#846 Best of Juicebox: Bolusing Insulin for Fat

Learning to bolus insulin for the fat in your food with Michelle from Waltzing the Dragon. Episode 471, Bolusing Insulin for Fat was first published on Apr 26, 2021.

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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 846 of the Juicebox Podcast

welcome back to another episode of Best of juicebox. Today's episode you may have heard on April 26 2001. It's called bolusing. Insulin for fat. It's with Michelle, from the popular blog waltzing the dragon. And Michelle and I spend this entire episode talking about how fat sometimes needs insulin. Do you ever see a rise after a cheeseburger and fries and not know what's happening? Hmm. I bet you have. Listen in you're going to find out more and find out how to take care of it. While you're listening today. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. Please Always consult a physician before making any changes to your health care plan are becoming bold with insulin. Don't forget to take the T one D exchange survey please complete that survey AT T one D exchange.org. Forward slash juicebox. And these episodes don't have ads on them right now. So I'm doing something special. I'm going to tell you about it as soon as the music's over. But don't forget that generally speaking, the podcast is supported by a ton of great advertisers, all of whom have links in the show notes of your podcast player, and at juicebox podcast.com.

I have this idea, since these episodes don't yet have advertising on them, although I'm open to selling it to someone who intend. But since they don't at the moment, I thought I would give some ads to people who live with diabetes in their life. So with that in mind, today's episode of The Juicebox Podcast is sponsored by balanced Chiropractic and Wellness. Dr. Jen is a longtime listener of the podcast. She has a young child with type one diabetes, and she's a chiropractor. So why don't you give her a? I don't want to say why don't you let her take a crack at your back? I said it anyway. Balance Cairo and wellness.com If you're in Iowa, I believe in the Des Moines area. Look Jen up 515-255-5330 All right, let's see who we have next. Oh, here's a good one. Lauren Powell. Powell, Law Offices. Dallas Fort Worth. Personal legal issues demand personal attention legal solutions that protect your future. 972-584-9382 Lauren's young child was just diagnosed very recently, just a couple of months ago. Here you go. You need an attorney. Head to power law. offices.com Let's do one more Ed. Oh, here you go. Ed. Oh, is a family garden center in 44. Pennsylvania. 44. Pennsylvania. That can't be a real place. I'm sure it is Edwards garden. center.com. I'm going to check out where this is. Oh, lovely photos. Let's see contact. Oh, yeah, I'm not lying. It's in 44 pa 570-287-4329. Edwards garden center.com. Check them out. Looks like they have ponds and water garden gift shops, gardening supplies, lawn care. They have some animals on site. You can see there's bunnies. Edie says his brother who's a part owner has been a type one since age 12. And Ed's youngest son was just diagnosed in May at age three. So if you're looking for garden center supplies, type stuff, average garden center.com. And I mean, otherwise, you just want to go to a place called 40. Fort for 40 Fo RT y fort fo RT. Fantastic. What a great name for a town. All right. We'll do more of those next week during the next best of, but for now. This is Episode 471, which originally aired on April 26 2001. With Michelle it's called bolusing insulin for fat. Hello, everybody, and welcome to episode 471 of the Juicebox Podcast. Today, we're gonna talk about bolusing for fat in your food. And it might be easier than you think to figure out. Michelle is here from the website waltzing the dragon to try to help us understand. If you're thinking right now Wait, that doesn't make any sense. There are no carbs and fat I only Bolus for carbs. Well, you ever eat pizza and get a weird high three hours later. French fries, milkshake, anything like that? Where you think it's gone? You've handled it but suddenly two and three hours later, this persistent high. If that's happened to you, you're gonna love this episode. And let's be honest, if you're using insulin, this is how Until

we're gonna get started in just a moment. But first, I'd like to remind you that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please Always consult a physician before making any changes to your health care plan. We're becoming bold with insulin. I'd also like to say right up front, that I've put a link in the show notes and a link at juicebox podcast.com, to Michelle's website. And that link will take you directly to everything that we've spoken about today and the way Michelle talks about it on her space. But I think this conversation will be enlightening. I hope you enjoy it. At the very end of this episode, I will actually read for Michelle site in case the conversational nature of today's show. Didn't let you take notes or, or kind of walk through things incrementally. So after you hear the whole thing at the very end, I'll walk you through it one more time. All right, little more music and we'll get started.

This show is sponsored today by the glucagon that my daughter carries, G voc hypo pen, find out more at G voc glucagon.com. Forward slash Juicebox. Podcast is also sponsored by the Contour Next One blood glucose meter, you can find out if you're eligible for a free meter, check into contours, tests trip program. Or while there's a lot more you can do so I can't just list it all but all the information you need about the Contour Next One meter. It's a contour next.com forward slash juicebox. There's links in your show notes. Links at juicebox podcast.com. Let's talk about bolusing for fat now with Michelle.

Michelle 7:10
My name is Michelle and I am the mom of two kids. Gemma who is 12 just turned 12 And Max who is 13. It's Max who has type one diabetes. He was diagnosed at just over a year in 2007. Actually 14 months to the day. Wow. Was how old he was.

Scott Benner 7:30
Wow, that's that's pretty damn Young. Geez.

Michelle 7:34
What is young? It was tough. I think it's tough at any age. You know, I think they're just different challenges.

Scott Benner 7:41
I agree with that. Yeah, I agree that it's that it's not like, Oh, I got lucky. I was diagnosed at 46 perfect age to be like, it's that's not how it is. But but that 14 months thing with a low body weight not being able to communicate well, it's just an end back then. I mean, he didn't even have the ability to break boluses down into smaller bits. And

Michelle 8:05
no, although he got his first pump at three years old. So that's when things really changed in terms of being able to break it down. But before that, for the first two years, we use diluted insulin to try and get smaller boluses. Like really half as much as you could drop in a syringe. Yeah, I don't know if you did that with Arden. I know she was quite young to where she two years old.

Scott Benner 8:26
She was yeah, she was just after her second birthday. What I did was I took expired insulin, squirted it into a dish, added food coloring to it, I drew it up into a needle and I would practice pushing the plunger slightly to make a drop come out. I just use the food coloring so I could see the liquid and then kind of think about okay, this much pressure made a drop come out. And that way when I used insulin for real, and the needle was in Arden, I could put that same pressure on.

Michelle 8:59
Interesting. Yeah, yeah. So it was

Scott Benner 9:01
a it was a good motivator to put weight on her. That's for sure.

Michelle 9:06
We're still trying Max's skinny as a rail. And I'm like, Where can we put these infusion sets? We need some fat.

Scott Benner 9:11
No kidding. Yeah. Well, do you know how you ended up on this podcast today? Do you listen enough that

Michelle 9:20
you messaged me, and I responded. So I'm guessing Jenny had something to do

Scott Benner 9:25
with it right? So Jenny and I sat down. So I knocked up I mean, I can pull the curtain back here a little bit like you people listening here, Jenny, like every couple of weeks on the show or something like that. She is awesome. She's my favorite person. But what but what I do to make that for everybody is Jenny and I carve out some time and we power through topics. And I do not tell her what we're going to talk about first. So did you say that? Yes. So I said okay, like we finished the topic and I said Hey Jenny next I Want to talk about how to translate fat into carbs for Bolus Singh? And she goes, I don't think I'm the right person for that. And I said, Oh, okay, that's no problem. And I just put it on my list, like find somebody else. And she says, Do you know that blog? And then she told me about your blog, which of course, I know because of the, the unique name to tell people your your, your blog title.

Michelle 10:25
So the website is waltzing the dragon. And it was started in 2011, with another diabetes mom, Danielle, and I started it. Because we realize that when we talk to other parents, we just got the most helpful tips. Like other parents knew how to put the theory into practice. Yeah, they knew what kind of infusion sets worked. They knew you know, how to get around things, like you're talking about, you know, food coloring and making some really small boluses. When you're still using syringes, that's the kind of stuff that we learned from other parents. And we just thought, wouldn't it be awesome if we had a place where the theory and those practical tips existed in one place where I could look up? I don't know illness management strategies at 2am. Well, my kids throwing up, and they would be there, I wasn't like shuffling through that junk drawer looking for that handout that I got. Yeah. So that's, that's where Walton dragon came from.

Scott Benner 11:24
It's interesting. I don't want to go too far into the weeds here. But it's interesting that you can't just devise one repository, and it exists everywhere. Because that's not how people find out about things. Don't I mean, like, the best movie I've ever seen in my life, you may never have seen or ever heard of. And so that other places keep popping up is a is a gift to people, because the internet is sort of, it's sort of cyclical, and at the same time, it's bubbled like you're in a sphere, you don't realize it, you're not seeing the whole internet, you're seeing the part of it, you see. So if somebody you know, has a blog like yours, that's great. And it can be frustrating for people listening. I imagine Michelle has felt this before too known how valuable the information you have is, and there's just you can't figure out how to get it to more people. Because you're not in charge of that. It's and I figured that out a long time ago, if the if people don't know immediately to go to the ADA to get information about something right, then that means that the ATPase information isn't so amazing that everyone who's ever seen it runs around telling everybody else about it, right, which is not to denigrate their information. It's just that that's not how it works. It's why you see somebody who's incredibly popular on Instagram today, who 11 months from now, you'll never see again, because everything just keeps going. But I always felt badly about like all this great information that just, you know, just kind of it cycles away. And so the podcast for me is, is an idea of like, how do you bring it alive. So that it it keeps existing and it keeps drawing people in and they keep finding it. So as soon as Jenny said the name of your blog, I was like, I've heard that name a million times. Now I don't read diabetes blogs. And I never have. But that was always a creative decision. I didn't want to, I didn't want to read something you wrote and then find myself saying it not realized that I had heard it from somebody else, right? So I always stayed very kind of insulated around it. But immediately is like, because how can you not remember that name like waltzing the dragon is just so unique. So anyway, I go there, don't please. And there's all that information. And I was like, Okay, I'm gonna send someone an email and ask. And I picked around I think I think I figured out how to get to you through Facebook. So I really appreciate you doing this. Because I want to take what you know about this one specific subject and kind of blow it up and leave it here inside of the podcasts for other people. So awesome. Yeah. So tell me how you first realized that fat made blood sugar go up.

Michelle 14:05
What would happen is we would go somewhere like McDonald's, like we had good control. You know, I wouldn't say it was fantastic, but you know, our overnights for good. We knew how to handle the kind of foods that we made at home. Max was pretty little so we weren't eating a whole lot of high fat food. And then when we started to, like I said go to McDonald's or have a pizza. We would have these incredibly high persistent highs that I just kept correcting and correcting and correcting and he wasn't coming down. And it was changing. Like it was frustrating for me. And it was changing our family's lifestyle. Like I felt like diabetes was winning. I felt like okay, we're no we're not going to go to McDonald's to get fries today because I don't want to deal with the highlighter. We're not going to have pizza tonight. Because I don't want to deal with being up all night and correct. correcting and correcting. And that was incredibly frustrating to me. Because we've always lived like diabetes, we have to pay attention to it, but it's not going to control us. And it was definitely controlling our family. Yeah. So. So I went looking for ways that I could cope with that. And within a couple of weeks of each other two different people brought up this idea of bolusing for protein and fat. Shannon, who was one of the CDs, one of the nurses at the Alberta Children's Hospital diabetes clinic, which is where Max is seen. And also Lorraine Anderson, who is a registered dietitian here in Canada, she worked for at the time animus was my son's pump company. And so I'd had contact with her over that. They both brought up this idea of both protein and fat, which we had never done. But it seemed perfect. And it seemed almost divine that they were both talking about at a time when I really needed to hear it. Yeah. So we started experimenting, as a family. And just to backup, I guess that's, you know, I remember talking at a conference and people said, Well, wait a sec, you know, I guess I should start bolusing for fat, because we've never done that. And you through the conversation, it came to be that they didn't really have post meal highs due to fat or protein. So So I was like, well, then you don't if it ain't broke, don't fix it. I mean, you don't, you don't need to do this unless you're seeing this pattern. That is one aspect of of diabetes management that you would like to address. But many people I mean, if you eat the same amount of protein, and most meals, or the same amount of fat and most meals, then you don't need to do anything different. Your insulin to carb ratios and your Basal rates after that are probably covering it just fine. I think the problem for us as a family was that we tended to eat low fat, but we didn't binge very often on things like pizza or, you know, burgers and fries at McDonald's. And so when we did I can really see the difference. Yeah.

Scott Benner 17:07
Well, almost divinely. Yesterday, Arden had a Five Guys double cheeseburger with bacon, french fries, and a milkshake. So she took her LSAT, and she came out of the LSAT and she's like, I want some food. And I was like, Okay, actually, she took a LSAT prep class and the guy said, when she's done, she's gonna want to eat and take a nap. And I was like, Oh, you don't know Arden, right? Like she won't boom, she ate this food, walked upstairs and fell asleep. What I've seen a few of these kids, he's aware of what was gonna happen, but what I knew for certain was much like you are not gonna have a cheeseburger every day, right? It's not going to be a meal like that every day. So now we have these fries. That are potatoes, which we know are difficult to balls for soaked in peanut oil. There is the protein in the burger plus the fat in the burger. There's cheese, there's bacon, then there's bread. And then she has it's a milkshake, a real milkshake like real ice cream, you know, milkshake. And she says

Michelle 18:08
not ice milk. But ice cream.

Scott Benner 18:10
Can I get an ice cream? Can I get a milkshake with Oreo pieces and Oreo cream. So they put the ice cream in, and then they scoop in chunks of Oreos and extra cream. Right? So what that tells me in my head, the way I think about it is, is that the the range of time that this meal is going to impact her in my mind goes right up to about five or six hours. Like that's how I first think about it. And then and then I just dump in as much insulin upfront, as I think she can handle. And then any indication that there's going to be a rise gets re attacked along the way. The problem is, when people are saying, well, how do I Bolus for fat and protein? That's not a real, you know, that's more of a here's what I do, you can try to see if it works for you. Do you have more of a formula for something like that? Absolutely.

Michelle 19:01
It's not my formula. No. But let me back up. Because you know, I've heard you talk about how you do like a Temp Basal, to deal with those sorts of rises that come from food. And we tried that. Danielle, the other original co founder of waltzing the dragon, that's what she did with her son, right? If she would set a Temp Basal after the meal for, you know, whatever, and her gut said was the right amount. And she had done all this experimentation. But when I tried it was an abysmal failure. Like, I tend to be very systematic anyway. I'm not a I'm not a kind of, you know, let's see what this does. I want I want to have something concrete. You and I are probably the yin to the others Yang but in any case, we tried it a couple of times and it just didn't work. Either he bottomed out, or he was still super high later. And I thought I do not have the mental energy that it's going to take to experiment with these rates and ratios and, and you know, pull numbers out of the air for the next two years until we get it right. I just don't. And so what both Shannon and Lorraine had brought to me was what's called the Warsaw school program. In Eastern Europe, they Bolus for carbs just like we do here in North America. But there's also more of a practice of bolusing for protein and fat. So they've spent some time figuring out well, what does that look like? Yeah. And so that was the program that I did more research on. And so what they basically say is that protein is kind of complicated it protein creates in your body creates some insulin, but it also stimulates the release of glucagon, which we know rises, raises blood sugar. And so the effect of it is, like, if you if all you ate was protein, the effect is a longer rise in blood sugar longer after you eat it. So it might be three to five hours, if all you ate was protein without carbs, it might be three to five hours, you give them maybe an extended Bolus, or a Temp Basal of, I don't know, maybe three hours, I think Jenny said something like 50%, I'm trying to remember she had a great way of looking at it. You do that after the meal, and then it covers that slow rise of protein. So that's part of what they talk about. Then they also talk about the effect of fat, which is not at all unpredictable, that raises blood sugar. And the reason is you get insulin resistant, you've got fat in your bloodstream, that makes your insulin less efficient. But you've also got that fat is harder to break down. So it takes longer to digest. So what we found with Max was that when he would eat a high protein slash high fat meal, he would go low first, and then he'd be storeyed. me high. And the reason was, if we gave all of that Bolus up front, so let's say he had cheeseburger and fries. And that would be think like, maybe at that age, it was like the McDonald's Happy Meal. So it might have been like, I don't know, 3640 grams of carbs for the fries. And then the burger might have been another 20. So we're talking about, let's say 60 grams of carbs. And with that would come maybe 3040 grams of fat, I'll say 30 at that age. So we would give the Bolus for the 60 grams of carbs, which you would think okay, that's great. If he just eaten the bun and potatoes that weren't, as you say, soaked in peanut oil, then that Bolus up front would have covered that. And everything would be great if we do the correct timing to the insulin and all that. But what's happening is because there's such a high fat content, it's digesting more slowly. So that initial Bolus is all getting in before all the food gets in. So he'd go low first, which of course we would correct. And then that correction would add to his high blood sugar later, right. So then we were fighting both

Scott Benner 23:15
because it's so incredibly difficult to say to yourself, Oh, I've gotten the meal insulin ahead of the impact of the meal. Now I'm going to correct with food, I actually have to Bolus the correction right now that is a hard leap to make in your mind. But

Michelle 23:28
I have to Bolus that correction with an extended Bolus. Or perhaps if you're still on injections with like a split Bolus because I need it because if I Bolus it now, he may go low again. And we found that that depends on the amount of fat to like, we don't do this. We won't even consider the amount of fat if it's under about 10 to 15 grams. Okay, so under 10 I don't even think about it. 10 To 15 Maybe depends what else has been going on in his day. Has he been you know, fighting some highs is he been exercising hard? Whatever then I might consider but over 15 We will almost always Bolus for the fat.

Scott Benner 24:05
Yeah, that makes

Michelle 24:09
because that's where we see the impact. Right? So getting back to this Warsaw schools, what they do is they talk about fat protein units. And there's this process that they go through to calculate fat protein units and I don't know Do you want me to it's all on waltzing the dragon. Do you want me to go through it? Yeah. Okay, so I'm gonna go through it basically.

Scott Benner 24:29
Yeah. I'll just tell people now Oh, geez. Alright, so it's your Canadian so it's waltzing the dragon.ca.

Michelle 24:37
And I'm actually today, although the.com will get you there too.

Scott Benner 24:40
okay.com will get me there too. But on this specific page, it's got kind of a long title. So is there a quick way that you can tell people to get through your website to get to what you're going to

Michelle 24:51
waltzing the dragon.ca/fat/fat

Scott Benner 24:54
Okay. I'm doing it to the wall to the dragon. dot see a forward slash fat. Okay? How fat and protein affect blood glucose? Okay, I'm here.

Michelle 25:09
So there's two articles. The first one that how fat and protein affect blood glucose is sort of the introduction, it just talks about the fact that what we just talked about, protein will raise blood sugar, slowly, fat will make you insulin resistant and give you a resistant high later, okay. And then the second article is how to reduce those spikes. Or avoid them might be a better word like, if you if you use the Warsaw formula, then you can, you can have a pretty close to flatline, if you you know, sort of tweak it enough for your own personal needs. Yeah,

Scott Benner 25:47
if you actually go through and figure this out. So this, this episode really is for people who want to look at a nutrition label, and say, I want to apply this to that. And I do want to agree with you, before we start, that I don't Bolus for all the fat art needs. I do think, though, that it's an elusive idea to people because I'll take I'll take a very basic example, every once in a while, like once or twice a year, I make my own potato chips. That's how bored I get. Okay, so you start with an amount of I use peanut oil, because it holds a nice steady temperature, right. And however much peanut oil you start with, you make your potato chips, you put your potato chips aside, each one's thin and crispy and doesn't even have a hint of oil in it. But then you go back and look at how much oil has been absorbed by the potatoes. And it's a fascinating amount of oil, right? So if you eat handfuls of these potato chips, you might as well take a cup, fill it with peanut oil, and drink it because what you're doing eating those potato chips, right as an example, or cheeseburger, or you know, all kinds of things like that, that have grease in them have way more grease in them than you imagine. And so, you know, did I know, fat from ice cream plus fat from cheese and fat from beef and oil from French fries and potatoes and bread was going to crush Arden. It did. And if I told you that based on the carb count of that meal, even though it was an insane car mount, I mean, gosh, by the time you go through the burger, the roll the role is the role is like 25. And then I just throw in five for the burger, because why not and a couple more for the cheese. And now I'm at 35 and then the fries are probably 50. And now I'm at 85. And the milkshakes probably like 80. And like, in my mind, I'm like It's like 180 carbs, right. And even though you give that insulin for that, it comes back to haunt you like a bad acts Absolutely. You know, every couple of hours, it's and you're putting in another, you know, oh, it's gonna happen again, here's two or three more units before you know it, you've used by half more insulin than the actual carb count kind of window.

Michelle 28:04
Absolutely. And the amount I've found since we've started bolusing, for fat, I found that the amount of insulin we use upfront as an extended Bolus is a fraction of what we will have to use to correct it. Right. It's absolutely insane. Like we might add a I don't know, like a three unit extended Bolus. If we you know, do it at the front, if we forget to or when we were learning this, we might have to use like eight or 10 units to get him back down to range. And so the difference is just striking, right? There's all kinds doing it proactively is is a huge benefit.

Scott Benner 28:40
You will being ahead of it, you're using far less than you will if you chase it. And absolutely when you're ahead of it, you most likely won't cause a low later because it's almost like that food almost precludes a low from happening. You know, it's almost the it's sort of the antithesis the idea when people are newly diagnosed, someone will tell you like, Oh, give them like a little protein and a fat at bedtime if you don't want their blood sugar to fall like that kind of no battle chest not, but except you're doing it times like 30. So yes, so you're very aggressive. You know, the way I think about it is balancing the impact of the insulin or the impact of the carbs with the action of the insulin and trying to keep everything working at the same time. So that when the foods finally digested and the insulin is finally gone, you don't crash later. But yeah, once you're chasing fat and protein like this, especially high fat, you're just it takes so much more insulin than you could imagine. And your Basal rate is nowhere near up to the challenge that you've that you've given it. Absolutely, absolutely. I'm sorry. I love our conversation, but I'm not letting you get to what you're trying to say. So,

Michelle 29:50
no, that's okay. I just want to back up for a minute because you mentioned a lot of things like if people are curious what sorts of things that we do this for. You've met spend a lot of them like we talked about pizza. We've talked about burgers, cheeseburgers, french fries. Funny if we have french fries, if we have homemade frozen french fries made in the oven, they don't have enough fat and we don't need to worry about it. But any restaurant we go to those fries will need a fat Bolus. Max loves nachos lately. So the tortilla chips have fat, which we don't really notice if he had say, tortilla chips and salsa or hummus. But if he has nachos, so he throws all that cheese on top of it, and sometimes even like ground beef on top of that. Absolutely. He'll need a fat Bolus for that. Yeah. Real ice cream,

Scott Benner 30:39
right. Yeah, go ahead and jump on your Nacho thing. Arden loves queso for most which, which might not be all over the countries and everything but it's a it's a restaurant you go into They fried the, you know, the tortillas right there for you. She buys the case. So we throw the chips away. And she uses like a toast Tito's brand, like instead. And it by half makes this an easier project for us. Absolutely. I don't know how, let me hear I'll say this to people who really are probably believe in me listening to the podcast, I I can't figure out how to Bolus for most chips for Arden. Like I haven't had the nerve to put in enough insulin yet that those chips need and pretty aggressive. You know, so I'm sorry. And you were gonna say ice cream in a second real ice cream. And that that's where people's confusion comes in online. Somebody will say, Hey, you have to do this for ice cream. And another person will say Oh, no, you don't. We don't have to, except there's no context the one person might be actually eating ice cream. And the other person might be buying something out of the freezer section that's 17 chemicals and might actually have very little ice cream in it to begin with. So right

Michelle 31:48
or what we do we have here in Canada a brand called Chapman's, which their frozen yogurt tastes just like ice cream. It's awesome stuff. But it's got a fraction of the fat. So when we're having it at home, I buy Chapman's frozen yogurt because then we don't have to stress about it. McDonald's for example, their soft serve is ice milk. It's not ice cream. So if you had a huge one, and maybe we might have to but like if we go to Dairy Queen, their soft serve is ice cream. Right? So it's got a much higher fat content. What peanuts if he has a great big bowl of peanuts, we might have to Bolus fat for that. compared to any other nut like not almonds, not even walnuts. I mean maybe he doesn't eat enough walnuts. But like he'd sit down with a bowl of peanuts, you know, like salted roasted peanuts, those we would have to Bolus for sometimes chocolate bars can it depends on how much fat is in them. Do they have things like cocoa butter or coconut oil in the ingredient list will make them kind of perk up. Oh, all the meats, pepperoni sticks. You know, if you have like a footlong pepperoni stick, they could have 1418 grams of fat in a single stick. Bacon. Yeah, baked ham. Like if we have ham for supper, probably that will have to be Bolus for and on the idea of pepperoni sticks to like if you can get turkey pepperoni. It's much lower fat. So sometimes we'll do that instead. Sausages. Yep. Sausages. Absolutely. Yeah, they have probably like the lighter Turkey ones even have like three grams of fat per like regular breakfast sausage.

Scott Benner 33:27
Do you know what I do that? Doesn't know. I keep Turkey and regular bacon in the house. And if she has pancakes or french toast, I put the turkey bacon with it. And if she has eggs, I put the regular bacon with it. And I don't know, I don't know that I tell her that I do that. And they're actually now well, she won't listen. That's good. So there are times when she will specifically say I want to have french toast with regular bacon and I'll go okay, then Bolus now. And you know, and I don't, she doesn't see the difference yet. I'll tell she'll be on the show one day, and I'll tell her little stuff like that. So she knows. But that's just the kind of stuff that I think is intuitive for you a person who paid so much attention to this or to me somebody who talks about it so much that I it's hard for me to forget it even you know, but for most people, most people are not going to think, oh, there's a higher carb value here with some more fat. I won't pair it with the same fat as I you know, I just think that's it's a bridge too far, especially when you're first diagnosed. And in your mind, you're thinking bacon, no carbs. Good. Right. You know, I'm sorry, I keep cutting you off. But you're doing terrific.

Michelle 34:35
No, that's That's great. Good. Good. Yeah. So what were we talking about? Well, listen, I want to talk halation I want to tell you to do about all that. Right. Before

Scott Benner 34:44
we get back to the calculation. You're gonna have to thank Michelle on your own mind here, or at least by visiting your website because she's got lists in front of her and I have never sat down and made this podcast without anything written down in front of me ever. She's trying very hard and I am just over here going like

Michelle 34:58
Scott yin and yang I got to be systematic. That's why this process works for me.

Scott Benner 35:04
And that's why I love you being here. Because there are, listen, I think there are a fair amount of people who pick up what I'm putting down, like they used to say, in the 80s. But I think there are also people who hear it and whose brains work like yours, and they're like, you gotta tell me a number or something, you know, and I just don't, I don't know how to do it. I am literally a person who looked at a plate two nights ago, it had chicken and carrots, and rice on it. And I looked at it, and nothing was measured. And I just looked at it, and I was like, chicken 10 Carrots, I don't know, 10 rice looks like 40 do 65 carbs. I literally counted the 60 and then said 65, which made me wonder why I counted? Like, why did I just like, just look at and go

Michelle 35:54
to get there Sure.

Scott Benner 35:55
Weird thing. And, and that that's, uh, you know, I do believe that most people can, with most meals get to it. But there's some of these things that we're talking about today that are just, they're just too much, you know,

Michelle 36:09
and just on that idea of looking at a plate, like, I think we've had to teach ourselves systematically over the last 12 years, how to do what you do intuitively. So what I would do is I would measure that whatever pile of strawberries or that, you know, mashed potatoes, or whatever it was French fries, I would, I would guesstimate what I thought how many carbs were in it. And then I would measure it and see how far off I was. And then from there, if you do that enough times, now you can start looking at a handful of cantaloupe. You know, a handful of potato chips, you can start looking at that and going, Oh, this is what I think. But I had to get there through very systematic like teaching myself, this is how far off you are right? Next time, guess a little higher, gets a little lower. So I had to get there very systematically, and you do it very intuitively, which I admire. But I would never be able to do with that kind of pull a number out of your bum approach.

Scott Benner 37:06
I imagine that that's my skill. If I put that on my CV, I'd never get a job. You were able to figure it out in a way that's quantifiable trust me I don't need to quantify it is to tell people stories about potato chips, and then get something out of it. Alright, so this. So just

Michelle 37:25
to point out, I didn't figure out how to make it quantifiable. I took a program that already exists. And I applied it to our family and it worked. That was a huge,

Scott Benner 37:34
you're very, you're very kind to give attribution where it's deserved. And I didn't mean that you've made it up out of thin air. I know. But you still went and found it and put it into practice. Like you could have showed me that at a certain time and Arden's diabetes, and I would have been like I didn't read that. That would have been like the end I've been

Michelle 37:50
told I can complicate things a little bit. Yes. And it's my nature to go into it and deep, deep detail. And this is an aside all of the information on the website. So it's it's less of a blog and more like a collection information repository and only because what you do very easily sharing your personal experience does not come as easily to me, I'm much more comfortable sharing the information than I am sharing my life which is why I kind of have a love hate relationship with social media. But there's a whole other topic for a whole other day. But what we've done on waltzing the dragon is set things up as beginner intermediate and advanced articles. And this one is solidly in the advanced. It's like not for the faint of heart because it does look intimidating. But if you follow it through, follow the example through it makes sense.

Scott Benner 38:42
Well, let me tell you that anybody who's made it 34 minutes into this wants it so give it to them.

Michelle 38:49
No holds barred let me tell you what you do bad.

Scott Benner 39:01
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Look, if you're the kind of person that's here learning about how to Bolus for fat in your food, then your data is important to you. And that data begins with your blood glucose meter. Are you using a good one? Is it accurate? Is it reliable? How do you know? You just take the one that doctor gave you or buy the cheapest one at the farmacy maybe you should check into the Contour. Next One blood glucose meter. This is the meter that my daughter Arden uses, it is absolutely the most accurate and fundamentally easy to use blood glucose meter that she has ever had. You can find out more about it at contour next one.com forward slash juice box. The Contour Next One blood glucose meter has Second Chance test strips, meaning you can touch some blood and not get quite enough, go back and get a little more without changing the accuracy of the test. We're wasting a test strip might not seem like a big deal. But can I get 3am It will be is the light on your meter nice and bright. The one on the Contour Next One is no allow you to see in low light situations. And the screen is simple and easy to use. And if you'd like you can connect the meter to your phone, they have an app that will connect by Bluetooth. And you can share your data back to your phone and make better sense of it later if you want. But if you don't want to use that app, you don't have to, you can just use the meter, it's absolutely up to you. Go to contour next one.com forward slash juice box to learn more about the meter and all the products that you'll find on the site. You know it's possible you'll even be eligible for a free meter. It's possible that the meter and the test strips will be cheaper cash out of your pocket than through your insurance company for other meters. This stuff is mind boggling. My mind is boggled. Before I get you back to Michelle and she talks in depth about how she Bolus is for fat. I'd like to remind you to support the T one D exchange, please go to T one D exchange.org. Forward slash juicebox. Take a few minutes to answer some simple questions and make the lives of people living with type one diabetes better. If you are a type one who lives in the United States, or the caregiver of a type one who lives in the United States, this is for you. It is super simple to do you can do it right there on your phone or your laptop. Again, it only takes a few minutes. It's 100%. HIPAA compliant, is 1,000%. Anonymous. And the answers you give go a long way towards helping people live better with type one. That's all you need to do. When you do that. You're helping those people. And you're supporting the show. T one D exchange.org. Forward slash juicebox. Please take a couple of minutes. All right, you ready for Michelle, she's got a whole system here, she's gonna tell you all about it.

Michelle 42:33
Basically, you start with figuring out how many grams of fat and how many grams of protein are in whatever you were about to eat. So you know, for your, for your cheeseburger, and fries. Example, you could go to the company website and see what did they say is the amount of protein and fat in that meal, you could put something at home on a nutrition scale, you could look at the nutritional panel of the packaged food. You could look in a food database, like Calorie King has a book or there are all kinds of apps that do it think we and Calorie King and one's escaping me track three. Anyway, any of these ways, it will tell you the grams of protein and the grams of fat. You add those together. And then you can convert that into units of energy, which is just kilocalories I don't fully understand this, except that I know that they've given me a formula, which is to convert the grams of protein into kilocalories I multiply by four Y, I have no idea. Maybe Jenny is a dietician as a better idea. I don't know I just take it on faith. To convert the amount of fat into kilocalories, you multiply by nine. So let's say the example that I've given on the website is for an ice cream bar covered in chocolate with nuts, real ice cream, as we talked about, it's a Klondike bar, you know, ice cream chocolate covered. So on the nutritional panel, it says there's three grams of protein and 14 grams of fat. So I multiply the three grams of 14 by four, the 14 grams of fat by nine. And I come up with the total kilocalories, which I've got here is 130 830 for

Scott Benner 44:22
the fat, so that's 14 times

Michelle 44:24
138, for both, so it is 12 kilocalories of protein, and 126 kilo calories from fat. Again, those are just units of energy. You just think about how much energy your body can take from that. So then you add those two together, you come up with that 138. From there, you calculate the fat protein units, which is just dividing by 100. Again, why I don't know Gotcha. The Warsaw school people know dieticians. Now. I just do what they tell me to do. This gives me fat protein units. The reason that this is relevant why that number is important is because it tells you how long to extend your Bolus. Okay, so they have a handy little chart, that just tells you, if you come up with one fat to protein unit, you extend your Bolus over three hours. If you have four fat teen protein, your fat protein units, you extend your Bolus over eight hours. So they just got this chart that's got 123 and four fat to protein units, I just look at the chart. And that's what my extended Bolus is. So then we go, we got fat protein units, but how do we figure out how much extra insulin we need? What is the size of this Bolus that we are going to extend. And what they say to do is to multiply by 10, and divide by your insulin to carb ratio for that time of the day. I often don't remember what it is. So for Max, like his insulin to carb ratios vary from 5.2 to like, 7.5, I just picked six. Because I mean, it's sort of I'd like to be very precise, because there's so many variables with diabetes that I like to make as many of them a constant as I can, so that there's less variability overall and less, you know, mass in the system. But by just picking six, I sort of acknowledged that there is variability in this, that even if I'm absolutely precise, there's still a different day, it's a different food, it's a different, you know, he's eating different things with the meal, right? So I just pick six, because it can be complicated, and that works for him. But I like it. When I look back at this example, I was using 15. So when he was younger, his insulin to carb ratio was one to 15. That's a very different thing when he was six than it is now that he's 13. Sure. So that's where the insulin carb ratio does matter on an individual basis. But whether or not you call it six, or 6.5 or seven, probably doesn't change things,

Scott Benner 46:55
a heck of a lot closer than the way it was going to go without

Michelle 47:00
the gas. Right, right. Absolutely. So if you do that, you come up with a number of units. So in this case, if I took that 138, and I divided it or multiplied it by 10, and divided it by his IC ratio, which for this example was 15, then I come up with point nine units of insulin. So I would have given him point nine units of insulin extended over three hours, 01 100, nothing up front, everything extended over those three hours. For the Klondike candy bar when he was six years old, he was six

Scott Benner 47:35
years. And that was that the entire Bolus or is the point nine, the extra on top just

Michelle 47:41
the extra for fat, right. So whatever the carb amount was in the candy bar, I would have Bolus up front and Pre-Bolus. Again, depending on the amount of fat might not Pre-Bolus. But this doesn't have a huge amount of fat. This only had 14 grams of fat Gotcha. So all the carbs up front with a Pre-Bolus as you normally would. And then after he's eaten, and sometimes a couple hours after he's eaten. That's when the extended Bolus comes in. So when it becomes a couple hours after is if there's a huge amount of fat, then even setting this extendable is right after he eats means he will go first.

Scott Benner 48:20
Yeah. So you have to understand then when that second wave arrives, and be just appropriately ahead of it with a Pre-Bolus. So your Pre-Bolus thing, the second wave, but using a number that you can rock solidly believe is going to handle the impact of it. Because you use the formula,

Michelle 48:40
because they use the formula, and I did some experimentation, right? So let me take this one step further and say and maybe I should have said this earlier, for anybody who's not listening to the whole thing. When they use the warsop program, they get a really high incidence of lows. So if you use it as I just described, a, your chance of going low is what I think and what many people in Canada think is unacceptably high. This is not best practice, according to the clinical practice guidelines. And that's run one of the reasons why. What's the

Scott Benner 49:09
opposite? Yeah, so I, I'm sorry, I find that when I talk to people, one of the most fascinating things is the word low and high is not quantifiable between people. So we if you said if you said to me, this will make you low. Yeah, I would

Michelle 49:26
be saying under 3.9 millimoles per liter, or I think for you guys, I've got my chart here somewhere. That's 70. Right. So under 3.9 or 70 milligrams per deciliter. Okay.

Scott Benner 49:38
And so for me, if you see if you were talking to me, and you said oh no, this is going to make Arden low. I'd think oh, like under 60. You know, which would it could it absolutely can Yeah, and it could it's just it's it's tough to just say it's this the one thing I've learned from doing the podcast is that people's idea of high and low are different like when I say absolutely my garden got really high after a meal I mean, 180 to 200. And when other people say it, they're like, my graph is just flat across the top. I don't know how far over 400 I am. So we can't tops out at 22.2. We can't have an equal conversation when you think high means 400. And I think high means 180. Sure, right. So I just always like to make sure that we're talking about that way. So I'm gonna go back over this because I am not the target audience for this. And I think I understand what you just told me. So this is kind of exciting for me as a person who couldn't. You don't realize how bad I was at school. So

Michelle 50:35
you see, you take this and it hasn't hurt you a little bit. How's it I don't

Scott Benner 50:38
know, my wife mocks me openly about it sometimes. So in that, in that vein, perhaps. So you have this example here of a an ice cream bar that has three grams of protein and 14 grams of fat, it also has 27 carbs. So you would have taken this ice cream bar, you would have known from experience. I don't know it needs a 10 minute Pre-Bolus Not too much for your son, whatever. 27 carbs was in his insulin to carb ratio, you put that insulin and he eats the bar. But then you take this information, three grams of protein, you multiply the protein by four, you come up with 12k cows, which are our total K cow from fat and protein. what is k cow stands for? Why don't I remember? It's a

Michelle 51:26
unit of energy kilocalories kilocalories. Okay. So you come up

Scott Benner 51:29
with 12. Then you take the fat from the bar, which was 14, and you multiply that by nine 126. You combine these together, you get 138. You take that 138? You divide it by 100. Is that right?

Michelle 51:43
Yeah. Okay, that gives you fat protein units.

Scott Benner 51:46
So then you came up with 1.38 fat protein units, is that correct? Yep. Totally. You just rounded it to one, because the chart only really works because the chart says 123 or four, right? And one fatty one fat protein unit indicates a three hour extended a Bolus two indicates a four hour three indicates a five hour four indicates an eight hour. Yeah, so So you came up with using his ratio. Now this is the part where I got a little behind. So you took the 1.38 times 10? Because that was his ratio. Is that right?

Michelle 52:22
Nope, because there are 10 fat protein units. So that protein, fat and protein get converted to a certain amount like glucose. So one fat protein unit is converted in your body, about the same as 10 grams of carbs would be? Okay. So if you didn't eat any carbs, and you ate one fat protein unit, that would be like eating 10 grams of carbs. Okay?

Scott Benner 52:52
This is the moment where I'm going to say this out loud. And take advantage of the of how popular the podcast is. The person who made the conversion calculator for the website, if you're listening to this, and you think you could program this into an app for online, please contact for Yes, yes, yes. Okay. And that'd be awesome. And you would you would get that code for your website if you wanted it. So, okay, so then you see you do this, this last bit here. And you can you came up with, it's going to be point nine, because you round it again, because you came up with point nine, two, you rounded at the point nine because that's how the pump would do it. 1.92 and you extended that over three hours. Now in this specific scenario. How long after the ice cream is consumed? Did you end up putting this in

Michelle 53:42
one hour? Okay, we started the accent balls at one hour after he started eating.

Scott Benner 53:46
So is that an indication to you that that ice cream cone has about a four hour life in his body?

Michelle 53:51
Yeah, I guess so. Yeah. All right. Well, plus the free will be longer because at the end of your extended Bolus, that insulin is going to last for another three hours it's gonna tell as well. And I've heard Jenny talk about how fat can affect you for you know, she said eight or 10 hours we have at times found that Max is still resistant the next morning like we're talking 1215 Even 18 hours later

Scott Benner 54:20
they'll be there sometimes. Right?

Michelle 54:22
It depends on how much right not the current and and other things like how activity how insulin sensitive is he right now or has he been you know, as he had a long weekend and sit around and video games all weekend, in which case all of this compounds

Scott Benner 54:36
Hey, let me tell you a fun story while we let this sink into people's heads before we move forward. All right, two hours ago there is

Michelle 54:43
an easier way to do this to let me say

Scott Benner 54:45
we're gonna get to that take the whole thing and make it easier we're gonna do a funny story but Michelle, listen, you gotta tease it out. I want people listening through the whole thing. All right, am I listen through rate is important to ad sales just so you all know.

Michelle 54:59
So listen to the And I go

Scott Benner 55:01
pick up artists contact lenses today, there, they we placed an order and they had to be picked up. And they get there and I'm in a, in an office that. I mean, I've been taking my kids to for so many years. There's a lovely woman at the front who's been there for ever. And we're standing around talking, and I said to the person that was helping me, Hey, I gotta go, I have to go record a podcast. And he said, what's it about? And I said, Oh, we're going to talk about how fat and protein impact blood sugars kind of more long term than people who use insulin, but probably think they do. And the woman behind the counter goes, I have diabetes. I've literally known her for a decade, I had no idea she was I struggle with this all the time. She goes, What are you doing? And I started explaining to her, she's like, how do I find this podcast? And she's like writing it down and showing me her phone and asking where podcast apps are and stuff like that. And I walked out and I just thought like, how do I not know but there she was she had a Medtronic pump on her belt. She keeps it covered with her shirt, wearing a sensor, nobody can see it. And, and there, she was just like

Michelle 56:09
he's in the wild.

Scott Benner 56:10
She said this topic vexes me. Just it just controls my life. And she's like, even if I just eat a piece of chicken, I'm down to just trying to eat a piece of chicken. And two hours later, my blood sugar tries to go up 40 points. And I said, Well, yesterday, your body can take that protein from that chicken and it converts it and stores it as glucose and then impacts your blood sugar. And she's like, I have no idea. I've had diabetes for decades. It's like now okay, I said so Okay, common. Yeah, just it was crazy. I mean, very, like, if I told you, I just thought to myself, Hey, I have a little extra time here. I can make it to the store and back again to pick up Arden's contacts, like I just tried to

Michelle 56:48
squeeze and you were supposed to be there, because she's supposed to hear your podcast. So lovely.

Scott Benner 56:52
Like I had a very nice feeling about the whole thing. Okay, so we just went through something, which let's be honest, is not that convoluted. But it's more than it's Yeah, yeah. Right. So you're telling me there's a simpler way I could have gone through this. What would that have been?

Michelle 57:08
Well, first of all, as I said, we don't Bolus for protein. And there's a couple of reasons for that. Number one, because we found when we first started using this formula, including protein Max always went low. And one of the things about protein is that it really only affects your blood sugar in a significant way. If you're not eating carbs, and we're pretty carby family, I mean, I don't I think there are very few times when Max, like he wouldn't sit down and have like a steak and a salad. He wouldn't eat a burger without the bun, I would do those things. I have celiac disease. So, you know, I tend to be I would eat more just protein alone, but he wouldn't. So in a way, because carbs are the body's preferred fuel source. If he's got carbs in there, then it's just going to use the carbs for fuel, okay, and the protein isn't going to have the same effect as if he had protein without carbs. Okay. So like think, you know, steak and a baked potato, you probably don't have to Bolus for the steak, although it sounds like you do. And it works. So maybe there's something I'm just missing there. But still valid solid? Wood?

Scott Benner 58:20
Yeah, I don't do a ton, like read a little bit, you know, and if it's, if it's more lean, I do a little less. I just, I just throw five I'm always thrown five like because you know that kids will put like a little dip in a bowl like honey mustard or something like that. People like how much is it? I'm I don't know, five more. Everything's always five more. Because isn't it interesting? I think for everybody who's listening, think how specific you are with your insulin. Oh, this is 43 carbs. And it's going to be 14.8 units or something like whatever you end up doing

Michelle 58:53
preaching to the choir.

Scott Benner 58:56
Right. And you're more frequently never right? Too weak than you are too heavy.

Michelle 59:05
Absolutely. Right. Because everybody, you're speaking my language. Right? Right. We laugh because if we go out to a restaurant, and there's no carbon information you're like at a mom and pop place. So there's no you know, Boston Pizza website to go to or whatever, you're just, you're there and the food's there and you have no choice but to pull a number out and just go blind, this many carbs. And it's funny when we do that, quite often his blood sugar is much better than when we systematically counted. Yeah. Now that being said, we still systematically count it because I think if I did that all the time, it would miss necessarily work out and there'd be one

Scott Benner 59:48
where you'd be in the parking lot going, well, Max can stand. But no, I think I'll tell you a measurement I use very privately in my own head when you're out in a row. Restaurant. If it's a chain, it's more, because I always think there's more. Just stuffing it is not food. And the better at taste. There's more because the better it tastes always to me means food and means fat and salt. Absolutely right. So the better it tastes, the you know, the more hit your pleasure center and makes you go I don't care about anything else in the world, but more you feel like that the more insulin it's gonna take

Michelle 1:00:25
five units of insulin Yeah, more.

Scott Benner 1:00:30
I just it, it became, like evident as Arden got older. And now I'll tell you, you know, now that she's a full blown lady. There's a whole other aspect of it, there's a you know, there's some foods that hit her differently now that she's mature than they did when she was a kid. And I don't even know if that's if I'm right or wrong about that. It's just, it's what it is. And there's some foods lately, there's a simple one, she likes these little baked Ritz crackers, right, so, so not the regular round Ritz crackers that everybody thinks of in the in the sleeve, those those we Bolus pretty easily carved for carp. But these ones that come in a bag that are like rich chips or something like that, I just take whatever the carbs are and add half if it's 20. It's 30. If it's 30, it's, you know, it's it's 15 more on top of that. And these things just hit her. I don't know what's in them, but it ain't good. You know what I mean? Have you looked at the label? Well, no, that would take a lot more effort, I just figured out how much insulin I'm just curious

Michelle 1:01:32
about how much fat and maybe even protein is in there I'm gonna look at or if it's a glycemic index thing, like if they you know, if they digest super slowly, then

Scott Benner 1:01:42
something, they hit her like a truck. And then the truck stays parked on top of her for a while. Yeah, it doesn't pull off and go, I'm sorry, it just stays there. And the reason I don't look too deeply into it. And this might be helpful for people to with younger children, is because she will cycle through these. Like, I don't know if other people's kids do that to

Michelle 1:02:02
be gone a month from now. So be a moment where she'll go, Hey, did

Scott Benner 1:02:05
you want some of these crackers that you love? And she's like, I hate those. I'm done with those and then she'll never eat them again and the rest of her life?

Michelle 1:02:10
Yeah, you go donate those six boxes that you just got on sale.

Scott Benner 1:02:13
Yeah, like here. This will crush your blood sugar. Congratulations. They're free now. But yeah, but no, seriously, it's um, she doesn't do the same thing for when she's on a great kick. Right now. I have four pounds, a great admirer, four pounds of grapes in my refrigerator right now. Because she just two weeks ago said, Hey, everybody, I'm doing grapes now. Like, there are things so let's stay stocked. And I was like, okay, so no worse things. Yeah. Right. So I'm like, okay, whatever, and then they'll be gone. Like, you know, I'll try to give her grapes three months from now. And she like, Ah, I don't eat grapes. What am I gonna do? You know? Anyway, I'm sorry. So, okay. There's an easier way to do this.

Michelle 1:02:53
Right? Okay. So what we do is we first of all, like I said, we don't include the protein. So what it comes down to for us is that we just take the grams of fat, we multiply it 5.09, which is the timezone and divided by 100. And all in one step. And then I might multiply it by nine or 10.

Scott Benner 1:03:18
So that's what's the multiplication for?

Michelle 1:03:22
That's the 110 grams of carbs, for one gram, one fat protein unit. Okay? So we, because he still sometimes goes low, if we use this with the 10, if he's in a good place, and things are, you know, he's insulin sensitive, and all that is going well, then I will reduce that number. So when he was younger, I might reduce it all the way to eight. And so that's another way to make it more conservative, reduce that risk of bottoming out. Gotcha afterwards.

Scott Benner 1:03:54
Well, I like to ask you to go through it again in a second. But I like the way you just said if he's insulin sensitive, and you didn't mean that in a bad way, you meant if the insulin is working the way I expect it to work in this moment. So I'm gonna get a reaction that I expect. And by expect, I mean, ratios, Basal rates are all doing what we expect them to do.

Michelle 1:04:14
Absolutely. Okay. And as an aside on that, like, I'll notice that they have a long weekend. Like they just had a five day long weekend from schools, teachers convention things by the fifth day because he hasn't been walking back and forth to school. He hasn't had gym class. He's been spending more time on the computer or hanging around with us watching movies and that kind of stuff by the fifth day, but probably the third day really. I know that we need to crank things up a bit. Yeah. And if I forget that, then it comes back to tell me we need to crank things up a bit

Scott Benner 1:04:45
being sedentary to me hits exactly like an old instruction set. You know what I mean? Yeah, you know, when you're at the last part of your infusion set, and it's starting to get like, suddenly like this should be a unit but it's two units and and you know, it almost feels like it It almost can feel like a leaky sight. It's almost like Oh, everything I'm putting in there. It's not getting in there is it like, but it's wrong. Yeah. But instead, it's everything I'm putting in there. It's not having the impact that it should, because he's been sitting around for a week or etc. i Right. I'm glad people can follow this. This is good.

Michelle 1:05:18
So on those days, I will absolutely lose use 10. So using 10 would be more aggressive because you're multiplying it by more. Okay, so eight would be more conservative.

Scott Benner 1:05:28
Do it. Do it with me one more time. So let's just put 10 grams of fat in this imaginary thing we're eating? Yep. How do you do it?

Michelle 1:05:37
10 grams times point oh nine. Okay. Should I times 10. Okay, divided by the IC ratio, which for him right now is six, we just use six across the board.

Scott Benner 1:05:52
So in that 10 times point oh nine times 10 divided by the insulin to carb ratio. Yep, that's it. Okay. So you're gonna

Michelle 1:06:01
come up with what nine divided by six? Did I miss something,

Scott Benner 1:06:06
I'm gonna second. Let's just do this the easy way, showing 10 divided 10 times point oh nine gets zero. 10 times point oh, nine times 10 divided by four. It's 2.25 2.25. That would be Ardens. Because our insulin to carb ratio is like four, four. So if there were 10 grams of fat in this thing that Arden ate, I would take 2.25 units and extend that over three hours.

Michelle 1:06:42
What did we come up with the fat protein, we have to pause at the grams of carbs times point oh nine because that tells us our fat protein in

Scott Benner 1:06:51
my stupidity. So that's

Michelle 1:06:53
So that's point nine. So just under one. So yes, it would be three hours, three hours. So now and I should point out that we never actually would do this for 10 grams of fat. That wouldn't be enough fat for us to bother. Right. But for example purposes,

Scott Benner 1:07:08
the first round numbers and simplicity, which is clear. But so that's a good point, though, because and why is that a good point? Let me Google something for a second. When I say five guys, five guys fries, fat.

Michelle 1:07:24
While you're Googling that, I just want to point out that they go to a local mall to do Pokemon Go to Brooklyn auntie, and they always stopped for lunch. This is my husband and Max. And nw is the usual meal on that day. And it has 64 grams of fat for a cheeseburger, fries. And a pop.

Scott Benner 1:07:45
Listen to this. This is from the Food Network, a large french fry has an unbelievable 1300 calories, 57 grams of fat, 1300 milligrams of sodium. So you're gonna get crushed if you eat if you eat this, because not only all of this, but the sodium is going to dehydrate you, which also slows down the insulin. We're

Michelle 1:08:06
never even take that into account just pulling numbers that are my bone like you just got because it's all

Scott Benner 1:08:14
taste good, more. So. So there's a good example 57 grams of fat in just those fries, just say so leave the milkshake out of it leave everything else out of it when I'm telling you, she used you know, just multiple 10s of units of insulin more, it really isn't that crazy because in this scenario here, if we just round this to 60, right, hold on a second. If we just round this to 60 grams of fat for Arden for the French fries yesterday and I do 60 times point oh nine, I get five five. That's right, times 1054 divided by her insulin to carb ratio is four. She needed 13 and a half units more insulin for the fat in those French fries than the carbs and those French fries indicated and think about how many carbs are in the French fries. So hold on a second in five guys, large fries carbs. Okay, there are 72 carbs. So So we've just decided Arden needed 13 and a half units of insulin for the fat in five guys fries. Now let's look at it as carbs 72 divided by 418. So while everybody's wondering why their blood sugar gets high, and they don't understand why it takes so long to come down. Arden needed 31 and a half units of insulin just for the French fries, but it had to be stretched out over the impact of the carbs because of how though, oil is holding it up, which we've talked about a million times this podcast and anybody who's listened to the program A series knows the food goes in, it starts digesting your leaching out carbs, the more fat that's in your stomach, the slower the digestion goes, the longer it takes, the longer you're slowly just basically infiltrating your blood with with sugar. So that really is telling honestly.

Michelle 1:10:21
And with that amount of fat, like I said, for the Klondike ice cream bar, we would start the extendable is one hour after and by the way, we just say, Alexa, she's gonna listen to me. Now, we would just say Alexa set a one hour fat Bolus timer, which usually results in hilarity because she often says five balls timer. But anyway, all that aside, we just set a reminder, right? So that we actually do that an hour later, if he had this much fat. If I did that, an hour later, he would bottom out first, okay, because the food would take that much longer to reach his bloodstream. And the evening the car be food,

Scott Benner 1:11:03
yes. And the easiest explanation for that, for most people is pizza, who, you know, you look up pizza and you go, this is 30 carbs a slice, you put it all in, and 45 minutes later, your blood sugar's 40. And you're like, I don't know what to do. And you drink a juice, and that doesn't work, and you drink another one, and then all of a sudden, the fat and protein hits you and the juice hits you and your 400. And you don't know what to do.

Michelle 1:11:23
Right? Right. And that wasn't a problem with the amount of insulin you took. It was a timing issue, timing that the insulin got in before the food did.

Scott Benner 1:11:30
I was talking to somebody the other day. And I said to them, in the end, all the things that we just talked about here, all we really said was right amount of insulin at the right time. It's all timing and amount. It's always it's always timing and amount.

Michelle 1:11:43
And fat messes with that in a big way. Because it's not just that you get that high, it's that it takes so much longer for it to digest, that you can go low in the first place. Okay, or like you've said, on other podcasts, you got this beautiful number, and you think I nailed that. And then four hours later, you know, you're through the roof. And that's why, because you might have nailed the first two hours of it, but not the next eight.

Scott Benner 1:12:09
All right, Michelle, there's one thing I'm still lightly confused by. So it's the idea of one fpu, two, three, when we did it in the short version, and we just said 60 times point, or nine times 10 divided by insulin to carb ratio. Yep. How what would How would I know if it should be over four hours or five? What number would change in that so we stopped,

Michelle 1:12:33
we stopped at the 60 times point or nine. So that's the fat protein units. And that was 5.4. So for five units, now here's here's the other thing that we run up against with 60 grams of fat. The turtle then goes up to four protein units. Okay. So beyond that, I take the Scott Benner approach, and I just guess more. So for five units, I might say 10 hours because for fat protein units would be eight hours. So for five fat teen protein units, I might go 10 hours or maybe 12.

Scott Benner 1:13:04
Okay. i Okay. So my confusion was, is that our original number that we started with kept us in the three hour range. Right, right. Okay, right, because we were only at 60. If we would have gotten to, is there is there a cheat in there? Is there a number of FP use that makes it to like in your mind? I know you don't think of it this way, but pretend you were me for a second. And sometimes I do. Yeah. So like, how many? How many? How many K Cal's would tell you, Okay, this is going to be four hours. Do you have that number in your head? Um,

Michelle 1:13:43
no, but I can reverse engineer it, like four hours would be to fat protein units. Yep. So then two fat protein units would be 18 grams of fat. Okay. So if you were looking at somewhere around 2020 grams of fat, you might say, Yeah, let's extend that four hours. Okay, you can totally just do that shortcut. The other thing is insulin is insulin. So once you know that you're looking at a four hour extended Bolus, you could do a Temp Basal. That will equate to the whole thing to the same thing I would normally do that, you know, it's pump doesn't care if you do an extended Bolus or Temp Basal, it's the same thing. It just draws it out. It's whatever makes sense to you in your head and whatever you can, you know, work with.

Scott Benner 1:14:29
So with 60 for the French fries, that actually puts us up into the more of like the five six hour range, right?

Michelle 1:14:36
Yeah, yeah, when Max has a NW and he's 64 grams of fat. We extended over 12 hours, 12 hours, which I believe is the upper limit of his current.

Scott Benner 1:14:47
And when you're doing that with a small person, what you're really telling the pump is I need extra basil for the next 12 hours because it is a small it's a smaller amount of insulin once you break it up over 12 hours. Yeah, Okay,

Michelle 1:15:00
well, that's all you could convert that into Temp Basal. I guess my problem with that is like, he's still growing. So when he goes to bed, he's got growth hormone, and his Basal rates almost double. So for me to go, Okay, how much of this would it you know, to tell it a Temp Basal I would have to sort of figure out okay, well, between the hours of 11pm and 2am, his Temp Basal would be double. Yeah, but earlier in the evening, it's not going to be like, so I just go extended Bolus, yeah, just give me give me whatever, an extra five units over 12

Scott Benner 1:15:32
hours. Yeah, Michel, the way if you if I'm sorry, if you've heard me say this justice overthrow it for a second. But I just think of, I've found a number of different ways to think about it over the time, there's an impact range that the food has, you know, from the minute it goes until it's done, and I tried to cover that range, with a heavier blanket of insulin. Sometimes I think of it that way. Sometimes I just think, you know, just basically like, oh, it's going to be cold overnight, I need an extra quill. And so you know, my blood sugar is going to try to go up between here and here. Because I've eaten something with fat in it, I'll just lay something heavier in the form of Basal overtop of it to hold it down. I've described it as carpet bombing, before, you know, just picking the picking the range where the food is, and just try to decimate it, you mean just stay on top of it. There's all different ways to I mean, however, people can picture it in their minds. The idea here is that this fat is going to force your blood sugar up over, over hours, and the amount of hours is going to depend on how much fat it is and all kinds of other stuff. And and still, what we're talking about. While this while this method doesn't work for the idea still exists that for some of you, protein will cause a rise a number of hours later, too. And if you can learn that you can count on that that a chicken breast with my meal is going to mean the two hours after I eat my blood sugar is going to try to go up 60 points. Well, then an hour after you eat the chicken breast, you could do a Temp Basal to stop that or an hour and a half eat the chicken breast you could Bolus for it even

Michelle 1:17:12
so my problem was always how heavy of a blanket do I need? Yeah, and how long am I going to put it on? So do I need that? You know, that light summer blanket? Do I need the really thick? Do they? What do I need here? And and so for me using this formula, Toby? How heavy should the blanket be? And are you going to have it on all night or just to the beginning of the night or what? So for somebody like that, who is eating the chicken breast and a salad and no carbs, and therefore needs to Bolus for it, you can use the same formula. But just the same way that I leave protein out of the formula and only do fat. You can leave fat out of the protein out of the formula and only do protein. It's fascinating.

Scott Benner 1:17:50
And I do mean this in a very kind way. Like I I would imagine you could take this wrong, so don't but the people who I've seen asked me for this information, as near as I can tell through the internet, have a similar personality to yours.

Michelle 1:18:08
What a shocker. I don't take that the wrong way. Yeah,

Scott Benner 1:18:10
it's fascinating because we're, those are the people who hear me go, I don't know, put in more than just don't let it cause a problem. They're like, No,

Michelle 1:18:19
when I tried that, Scott, because my brain doesn't work that way. When I tried that, it just failed. And I was discouraged. And I was like I cannot put in the energy that it's going to take to keep trying and experimenting and figuring it out and trying this in China. I just can't. And the other thing is you have this incredible memory, I have asked to be introduced to people that I have met before people I have had in my home at my dinner table I have asked to be introduced to and so I don't have that memory. So if I don't write it down systematically and come up with a process that works, then I'm starting over every time I sit down with that food on labor time, I don't know what we're gonna

Scott Benner 1:19:02
try. So I can't take credit for memory. It just occurs to me. Like I just look at it and then the answers in my head. I don't have a process to come to it. And I can also that's awesome please It's an odd gift to have but I would much rather be cute you've got that's incredibly valuable to show what if I ran a sub for 60 and could catch on with six feet five then I could pay someone to do this we

Michelle 1:19:28
haven't different

Scott Benner 1:19:31
but but it isn't it this conversation has been in an extended way interesting for me because I can see now that you don't think in pictures. And I think in pictures Yeah, right. Yeah. And numbers and language right. And the people who I hear describe me as Oh, it's this guy. He's just really aggressive with insulin. I was like, Oh, they think in numbers. Not in pictures, right? I sound like a lunatic who's just yelling like pour it on and see what happens. But I don't think you

Michelle 1:20:01
do that based on your sense of what is appropriate. And I'm saying I don't have that sense. Yeah. So I can take this formula. And then once I know, then, I mean, you don't have to go through the formula every time. It's not like I spent all my time, you know, doing Warsaw calculations. Once you know, and you have that same food again, you just use the same thing. And, and I literally kept track. I said, so what was the result? Okay, he went low first. Okay, I'm gonna give maybe less upfront and extend it more. I'm, you know, I could tweak from there. But once we've tweaked it, and we get success, well, then when we have McCain's frozen pizza, this is what we do. Yeah. Or when we go out to NW on PokemonGo day, this is what we do. And so I think it gets us both to the same place, but just a different path to get

Scott Benner 1:20:51
that well, no, I think the last 30% of the process is the same for you. And I, I think it's the how we understood it, how we made the decision. And when we use it, that yours is more calculated. And mine's more like, that feels like five units to me. But you know, and it also

Michelle 1:21:07
puts me in a position then when I get one that I don't know, and I don't know how much fat is in it, I don't know how much protein it is, I can look at and go Well, it looks like an a and w meal or it looks a little closer to you know nachos, or it looks like then I can be in the ballpark, I can say well, I have no idea on this one. But I'm going to compare it to something I do know something we've done before. And I'm going to try this. And that gets me in the ballpark. And it makes Max's blood sugars post meal, manageable, so that now we can do the bumping and nudging that you talk about rather than this, you know, runaway freight train, but nothing has helped. There

Scott Benner 1:21:45
is nothing maybe more confusing than seeing a blood sugar that's 280 putting what you think is a massive amount of insulin on it and watching it go to 260 and then bounce back to 280 again, Oh, yeah. Then your brains just like fried, because you're only thinking correction factor, and not considering any of the other things that are happening. And then you're just staring before

Michelle 1:22:07
we started analyzing this had no idea like I might think oh yeah, it's fat. But then when you think 64 grams of fat. That is that puts my understanding on an entirely different level for me to go oh, that's why when one unit would normally work, and I gave him three units. Thank you. Let's watch for the low. That's why I didn't even touch his blood sugar. Because we're talking about this astronomical amount of fat

Scott Benner 1:22:32
right? Because and obviously Arden's insulin, insulin to carb ratio is different than other people's but because a large French Fry from five guys for Arden needs 28 or 30, like 32 units of insulin 32 units of insulin, her pump only holds 200 for three days. Right? So I can. And so anyway, this was really great. Did we not say anything that you wanted to say? Did I find a way through it all?

Michelle 1:23:04
I think so let me just look and see.

Scott Benner 1:23:06
Look at your notes, please. Oh, usually people with notes. So check it out.

Michelle 1:23:11
Systematic. One other thing to think about is there are times that we would have, he'd say he'd make himself nachos for lunch. And then we have pizza for supper, or, you know, we'd go to McDonald's for separate. If this happens twice in a day. The the effect is compounded. So like if I sort of imagined that, you know, his first is not just for lunch, there's some fat swimming around him his blood, and that's making things a little bit harder to deal with. But we covered it and things look great. But underneath the surface, he's still got that extra fat in his blood. Now we go and we pile on more fat, that's going to need even more of a hit. So yeah, you're more insulin, more insulin really applies if you're eating fat more than once a day, which doesn't happen incredibly often for us, but we've seen the effects. Yeah, and I think already sorry.

Scott Benner 1:24:05
I was gonna say I see it with Arden during her period, like when she gets like cravings, sometimes cravings. They match each other. So it goes, you know, I've had days that have gone from nachos to Chinese food, you know, and you're just like, well, this is gonna be like, it really does feel like, you know, like, like, the greatest football team of All Times has shown up the play you and you're like, Okay, I guess we're gonna lose. Let's try not to lose by too much.

Michelle 1:24:37
And that's where you know, when you if you'd normally do Chinese food, you go well, this is how many units it needs. And we need to extend it over this many hours. The day that you have Chinese food after nachos, you need to ramp that up. It'll change or at least we find that we do because the effect is is cumulative.

Scott Benner 1:24:55
I definitely see that too. Okay, I'm sorry to cut you off. You're gonna say something else. No, I think that that might B, I think we've, I think we've addressed that I've got here. Well, Jenny was right, you were the right person to talk to about this. So thank you. I have to say this to pleasure. No, I had a good time. But let me say this because I want to mention again, it's waltzing the dragon.com or.ca. There'll be links in the show notes for you to go find it. I'm going to try to talk Michelle into the day that this goes up to like popping up in the Facebook group and chatting with people about it if she wants to. I would love to, but I want to say this, and I mean, this genuinely. She would never say this out loud. But there are not that many places where Jenny directs people for diabetes advice.

Michelle 1:25:37
So you made my day because I really admire her she is a smart cookie. And as great advice is

Scott Benner 1:25:43
a big deal. She's I've outed her now she's only ever told me that privately but there are very few sources that Jenny will tell somebody about so that she brought was a big deal. So I that's how I knew right away to reach out to you because if she was willing to say it out loud, that I knew it was going to be a good conversation. So thank you very, very much. This was amazing. Thank you for your time. Scott. Are you kidding me? You stop it. This is this is all all the things go to you. A huge thank you to one of today's sponsors, G voc glucagon, find out more about Chivo Capo pen at G Vogue glucagon.com forward slash juicebox you spell that GVOKEGLUC AG o n.com. Forward slash juice box. The episode was also sponsored by the Contour Next One blood glucose meter. Learn more at contour next one.com forward slash juice box. There's links in the show notes and links at juicebox podcast.com. For these and all of the sponsors.

You can support type one diabetes research and the Juicebox Podcast. The T one D exchange is looking for type one adults and type one caregivers who are US residents to participate in a quick survey that can be completed in just a few minutes from your phone or your computer. After you finish with the questions. And they're really simple questions. I did them in maybe seven or eight minutes. You'll be contacted annually just to see if there's any updates to your information, and to be asked any further questions if further questions exist. This is 100% Anonymous, completely HIPAA compliant and it does not require you to ever see a doctor or go to a remote site. Now every time someone completes the process using my link, T one D exchange.org. Forward slash juicebox. you'll not only be benefiting people living with type one diabetes, but you'll be helping out the podcast. Just use my link in the bio, then click on Join our registry now. And then just simply complete the survey. T one D exchange research has led to increased insurance coverage for blood glucose meter strips, changes in the American diabetes Association's guidelines for pediatric agency goals and even helped get Medicare coverage of CGM devices. So if you've ever wanted to help out people living with type one diabetes, or the podcast, or maybe both, this would be a simple, quick and safe way to do all of that T one D exchange.org. Forward slash juicebox. Okay, now I'm on Michelle's website, waltzing the dragon. And she has examples here for you. This is very clear and easy to follow. She's got a lot of examples of what foods are high in saturated fat here. She talks specifically about the what the Warsaw approach is. And she walks you through an example number one identify how much fat and protein the food contains. And she has an example here that she used on the podcast. It's an item that has three grams of protein, and 14 grams of fat. Number two, you convert into units of energy. It's kg cow from protein equals protein, and grams times four kg cow grams. Now when you see that, you're just like, Oh my God, I don't know about you, my brain goes, ooh, I guess everybody's blood sugar is gonna be high because scouting and figuring this out. But if you've got the kind of brain who loves this, go look at it, because it is incredibly well. I know. When I look at it, I think if my brain work this way, I know I would appreciate how this is being shown to me. Number three, calculate the total calories. Number four, calculate the fat protein units. Number five, how long to extend the Bolus it walks you through it very easily step by step instructions, gives you the amount of extra insulin that you need step six, and then it talks about the end result. She says here to make a long story short, in this example to cover fat and protein. Her son had this bar after supper, she would first give the usual Bolus with the carbs before he starts eating. Then later, she would deliver an extra 2.3 units of insulin in this example, in an extended Bolus that covered a duration of three hours. So you've heard her talk about it now for an hour we've been talking about in the podcast. If you want to see her step by step instructions, there's a link in the show notes for this episode. And there's a link at juicebox podcast.com. For again for this episode 471. Now, in the meantime, I'm going to be paying closer and closer attention to how I'm using this idea in our life. And I'm going to come up with a way to say it that doesn't involve adding, subtracting, multiplying or dividing. I'm gonna come up with a way to talk to you about this. And I will be sharing it as soon as I absolutely can. You know me, I'm just like, there's a lot of fat in this and then I, you know, I just got a lot more insulin than I stretch it out. You've heard me talk in the diabetes Pro Tip series, you know how I do it. If you've liked this and never heard of the diabetes Pro Tip series, I really think you should check it out. Because if you like this conversation, you'll love those conversations. The diabetes pro tip episodes begin at episode 210. They're available at juicebox podcast.com. In your podcast players, or if you just like to see a list of them diabetes pro tip.com. I hope you found this interesting. If you did, please share the show with someone else. And of course, check out Michelle's website waltzing the dragon.ca or.com. And there's of course links right there in the show notes and at juicebox podcast.com to this exact article. I'll talk to you soon.

Thanks so much for listening to this episode of the Best of the Juicebox Podcast. Don't forget about those type one related businesses that I told you about earlier balance Chiropractic and Wellness in Des Moines, Iowa with Dr. Jenn balanced Cairo and wellness.com 515-255-5330. Give Jen a crack at it. I don't know that should be your tagline. Jim. Give me a crack at it. Let me take a crack at we workshop it but I think let me take a crack at you. I think that's what we would go with. Who else? If you're looking for a lawyer in the Dallas Fort Worth area Powell law offices.com Check out Lauren Powell 972-584-9382. And, of course, Edwards garden center.com 44th, Pennsylvania 44 570-287-4329. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast and don't forget to check out the private Facebook group Juicebox Podcast, type one diabetes and tell a friend about the podcast or leave a fantastic rating and review in the app that you listen in. On don't forget to subscribe or follow in that app like I don't know Spotify Apple Music Odyssey I found out earlier I was in recently I found that out. Apparently I'm everywhere. If you can listen to it, you can listen to the podcast and it. Subscribe and follow

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