit of good information or attention to the information you have. Right? Had you only had finger sticks, that would have been harder to do? Oh, of course. Right? We we have access to where our levels are trending now because thankfully, a lot of people have access to using a continuous monitor. Right. So that's a teaching piece in terms of Pre-Bolus. And the idea behind it and a comfort level around starting to do it if you've never had that, you know, in your habit before for food is where's your blood sugar, like you said, if it's level coming in or on the way to a place you're going to eat. Maybe you don't Pre-Bolus until you get to the parking lot or until you actually get seated especially you know, if it's more of a sit down kind of place, you have this waiting time. Whereas, you know, if your blood sugar is already heading up, you're going to do something about it, even if it's just the corrective insulin that you take right now. So that you can get some things leveled off before you actually sit down and Bolus for the food. So there's a lot that you can use your CGM in a high level way to learn how to put insulin in in the right place.

Scott Benner 18:26
That story is a collection of my I mean, 14 years of knowledge having a CGM, knowing how to Bolus for foods not the first time she had macaroni and cheese. You know, like there's all kinds of stuff that I knew about that it is not the story about the time we Pre-Bolus in the parking lot of a restaurant and then walked in and found that no one brought their wallet with them. Oh, that's fine. Yeah. So we were like, just back in the car, just hammering home, trying to get some food before the Pre-Bolus word still worked out. It was just a little more stressful.

Jennifer Smith, CDE 19:00
My strategy would have been like, somebody goes home to get food, get the wallet, the rest of us go into the restaurant and order. And that would have been my strategy

Scott Benner 19:09
with me and kids at that happened a long time ago, I would have been abandoning small children in a restaurant, but which by the way, they probably would have been fine. I mean, look where they ended up with my help. So this person says, Oh, this is about timing of a Pre-Bolus. And I'll tell you, you know, this is the next step. When somebody wraps their head around, I'm going to Pre-Bolus They want to know how long, five minutes, 10 minutes, 15 minutes. And to me, I mean, it that has a lot to do with where your blood sugar is at the moment. What it is you're going to eat next. And then you got to practice. I mean, right. You know, if you have more to add to that, go ahead, but I haven't been able to figure out any more than that in all these years.

Jennifer Smith, CDE 19:50
No, I mean there is there's an assumed strategy to get going with again, a lot of it is relative to the content of the meal and You know, if you're sitting down to a chicken caesar salad, you're probably not going to have a really long Pre-Bolus Again, depending on where your blood sugar is sitting. But even then a meal like that being lower on the scale of glycemic index comparative to a big bowl of rice and grilled chicken. There's a difference there, you know.

Scott Benner 20:22
So well, Jenny, somebody said something I want to pick your brain about, they said, there's a rule of 10 that they were taught. It said, take the blood sugar you have now and divide it by 10 for your Pre-Bolus time. Have you ever heard that?

Jennifer Smith, CDE 20:41
I have not. That's an interesting concept. So if your blood sugar is 180, you should have an 18 minute Pre-Bolus

Scott Benner 20:49
s3 Pre-Bolus a half an hour before? So I

Jennifer Smith, CDE 20:53
guess. I mean, to a degree on the lower end of blood sugar, it still tells you, you still need some whatever. Pre-Bolus you know if your blood sugar's 70. That's still a seven minute Pre-Bolus time.

Scott Benner 21:05
Yeah, I that's the one thing I still can't hammer through Arden's head, like without me there. Going back to the ice cream store. I said, Why didn't you Pre-Bolus The ice cream? She said, Well, my blood sugar was 90. And I said, that don't matter. You still need to Pre-Bolus

Jennifer Smith, CDE 21:21
good blood sugar,

Scott Benner 21:23
good blood sugar. We're trying to keep it here. And right. And she just was like, okay, and then that was it. But she's 18. And, you know, yeah. But anyway, Pre-Bolus your meals? Like, I'll tell you right now with no, I have nothing scientific to back this up. You start Pre-Bolus In your meals, I think you're a once he goes down a point. I just think it does. You know, I think if you wonder why you can't get into the sixes, and you're not Pre-Bolus eating meals, that's probably a large reason why

Jennifer Smith, CDE 21:54
this, especially if you're a one C is if it's under eight, but not quite where you want it yet, let's say in some range of five and a half to six and a half. If that's your pie in the sky kind of place to get to. If you're higher than that. Pre-Bolus I would agree with you. It's a lot of the reason that that a one C tends to be higher is the post meal time period that's left higher than you want it to be. Especially if your overnights are really solid value that's in target and right where you want it to be. If you're having post meal excursions, getting those contained with just the concept of a Pre-Bolus If you hadn't been doing any at all will likely bring your agency down.

Scott Benner 22:38
I like that you've been saying excursions lately?

Jennifer Smith, CDE 22:41
Oh, yes. I like that word.

Scott Benner 22:44
My new favorite. It's my new favorite thing. I don't know why exactly. We left anything out here. Are we good?

Jennifer Smith, CDE 22:53
Um, I don't think so I think from a base level, it gives a good idea of the Pre-Bolus concept. I mean, there's certainly a deeper dive into it. But other than that we've given a good,

Scott Benner 23:05
right click go head over to the, to the protests to learn more, but I'm just going to tell you right now you got to Pre-Bolus your meals, like there's situations where you can't if you're eating when you're 60 I get it if you'd be scared. But generally speaking, please Pre-Bolus Your Meals

thanks so much to Ian pen from Medtronic diabetes for sponsoring this episode of The Juicebox Podcast. Check it out at in Penn today.com. If you can't remember that there are also links at juicebox podcast.com. And links in the show notes of the podcast player you're probably listening in right now. And if you're not listening in a podcast player, I mean, can you please subscribe and follow on a podcast app and helps the show and honestly it's easier for you. The episodes come right to your phone and the Phone is right with you constantly. Mine's right here. See, I just picked it up. Everyone always has their phone or just blood sugar's 126 In case you're wondering. So let me just tell you again, because I know there are a lot of episodes of the podcast if you're looking for the defining diabetes episodes, or for the diabetes pro tip episodes there of course, right in your podcast player, just go to all episodes and you scroll around and you can find them or search and find them by searching for something like diabetes, pro tip or defining diabetes. There are also lists available in the private Facebook group, which by the way, is completely free Juicebox Podcast type one diabetes, so not only you're going to find a Facebook group with 27,000 members in it, people just like you who are sharing experiences and ideas. But at the featured tab at the top, you'll find all the lists of not just these series but all of the series It exists within the podcast and there are many. There's even a special website diabetes pro tip.com, where the defining diabetes and diabetes pro tip episodes are, even if you just needed to see the episode numbers that correlate with each episode so you can go back to your podcast app and and look for that episode. I may have just made that sound more difficult than it is juicebox podcast.com diabetes protip.com Juicebox Podcast, type one diabetes on Facebook, or just scroll through your podcast app or use the search feature. The defining diabetes series is amazing, as is the diabetes protip series you don't want to miss it. If you've been enjoying these bold beginnings episodes and you want to dig down deeper, those two other series. Those are the place to go. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.