#211 Diabetes Pro Tip: All About MDI

Scott and Jenny Smith, CDE share insights on type 1 diabetes care.….

I am thrilled to welcome Jenny Smith, CDE back to the show. Jenny will be joining us for an extended series of conversations that focus solely on the management ideas that we discuss on the podcast.

Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com.

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Alexa - Google Play/Android - iHeart Radio -  Radio Public or their favorite podcast app.

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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 0:06
Welcome to the Juicebox Podcast. I'm your host, Scott Benner. And you're listening to the second installment of my series with CDE Jenny Smith. This episode titled all about MDI is just that it's a conversation about multiple daily injections. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, and to always consult a physician before making changes to your medical plan, becoming bold with insulin.

How frequently does someone leave a diagnosis with an insulin pump?

Jennifer Smith, CDE 0:50
I would say never.

Scott Benner 0:55
Johnny Smith has lived with Type One Diabetes since she was a child. She holds a bachelor's degree in human nutrition and biology from the University of Wisconsin. She's also a registered and licensed dietitian, a certified diabetes educator, and a certified trainer on most makes and models of insulin pumps, continuous glucose monitors, and continuous glucose monitors. And besides that, I just really like the way she talks about type one. Jenny Smith is a CD. But she's also a consultant at integrated diabetes, where she helps people who are struggling to figure out their type one, you can find out more about what she does at integrated diabetes.com.

Jennifer Smith, CDE 1:37
Part of the reason for that not leaving a hospitalization or a doctor's office with a pump is because of all of the red tape that you have to sort of go through for ordering and you know, that kind of stuff. I would say the rare case, this is probably 10% of the time, maybe even less, somebody's pretty quick to get the order written by their prescriber. And in fact, I worked with somebody maybe a month ago that her little boy was diagnosed and how to pump within about six weeks. Okay, but that's pretty quick. It's not typically that fast. And

Scott Benner 2:14
most people are going to get diagnosed with Type One Diabetes and leave with either pens, or syringes or syringes, right, yeah. And so whether you are a person who thinks right away, I have to have a pump and you hammer through insurance and get it six weeks later. Or if you're a person who gets told, we don't give pumps to people until you've had diabetes for six months, or any of those arbitrary times that doctors throughout one year

Jennifer Smith, CDE 2:36
or until you're in perfect control, then you can have a pump.

Scott Benner 2:40
You know how to do this so well that you'll never want a pump, we'd be happy to give you one, which will never come. And so some people are going to need to know what managing with just MDI looks like. So multiple daily injections. These people are going to get some sort of a fast acting insulin that they can use it meal times and to try to adjust highs and they're going to get a slow acting insulin, that's going to be their basal insulin. Right, though, so let's start slow with the basal insulin. There's a lot of them on the market at this point. Back when Arden did MDI we were using 11 mir. And we found that we had to split it half a dose every 12 hours. How? How much of that is really good advice about slow acting basal insulin,

Jennifer Smith, CDE 3:28
specifically, that what you found with 11 year as a specific brand or type is very common.

Scott Benner 3:36
Okay? While while you know, the makers of love of beer will say that it is a 24 hour acting insulin. What we find, especially with the smaller doses, is that dosing twice a day or two injections of it works much more optimally because it doesn't carry a full 24 hours. That was absolutely my finding. I think a lot of people find that. So that's the first thing to understand. If you say to yourself, every day is certain time my blood sugar goes up. And I can't understand why I bet you it's about 18 to 20 hours after you've injected your long slow acting insulin. And so the important thing to remember when you if when you make the decision to split your basal insulin is that it might not be a 5050 split. So right say you have your five units or a one unit, it doesn't matter. It doesn't mean you're going to put in a half a unit and then a half unit again, 12 hours later, it might end up being three quarters of a unit or one and then a half later, there's your because your body has different needs at different times.

Jennifer Smith, CDE 4:40
Right. And that kind of goes into understanding the needs of the different age groups. kids and teens tend to have a much more profound increase insulin need in the overnight like literally like as soon as their head hits the pillow kind of thing and through and into the overnight. So splitting dose for, you know, multiple daily injections with the basal insulin, you may have a heavier dose in the evening than you do with that morning time, the heavy dose in the evening carries you through the increase in need overnight as well as the morning which is a little bit higher resistance as well. And then your dose in the morning kind of carries you through the day when you're more active, right? And you likely will need a lower bazel amount.

Scott Benner 5:26
And so all we've really said here, and I I repeat this a lot to people is that setting up your slow acting baseline so when you're on MDI is about amount and timing, right, yeah. We're gonna say this in the next episode, but so make sure you get to that next episode, but you have to balance the impact of the insulin against the action of carbs or body function, right. So it's just, it's about a tug of war between those things. And that again, I'll talk about a little later.

Jennifer Smith, CDE 6:00
And that's we're watching you know, glucose values, especially if you are privy to getting a CGM early on, which I do encourage over I've said it a million times to people that I work with, if I had to decide on a technology piece

Unknown Speaker 6:14
between CGM and a pump. If somebody was going to take one away, I would 100% keep my CGM, right 100% take my pump, I'll figure out my multiple daily injections. As long as I've got the data and the trend of what's happening. I can figure it out. If you were gonna I would 100% agree with you if you're going to say that one thing's more important than the other, which I think is a bit of a, you know, yeah, you're right. I I'm not looking to give one of them away. Well, they're my way Endymion. When you when you lose your pump, when you're using MDI, what what that means is that if you want that kind of like, tighter control, I guess, you're going to be injecting more. If that doesn't bother you, then right on, you know, like, that's absolutely fine.

Jennifer Smith, CDE 6:56
You also actually what my friend ginger does. Ginger Vieira, who I wrote the book with the pregnancy book, which, you know, she long term has been multiple daily injections. She uses CGM, she is not scared to give 12 1620 micro dosing adjustments through the course of the day to keep things tightly managed.

Scott Benner 7:19
And so and i think so I always say the same thing. Here's what you gain with a pump. You don't have to inject all the time. And you now have the ability to manipulate your basal insulin. Yeah, but other than that, there's no more

Jennifer Smith, CDE 7:31
precisely right, we can manipulate bazel with injected bazel. We don't, we don't recommend it. Like we would on a pump, it's difficult to difficult, it's difficult to manipulate. But you can use your precision to do that on a pump. Yeah,

Scott Benner 7:48
the first time I thought about getting on a pump, and I didn't know anything about them, and I went to a pump class at our children's hospital. You know, even back then I didn't realize that, that my basal insulin would just be fast acting insulin given by the pump, but in smaller doses, like, like spread out over minutes and hours, right. And I didn't, I didn't think about that. It was explained to me in that room. And then I thought I could shut it off. Like because how many times I thought, Oh, I wish this level Mir had an off switch right now. Right? Turn it off, she's stable, and she's at but I know she's gonna go down because this, this level here, she's gonna keep working in the

Jennifer Smith, CDE 8:25
bank. And I don't want to feed her three juice boxes just to prevent it right looking for that.

Scott Benner 8:30
I have become adept at manipulating Arden's blood sugar with basal insulin through her pump, but that's not what we're talking about right now. But we'll get to it in a different

Jennifer Smith, CDE 8:39
kind of leaves in it goes very well with MBI because you can manipulate differently even if you are on MDI.

Scott Benner 8:48
And so so I guess the first thing I would just very basic ideas you're injecting you need to pick multiple sites keep rotating your site you can put in so on and over and over in the same spots it's it's incredibly important because you your your spot, your spots will become saturated, you can actually what do they call that when that when you can actually see like bumps under this under your skin from

Jennifer Smith, CDE 9:11
Yeah, it's it's really a either a scar tissue development or potentially fatty tissue under the skin that that light, light bow hypertrophy. Other big, you know, fancy words for it. But really, it's just when you inject in the same place over and over and over and over again, you're damaging the underlying skin tissue. And it can lead to like I said, either scar tissue or fatty deposits, and unfortunately, then the absorption in those areas, is quite variable, quite variable, if anything at all,

Scott Benner 9:46
and you could lose your favorite place and never be able to use it again and walk away. So when your doctor or your nurse practitioner tries to scare you with whatever gin, whatever Jenny just said, they're like, something like that just thinking of myself. Just think to yourself, Well, that sounds scary. what she meant was rotate your sights,

Jennifer Smith, CDE 10:02
rotate your sights, and there, you know, there's so many places on the body to use. I mean, the backs of the arms, the lower back the upper, but the legs, the tongue, the tummy, the sides of your tummy. I mean, you've got a lot of places to use. So I think with little kids,

Scott Benner 10:19
that's always a it's a question with parents, you know, mainly because little kids, there's, there's so little, I mean, Arden was too, right. So it's, it's like it's finding the place on such a little body. And I'm let me veer off for a second to say something that I think people will find valuable, especially parents. I did some quick math, and in the time between art and being diagnosed, just after her second birthday, and when we got her on an omni pod, when she was about four and a half, I think we ejected or, you know, or stuck her fingers a combination of 10 to 15,000 times those years, right? Or a lot. And every time broke my heart in a way that I find difficult to put into words. and years and years later, we had been on the on the pod for years, before we ever ran into a situation where I thought I should inject here just to see if my site is bad, right? So we had had, we were on a just a really great run with with insulin pump sites. But one day, a number of years after we switched from from MDI. I said to Arden, hey, I'm not sure if this site's bad, and I don't want to change the pump if I don't have to. So um, you know, in Jackson, and so on, if it starts going down right away, I'm gonna say the pumps, sights bad. And if it doesn't, then you're just resistant for some reason, we're gonna give you more insulin. So I put it up on the counter. There she is, you know, she's like, six, seven years old. I pull out the insulin, and she's just going along. And I bring out the syringe and she says, What is that? And I was like, it's a syringe. It's a needle, I'm gonna put the insulin and then she goes in then what? And I said, Well, I was thinking of injected. And she was like, Well, well, well, well, well, wait a minute. Like really? Like, what are you doing? I'm not getting a needle. That's not something I do. And I was like, do you not remember these? No idea. no recollection of ever getting a shot ever. So I know, it breaks your heart as a parent. But I don't want to say kids are resilient, but time has a way of, you know, blurring the past. So yeah,

Jennifer Smith, CDE 12:27
absolutely. Absolutely. And that's, you know, even pump sites then, you know, same thing with rotation. Yeah, yeah, they all need to be rotated. And that becomes a, I think it as an as an omni pod. Plus, there are so many more places that you can put that pod. And easier, especially from the kid standpoint, or anybody who has dexterity issues or whatnot. You know, because there's no tubing, there's no tubing, and you can pop it on. And that's even easier than an injection.

Scott Benner 12:59
I've seen people put them backs of arms. Arden wears hers, you know, the left of the right of her navel on her stomach, and you can even and she wears them on her thighs. You can even rotate within a rotation. So you could put it on your stomach canula facing your belly button and then the next day turn it and you know, put it the other way like you can. If you have four spots, you have 20 you know maybe because you can just kind of start moving around a little bit. I've grown grown women who wear them on their breasts like that one. Like I show that every once in a while somebody will kind of like pull their shirt down online. I said it's the Arden arms like I've never done that though. Yeah,

Jennifer Smith, CDE 13:37
yeah. I've not tried that myself. Although, you know, this year, Chris Freeman.

Scott Benner 13:43
I was gonna bring Chris on.

Jennifer Smith, CDE 13:45
He wears he wears it on his chest. Yeah. And I know he also wears it on like his upper back. And I've seen people on many of the like the Facebook, diabetes groups and whatnot. The places that I mean, people wear them on their calf. I've seen people wearing them on their forearm. Now, although not approved site. Again, this is where your diabetes will vary. And you figure out what works for you. But you know, yeah,

Scott Benner 14:13
for people who don't know Chris is a four time Olympian and a cross country skier. And there is a picture that he shared years ago that is to this date, the most popular thing I've ever put on my website. So ladies, you might want to look at why you're clicking on things, but it's Chris without his shirt on. And he has no body fat to speak no, because we're the reason he wears it where he does and my point is he still pumping and using a dexcom and so if someone tells you you're too skinny for this, or I've heard it both ways, so funny. Oh, you're too your kids too chubby for that pump. Your kids too skinny for that pump. I there have been I've heard a million different excuses. But okay, so MDI, so rotate our sites. What are other good practice? is around MBI.

Jennifer Smith, CDE 15:01
Other really good practices, make sure you are changing the syringe, if you're using a pen, really, really important as syringe itself, as well as the pen needle caps. In fact, one of the very, very common practice for people to do is reuse the pen cap. And by reusing, they actually store the insulin pen with the needle cap, screwed on to the pen. Really not a good idea, it can introduce air into the pen. And it can change the way that the pen dialing and actually dose the insulin. So if you are going to reuse the needle cap, I don't recommend doing it. But if you are going to do it, take the needle cap off in between those uses. Always make sure that you're wiping the top of the needle, or the insulin pen itself, you know, with an alcohol swab, just cleanliness. Those are kind of the basics.

Scott Benner 16:01
Okay, well, what about and I realized to go back for a second, you were starting by saying don't reuse a syringe, which never in my wildest dreams even occurred to me, but you're telling me people do that, too.

Jennifer Smith, CDE 16:10
People do that. Absolutely. And, you know, having worked with people across the spectrum of economic setting, just like insulin is expensive. I mean, even though a box of syringes is not expensive, even off of the shelf, it's not expensive without a prescription. Again, it may be something that people are reusing because it's an expense that they could decrease somewhere, right? You know, so if you

Scott Benner 16:40
could avoid that, please do. So I have a question. And here's a good place to put it. I'm probably gonna bring it up again, we talked about pumping. So the quickest story would be that one day I took off Arden's pump, and I saw a little redness under where the adhesive was. And I was quite literally standing in my house, rubbing my hands together thinking, because I was scared Oh my God, is she allergic to this adhesive, and we can't pump any more like my brain was racing. And I'm rubbing my hands together and rub my hands together. And as I was doing, and I thought, Why are my hands so dry? And then I realized I'm constantly touching alcohol. Yeah. And so I do a little research and I find out that in Europe, it is not common practice to clean anything, a site with alcohol. And I was like, Huh, so I stopped doing that. And Ardennes never had that problem again, and my hands don't crack as much in the wintertime. And so is that a lawsuit? decision? Like do you say to somebody clean this with alcohol first, because every once in a while someone's gonna get an infection or why do we teach it and some other places don't.

Jennifer Smith, CDE 17:53
Alcohol itself is not a I guess the best thing that that I can call in layman's terms, it's a degreaser. It literally wipes clean, that area of any freeze any any skin moisture, any lotions, anything that could be on there. It's not antibacterial, okay, it's wiping the area in Sure, right. But the real reason for cleaning the site is just to make sure that you've you've taken care of anything that could be there and as far as adhesive component, it's very likely of course that the adhesive isn't going to stick as well if you've got body lotion on it or if you haven't taken a bath in two days and you're putting it on your skin and your skin has done its normal thing and you've got oily skin so the adhesive isn't really gonna stick as well. What do I tell people, I also do not use alcohol. Oh my gosh, a CDE that doesn't use alcohol swabs. But I do of course have a clean site. And by clean site I make sure that I wash the area. Soap and water make sure that it's clean dry it and that's what I you know apply on top of then you're entirely 100% right? Alcohol is it will dehydrate the skin and used over and over and over especially for kiddos little kiddos who have very sensitive skin to begin with. You're just asking for more. I mean, there are skin barriers if you do truly have a you know, a site problem. But yeah, even for injections though, making sure that the injection site is just clean. I mean obviously if your kids been outside rolling in the mud or in the sandbox or doing whatever they've been doing in the rain puddle, clean the site,

Unknown Speaker 19:47
jacked into it.

Scott Benner 19:48
Do the same thing. I use warm water, clean towel, a clean towel to dry it, let it air dry, something like that. It goes on, you know, schedule your pod change around your shower, you know Get out of your shower. Sometimes, you know, I see some people like, they call them naked showers where they change all their gear, they take it off before they jump in for free or for a couple minutes, they jump out and they do it, then there's a bunch of different ways to do it. But I think the important thing here is to use your common sense, right like to. And that's all I did that day, I thought I'm drying her skin out, and then throwing this adhesive on top of her. No wonder there's a reaction here. Absolutely. There is a wonderful post on my blog about how to treat real severe adhesive allergies, it is one of the most popular posts over the last five years. And I'll link it in this so that people are great. It was written by a mom who devised a infallible plan. And when you see the pictures of the reaction that her poor kid was having, it was an all over body reaction. And she figured out a way for it not to happen and him to keep using this stuff. So that was really good. I remember the first time Arden was in like a thin pair of like yoga pants as like a four year old, and or a three year old or four year old and I wanted to give her a shot in her leg. But we were out and I just was like, I'm just gonna jab the knee right through the pants. And that's what I was like, okay, maybe all these rules aren't that important. And and you know, and so she was like, Oh, my God, what are you doing? And I said, No, it's fine. I brought it up in you know, now I say I've done that in the past and she was mortified. She's like, why would you? I was like, Listen, we were in the mall, you know, like, like, what do you want me to? Because I and here's something I really believe. And I think this is a great place to bring it up. I don't think you should hide when you give yourself injections. No, I agree. I think that not just not hiding. But why in a public place? Would you go to what is arguably the dirtiest, the bathroom to write up a hole into your body?

Jennifer Smith, CDE 21:56
Absolutely. kind of goes along with nursing for women. Why should you have to go to the bathroom to nurse when it's the same thing. It's the comfort level of other people. It's not your comfort level that you're worried about.

Scott Benner 22:13
The Dexcom g six CGM is now FDA permitted for zero finger sticks. That's right, the continuous glucose monitor that Arden has been using forever, does not require calibration from a blood glucose meter any longer. But do you know what it does do? It allows you to see your blood sugar, speed and direction. Are you rising at two points a minute falling at three points a minute, the dexcom CGM will let you know with customizable alerts. And if you're the caregiver or someone who loves someone with type one diabetes, and you'd like to be able to see their blood sugar when they're not with you, that's possible too. Because Dexcom has a share and follow feature that is available for Apple and Android. My daughter's in school right now. We just gave her insulin for her lunch, and I can see her blood sugar. Her blood sugar started to creep up on us a little bit. So I got an alert and we added some insulin stopping arise. The dexcom g six features an applicator that is virtually painless. My daughter says she can't feel it at all. And it's completely automatic. One button push and the sensor bed has been applied. You snap in the transmitter and you're on your way. You can see your blood sugar's on your Apple watch or other smartwatches on your iPhone on your Android phone. You can share it with anyone in the world anywhere. I can tell you without hesitation that the Dexcom continuous glucose monitor is without a doubt one of the main reasons why we've been able to keep my daughter's a one c between 5.2 and 6.2 for five continuous years. To find out more go to dexcom.com forward slash juice box or the links in your podcast player show notes or at Juicebox podcast.com. It's going to be the best decision that you ever made. In 2008, we made the decision to get my then four year old daughter an insulin pump. It's a decision that I wish we would have made years sooner. After seeing everything that was available. We easily settled on the Omni pod that was back again in 2008. Today Arden is about to turn 15 years old and she has been wearing it on the pod every day since then, every day. And as I mentioned in the other ad, Arden z one z has been between 5.2 and 6.2 for five solid years. How do we do that? Well, we start by seeing an insulin pump is more than just a way to not have to take shots. The Omni pod gives you the ability to do temporary basal rates, that's increases or decreases in your background insulin, extended boluses which will help you spread out your insulin over the life of a meal and so much more. The Omni pod has no tubing at all. The pod is self contained. You wear it on your body You control it with a wireless controller. So there's no tubes running through your clothing, and no pump that you have to jam in your bra or down your pants or wherever people have to put their palms that just doesn't exist with the Omni pod. What does exist is the ability to swim while you're getting your insulin bathed while you're getting your insulin and live life untethered. The Omni pod even features self insertion, just push a button. Now I want you to go to my Omni pod.com forward slash juice box. And when you get there, you'll get a free, no obligation demonstration pod sent directly to your house. Check it out and see what you think for yourself.

Jennifer Smith, CDE 25:46
It's the comfort level of other people. It's not your comfort level that you're worried about. Exactly.

Scott Benner 25:51
And so let me tell you, the briefest story. I'm in a restaurant one day with my kids. Were leaving that day. And there's this little girl seriously a little girl injecting at her table. And I stopped at the table, none of my business. I said, Excuse me. I just want to do it. May I say something and they looked up at me in horror, I realized now and I said, My daughter has type one diabetes too. And I want to say good for you for injecting here at the table. There's no reason for you to hide. You're doing a great job, little girl. Last year, I got to do the math. Last year, seven years later, I had to make a phone call about jury duty. And I said, Look, I would like to skip jury duty because I'm the sole caregiver for my daughter, I help her make her insulin decisions. And if you listen, if you'll let me be on my phone while I'm there, I don't care. But if you don't want me on my phone, I need to ask the skip. Right. And the woman says oh, I completely understand. My daughter has type one diabetes too. And I gave her my name. And she says is your daughter's name Arden and I was freaked out. And I thought Yeah, why? And she goes, I read your blog. And I said great. She goes, actually you're gonna find this strange. You've been a real help to my daughter through her life. And I said why? And she said, because you bumped into us in a restaurant, the week a week she was diagnosed, and you told her she was doing a good job and she shouldn't hide. And she's like, and it's been such a big deal in her life. And I was like, wow, oh, touching. I'm gonna get out of jury duty. Right? And, but, but absolute 100% honest story. Like Don't, don't hide, you know, and because Jenny's right it is for other people. It's not for you, and it quietly you'll you feel shame like it quietly will make you feel shameful about what you're doing and you should not be ashamed of accounting type on

Jennifer Smith, CDE 27:50
that at all. It's just like, you know, I mean, everybody wears it I mean, it kind of goes along with everybody wears their pump differently. And there are a lot of people especially Omnipod wares who wear them you know, only in like, unseen locations. Man I like I wouldn't bipod there get decorated with stickers and I used to like color them with markers and now that now that you know we have the 3d printer kind of thing. We don't but I ordered a Wonder Woman 3d print pack snaps. It snaps over the top. It's awesome. I actually got my six year old pick it out because he was like, wow, all those are cool. You have to get Wonder Woman mommy are wonderful. I was like great. I missed that one.

Scott Benner 28:38
But mommy was ours but okay.

Jennifer Smith, CDE 28:41
In fact, one of my favorite places to wear it is on the back of my arm because honestly because it isn't visible. Yeah, not like the other places on my body aren't good. It's just I like to wear it good spot visibly, you know,

Scott Benner 28:54
I would tell you that Arden has in the past seen other people using insulin pumps on the pod and CGM. And it she's not the kind of person who runs around excited about it, but it has quietly given her a lot of comfort. Yeah,

Jennifer Smith, CDE 29:08
yeah. It's always fun to when you run into I call it diabetes in the wild. Like you run into somebody at the grocery store who's like, you know, boldly got their pump, like hanging off their pants or, you know, clip to their jacket or you know, something like that, because I I always reach out I'm always like, Hey, you know, look, you

Scott Benner 29:26
pumps we've all got pumps, and it kind of starts up a conversation and it's, I don't know it just because diabetes is so like, it's such a silent on scene. For the most part. It's just a nice way to bring it to a visible and make it make it normal because when and here's why that's important. I interviewed a singer A long time ago, a Broadway singer named Kelly. And if you go back and listen to Kelly's episode, which I'll link in the show notes, she hid for a long, long time. And it was not good for her. When she finally decided not to do that it was freeing. So I'm saying don't put yourself in a position to begin with, you know, just be yourself and write and this is who you are. And look, I'm not judging you, if you can't bring yourself to do it in public. I'm not saying. But I'm saying if you can do it, do it, you know, you'll be happy with what happens. So, okay, so what are we not? I haven't, I haven't injected insulin in a really long time. So let me tell you one thing that happens to me all the time, every once in a while when I have to give a needle I'm not good at it. tells me I'm not good at it. And so what, what is, like, what should I be doing? Is there a pinch? Is it quick? Is it slow? Like, what's the right way to stick that needle in there?

Jennifer Smith, CDE 30:49
Do it? Yeah, I mean, you know, obviously, the age old recommendation is to pinch up. To put the needle in, when I was initially diagnosed 30 years ago, we were told to inject at an angle almost at like a 45 degree angle. Quite honestly, now the the recommendation is just like most 90 degree pump sets, just straight up, putting it straight in, no angle is needed. A lot of people have questioned to about the needle length, and all of the research and studies that have been done. Regardless of body type, and body stop body size. Even those really, really micro looking needle lengths, they give you the same, the same ability to put the insulin under the skin in the place that it needs to be, which is the sub q tissue, like the that kind of fatty layer for absorption. So pinching up the skin, putting the syringe or the the needle that's on the the pen straight in 90 degree angle, and then just push the insulin in,

Scott Benner 31:59
that I have to keep the needle in for a second or is that a pen thing?

Jennifer Smith, CDE 32:02
That's for the pen. Really, the recommendation is it does vary. I've heard people being told that they're supposed to count to 20. I've heard people say that they're supposed to count to five. When I was initially educated, we were told to tell people count to 10. So that is what I educate with. And it's interesting because if you have ever given a syringe injection versus a pen injection, you will notice the difference if you pull that pen needle out right after and you don't give that count to 10, some of the influent can leak out. Okay. So that's the reason for that count. And whether it's a basal insulin or your rapid acting insulin or a regular insulin. If it's a pen, you do need to do that count.

Scott Benner 32:49
Okay. All right. Um, let's see what you think of anything that I'm not asking you about because I'm at a disadvantage when talking about MDI.

Jennifer Smith, CDE 32:57
I mean, the only I mean, we kind of, you know, bazel insulin, of course, rapid acting insulin, you know, there are multiple of them on the market. And there also is still some use of regular insulin which we called short acting insulin, it had a longer profile of of working in the body than our rapid acting insulins have, it also didn't work as fast. So again, this is where figuring out what your needs might be. For the most part, the rapid insulins on the market, the three age old ones, you know, human log novolog, a Piedra, technically, they're all supposed to work pretty much the same way I can tell you my personal and have one is that human log and Nova log work pretty much the same for me, a Piedra does not I've tried it, it doesn't work the same for me. Then there's also of course, Vf, which is faster acting insulin aspart, which is just faster acting novolog insolence. It does have a faster onset of action, and has, in my experience, having used it for a bit of time, it seemed to have almost a more clean finish to working. It was done and and that was kind of the end of its actual in my bazel was kind of kicking in and doing what it was supposed to do. But you know, determining what again, works for you insurance wise, many insurance plans have a preferred or a tiered kind of both bazel and rapid acting insulin for you to choose. monetarily, if you can go outside of you know, tier one or tier two, most influence are tier two. If you can go outside of that, they'll usually be a tier three and your copay is just going to be more. But if you prefer one over the other, that might be the course of action you have to do. If you can't, then you're kind of stuck using what the preferred is

Scott Benner 34:52
okay? And I'm gonna ask you one question and then we're gonna switch to another episode and talk about insulin. So the one thing I've found That when I talk about Pre-Bolus with people, and you know Pre-Bolus thing is a pumping word, it just means putting your insulin in before your food, right. So you can, you can pre inject you call it whatever you want. But but some, but a lot of times what you'll hear from especially parents is I don't want to inject them twice at a meal time. And I say, look, I understand that, but but if you can't be sure of how much insulin, how much food the child is going to eat, you still need to get some moving first. So if you're on MDI, and you're seeing crazy spikes at your meals, it's because you're not Pre-Bolus thing, I'm guessing, or a lot of other reasons that you'll hear through the next bunch of episodes. But you're gonna have to make that leap in your head like I'm gonna, if I can't trust he's gonna eat all this or she's gonna eat all this, then I need to put some in now, and summon later,

Unknown Speaker 35:49
right.

Scott Benner 35:52
Please remember that the Juicebox Podcast wouldn't be possible without its sponsors for today's episode on the pod, and Dexcom Dexcom, the makers of the G six continuous glucose monitor, and of course on the pod is the tubeless insulin pump that Arden has been wearing for over a decade. You can go to my Omni pod.com forward slash juice box to get a free no obligation demo of the pump sent right to your house. Or you can go to dexcom.com. forward slash juice box to find out more about art in CGM. Heck, you could do both. The next episode of my series with Jenny Smith is called all about insulin. And it's available now at Juicebox podcast.com. are right there in your podcast app. If you're enjoying the podcast, please leave a rating and review on iTunes and take a moment to share the show with someone who you think it can help. Thank you for listening for being bold with insulin, and for remembering that nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise. And to always consult a physician before making any changes to your health care plan.

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