#267 Ask Scott and Jenny: Chapter Three

Answers to Your Diabetes Questions…

Ask Scott and Jenny, Answers to Your Diabetes Questions

• Let’s talk about standard deviation and target range.

• Let’s talk about Loop and absorption time to better understand food impact, glycemic index and extended bolus.

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

+ Click for EPISODE TRANSCRIPT

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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
This episode of The Juicebox Podcast is sponsored by in pen from companion medical. 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 any changes to your healthcare plan, or becoming bold with insulin. MDI users, this one's for you. How would you like to live your life less complicated? You can do that within pen in pen is a reusable injector pen that has its own smartphone app. They talk to each other through the Bluetooth. that Bluetooth is magic, isn't it? You know what the app does? I'm going to tell you a lot of battle over the next few weeks on these Friday shows. But for right now, dose calculator dose reminders reporting actually tells you if the temperature of your insulin has gone out of range. Not only that, it connects to your CGM. Ooh, I got you there tonight, an app on your phone that connects to your continuous glucose monitor that connects to your insulin pen. Now you want to know more about indepen don't you? Check out companion medical.com. Welcome to ask Scott and Jenny. In today's episode, I Scott and Jenny Jenny Smith from the diabetes Pro Tip series in defining diabetes. You know Jenny, Jenny works at Integrated diabetes. She's a CDE, a registered pump trainer CGM trainer dietician, she has type one. Her favorite candy is dark chocolate peanut butter cups. And if Jenny was a professional baseball player, she'd be Hank Aaron.

In today's episode of the show, Jenny and I are going to be taking questions from you the listeners. In this episode, we're going to talk even more about understanding standard deviation and absorption times for loopers. Now that absorption time for lupus thing, don't get confused and think if I'm not looping, this doesn't work for me. It's also going to be able to inform you about how to understand your extended boluses. Trust me, it's all about timing and amount.

mirdif asks one interesting journey after we did standard deviation in a defining diabetes. I get this question a lot now. So obviously we there's something we didn't say there. We caused more questions than then

Jennifer Smith, CDE 2:42
then I think I read this one, what three day

Scott Benner 2:45
target for standard deviation? And if you set your targets tightly for alert purposes, will it look like your standard deviation is greater? Will that not affect the value of murder? We did talk about this in the office? Because I've had the same thought. But I won't. Yeah, I'll let me go over it one more time in case we missed something in that episode.

Jennifer Smith, CDE 3:03
Yeah, so standard deviation really speaks to the variance up down. So even if you had your target set, let's say, in your CGM, you have your target set from 80 to 120, let's say a very tight target, okay. But you have this roller coaster that's happening this up, down, up, down, up, down, up down, you know, from, you know, on the low end, maybe in the 50s. And on the high end, maybe up to like the 120s, you're still you're going to have a higher standard deviation, because the variance even within that target that you're still meeting, you're still having a roller coaster. Now the standard deviation is going to get higher. If you have more variance, let's say even if you're your target is that 80 to 120. And you're going from 50 all the way up to 300. And way back down and way back up to 250 and back down, then the standard deviation is even going to be larger than it was with a roller coaster within a target. The aim for standard deviation. I'm always kind of cautious to say we're aiming for a standard deviation of this solid rock, you know, this one number. The lower the standard deviation, the better. That's that's the easiest way to say I mean, if you're looking at a standard deviation of 70, you've got a heck of a lot of variance you do. Your CGM graph probably looks like a roller coaster at an amusement park, right? That's not what we want to aim for. Even within a tight target. You still don't want all of this happening. You want more gentle rolling hills from you know within less or within a tighter range, right? That's going to bring the standard deviation down. So if you have you know, a target range set from 150 to 180. And you're meeting it and your standard deviation is 21. That's a beautiful standard deviation, but your target is leaving you high. Right? So you're doing a good job of keeping things to a minimum as far as excursions, but you just need to ratchet your target down to keep that same low standard deviation. So I hope that makes sense. I'm going

Scott Benner 5:29
to share what we do because it's by no means the rule but it's a place where I've become comfortable with living life and finding a balance. Right. So Arden's target is set at 70. And 120. I'd love to be between 7120 as much as possible, it's not as much a target as it is. alarms for me, like when do we have 120? So I know what to do, right. I love for Arden standard deviation to be lower than it is. But in honesty, I tried just not to go over 40 Like that's like, and that's not great. Yeah, but it's, it's I shoot for more like 35 I try not to go over 40 If you look at Arden's graphs, they're interesting in that 18 hours of the day, her blood sugar is like 80. You know, most of the time, there's two meals that are varying cause a variance Right. And, and she'll jump up usually, it's like 181 60, conventional pumping, I was able to get down a little more quickly. But we're doing now not as fast. But conventional pumping, I didn't have 18 hours of ad that was solid. So in my mind, it's a bit of a trade off, and I'm learning how to do the meals better. I think that you should think about standard deviation more in the context that Jenny put it in. You don't want it to be 70. Not good. Right. But if you're shooting for 20%, or something like that, probably not that realistic. So I've heard under 40. I don't know where I've heard that from is that a reasonable like Mendoza line for

Jennifer Smith, CDE 7:13
under 40? Absolutely. I mean, if you're really it, I usually with the with the people that we work with trying to aim for, you know, the 30s or without consistently running just way too low with little deviation, the 20s can be great, as long as like Arden is kind of hovering at that at with little deviation. Great. That would be awesome. You might be in the 20s. But you know, 30s is kind of where we aim. Overall, with a little bit lower or whatnot. Depending on what situation in life you might be at two, with the women that I work with through pregnancy, we aim lower, tighter overall everything.

Scott Benner 7:55
Let me give you an example because I'm looking at a live grant for art and for 24 hours, right? So in the last in the last one day Ardens a one C has been 5.8 with an average blood sugar of 119 that put our standard deviation at 42. Now if you go out over 90 days, Arden's averaged a one C is 5.6. Over 90 days, her average blood sugar's still 115. But her deviation will probably go up. It does. So it goes it says 45 Over the last 90 days now we are still learning some things and so we have some more prolonged blood sugar's but for instance, in the last seven days, her standard deviations 38. Right. So as I get better at it, you know, over the last 90 days, because you know of this loop thing, you know, you see it come down, I will get the deviation consistently under 40. I think it's going to be more consistently like 35 Once I figured out the meals, but then, you know, I think Jenny's Right. Like once you have the tools in place and things are working. I see standard deviation not as a target. I see it more as See, I don't want to call it a report card, because I don't mean it like that. But I think of that more something you look at later to say, oh, things are getting better, not something right day to day. It's like a comparison

Jennifer Smith, CDE 9:19
almost to say this is where I was this is where I am now. Oh, it looks like it has improved.

Scott Benner 9:26
I would look at if you're looking day to day, I just look at average blood sugar, and I try to keep it lower. And then I look at at deviations like high high deviations. Obviously I don't want a low blood sugar. So I don't have a lot of problems with lows. But I don't want to see big spikes that lasts too long or big spikes. Right. So Meredith, I hope that answers some question and then I'm about to tell you something about in pen. And I think I should first warn you it's possible the information could blow your mind. So I don't know what you want to do put a hat on or hold your hands in the side of your head or something like that, but When you Bolus within Penn say you're having some food, right? And you look at your plate and you're going 10 times, you decide that's 35 carbs, you go into the in pen app, tell it 35 carbs, and it tells you how much insulin to inject, right? Hold yourself tight now because the here's the rest of it. Now pen users, no, you have to prime your pen a little bit. So you prime the Impend, and then dial up the insulin that the app tells you, let's say it tells you a 3.5 units, you inject those 3.5 units, the in pen actually can see the difference between the prime and the 3.5. And it doesn't. So you know, I'm saying like, when it's calculating how much insulin you have, it's not saying like 3.5 plus the priming amount of insulin it know, how does it know? The fascinating, right, like just boom, I don't understand. I mean, for a pen user, or somebody who's doing injections, this is an incredible leap. Your insulin on board is being kept by an app on your phone. And it can see the difference between the priming of your pen and the Bolus. Get out of here. You obviously need to know more companion medical.com. There's links in your show notes at Juicebox Podcast comm. And one more thing, starting I think next week, maybe the week after these ads are actually going to be a conversation within pen user and world champion, paddle boarder, Fiona wild. Fiona is going to tell us what she loves about it. And it's enough of me telling you what I can, you know, read in a PR kit. Let's hear from a real user. I'm wondering about carb types, oh, entering into a loop. I get confused about what to put when I'm eating a combo meal. For example, what if I'm having pizza and fruit or a burger and veggies or, you know, like yogurt fast carbs plus protein? She said I thought maybe since Jimmy was a dietitian too. This might be something she can help decipher how to Bolus for different combinations. So what Matty's bigger question is and how this will work out for the rest of you is she's really asking about absorption time, I think in loop right, to

Jennifer Smith, CDE 12:15
an glycemic index to a conventional pump system. Yeah, in game

Scott Benner 12:19
conventional pump system, it's going to be glycemic index. And the idea of extending boluses or temporary or something like that. So it's, it's crap, slightly different tools, same reason. But to give people context, you don't listen, who don't use the looping system, you will tell the loop Hey, I'm eating 35 carbs now. And then you have to tell it how long you expect it to be in your system, how long you expect it to take to absorb is that one hour, 30 minutes, two hours, three hours, like that kind of thing. If you get that absorption time wrong, when you put the setting when you put the carbs in the loop, it really big causes a lot of high blood sugars when you get it wrong the wrong way. So do you have any thoughts on this? Because I'd actually love to hear them. I'm gonna sit back and listen like a listener for a second.

Jennifer Smith, CDE 13:03
It's a very good question. I think that the icons that are within the fast moderate and slow groupings, if you are a looper and using them are defined by like a glycemic index nature, right there fast ones are going to get absorbed pretty quickly loop says they're two hour moderate or like a three hour really slow, which would be like high fat, really high protein kind of meal would be a slow absorption, right? icons like a lollipop, a taco or pizza. Okay. Now, most mixed meal, she brings up a good question. Most mixed meals that are a content of carbohydrates, and protein and fat and healthy fiber. Good example being something like grilled chicken, steamed veggies, and maybe like quinoa or brown rice or something like that, right? That's a good mixed meal, a three hour absorption would be a good place to start. It's mixed. You've got a little bit of everything. Now, on the flip side of that, let's say you have like a thumb size of grilled chicken, one broccoli spear and a plate full of brown rice. Hmm. Question time there is based on the content, right the content but the portion that's the glycemic load. It's not only glycemic index, but it's the amount if you've got a plate full of high index carb that you're eating, very minimal little other things that's no longer a combination meal. That's more like a two hour that's like it's fast now rice is as an example in this can be a can be a bad example because some people's experience with rice can be longer impacting same thing with pasta. Some people get really quick impact from pasta some people get really like long drawn out. And I mean if I went into it further, some of It has to do with cooking method and again what you eat with it and whatever. But in a simple answer, most combination meals that are not heavy simple carb should be about a three hour absorption for our absorption would definitely be those Merle meals like she's saying, let's say I'm eating a big old cheeseburger and french fries but I'm also having an apple on the side, that's still a fairly long digesting meal. A trick or a tip that might work it let's say you're eating the apple First eat the apple, put it in as a 15 gram you know kar Bolus absorption two hours. And then when you go ahead and Bolus for the rest of the combo meal, or go ahead and rest as the rest as a four hour absorption. That way, you're kind of addressing both types of food and the way that they may be being digested because of how you've kind of eaten them. Whereas the apple at the end of the meal sitting on top of the burger and the French fries and whatnot. Group it in and to for our absorption.

Scott Benner 16:10
I was gonna I was gonna say to rice so at home. I only use a basmati rice. It's okay, and that does not impact Arden nearly like if we were to go to a Chinese restaurant, she was just going to grab like white rice, right? It's just it's easier. You know, bread with no high fructose corn syrup. Great way to cut yourself a break. And pasta, I use dreamfields It does not hit Arden nearly like other pasta does. Both in intensity and time. So there are sort of ways to like cheat around it with certain foods and what you said about about cooking methods I just made I just made another another note for myself about something we could talk about in the future. Because that's really interesting.

Ask Scott and Jenny was brought to you today buy in pen from companion medical, please go to companion medical comm or click on the links in your show notes of your podcast player, or the ones you can find at juicebox podcast.com. For more information. Just think about what it would mean if your insulin pen could keep track of your insulin on board and so many other things. Just like a pump. The impact is fantastic. It's like that little train that just keeps going get any mean climb and Chugga chugga chugga that thing you don't I mean, it's like no stopping us. Now that's not the train. But if the train could sing, you know if the little engine that could could sing I imagine it would sing ain't no stopping us now. What would that even sound like? I'll leave you with that thought. As it fills your head all day long and torments you. You know what? That's not fair. You need to get that out of your head. Do this instead, think about this companion medical.com with links in your show notes for juicebox podcast.com

About Jenny Smith

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

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#265 Ask Scott and Jenny: Chapter Two

Answers to Your Diabetes Questions…

Ask Scott and Jenny, Answers to Your Diabetes Questions

• Does bathing affect blood glucose levels?

• How do you handle alcohol?

• How do you crush a high?

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

+ Click for EPISODE TRANSCRIPT

---

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

Scott Benner 0:00
This episode of The Juicebox Podcast is sponsored by in pen from companion medical. 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 any changes to your healthcare plan, or becoming bold with insulin. MDI users, this one's for you. How would you like to live your life less complicated? You can do that within pen in pen is a reusable injector pen that has its own smartphone app. They talk to each other through the Bluetooth. that Bluetooth is magic, isn't it? You know what the app does? I'm going to tell you a lot of battle over the next few weeks on these Friday shows. But for right now, dose calculator dose reminders reporting actually tells you if the temperature of your insulin has gone out of range. Not only that, it connects to your CGM. Ooh, I got you there tonight, an app on your phone that connects to your continuous glucose monitor that connects to your insulin pen. Now you want to know more about indepen don't you? Check out companion medical.com Welcome to ask Scott and Jenny. In today's episode, I Scott and Jenny Jenny Smith from the diabetes Pro Tip series and defining diabetes. You know, Jenny, Jenny works at Integrated diabetes. She's a CDE, a registered pump trainer CGM trainer, dietician, she has type one. As a matter of fact, if it was the mid 70s, Jenny would be the Bionic Woman of diabetes care. She'd be Jamie summers. And for all of you who don't get that reference, I hate you for being young.

In today's episode of the show, Jenny and I are going to be taking questions from you the listeners. In this episode, we answer questions about bathing and whether or not that affects insulin drinking and how to handle it. And the third thing not lying to you, I cannot make out my handwriting. Oh, you'll have to figure that one out. I mean, it's only like 20 minutes long. You can do it. I wish I was kidding. That is what just happened. Right? You're ready.

EDAA EDA is editor right EDA at its at a let's call it says this is interesting because I think we kind of gone through this in our exercise episode recently. But she said okay, another doctor rule. When we got diagnosed, we were told not to take a shower and our past post insulin intake is I read this one is that is that true or false? My son's eight years old needs a shower every night. But sometimes we have to alter our night routine because he was given insulin. This is interesting because I think this is a great example of doctors trying to give you boilerplate answers to life's questions. And now doesn't consider that for the rest of time in memoriam Ed his kid is sitting around dirty not go into because he had a snack you know, I get the overall. So I've never really seen it Arden showers in her blood sugar doesn't get low is that because our Basal is right. And she doesn't have too much insulin in her body when she gets in the shower. What is that about it? Because I've seen it happen to where she jumped in the shower and her blood sugar falls?

Jennifer Smith, CDE 3:26
Yeah, it's it's really I mean, it has to do with the fact that in a shower unless you're literally taking like a Polar Bear Plunge which you're in the Midwest, you do in the middle of winter, right, that I guarantee is not going to cause your blood sugar to fall.

Scott Benner 3:42
You guys now have a great image of what Jenny looks like going from her shower to her towel to her bed.

Jennifer Smith, CDE 3:50
So, overall warmth to a site that's infusing insulin warmth creates, you know, it causes the blood vessels to move closer to the surface of the skin. And since that's where we're kind of infusing insulin, you get more vasculature, you get more circulation, I guess is the easier term so that your insulin actions speeds up. So you can get drops in blood sugar now, does it happen for everybody? No, it doesn't happen for everybody. The warmer the water, the longer the time that you spend in the water, etc. I know myself, you know, I mostly take showers now i with two little kids, they really don't have time to lounge in the bathtub for like three hours and read a book so

Scott Benner 4:39
Calgon commercials a lie, Jenny. It's a

Jennifer Smith, CDE 4:41
lie. It's totally a lie. Sometimes. In fact, I've said I need a Calgon moment my husband like sort of laugh in the background like I seriously

Scott Benner 4:50
fight. You know, now that he knows he could be replaced by dark chocolate peanut butter cups.

Jennifer Smith, CDE 4:57
Actually, yeah. Forgot I told you about

Scott Benner 4:59
that. Yeah, get in line and just laugh when Jamie says lamb.

Jennifer Smith, CDE 5:05
So yeah, you know, if I spend five minutes in the shower, I definitely don't see a change in my blood sugar now is my and I were Omni pod. So my pod is not like soaking in warm fits, you know I'm moving around in the shower, not just letting the shower water hit specifically that place. But for a kid who might be taking a bath, whether the if maybe the pump site is completely submerged in the water, if they're like my six and two year old who loves to like, play in the bathtub until it's literally like frigid, Ice Cube cold. And then they scream when they have to get out of, you know, if that's the case, it may be a reason that doctor is being I've never heard that a doctor actually even bring that up. So I think it's interesting that their doctor mentioned that

Scott Benner 5:51
at all a lot. I've seen this a lot. So,

Jennifer Smith, CDE 5:55
but really, yeah, I think it's interesting. But you know, it's, I think it's a preventative for hey, let's, let's not have you have low blood sugars just because you're taking a bath, but quite honestly, you know, if he's taking a bath, and you're doing an injection and his upper arm, technically, the bath unless he's laying down in it shouldn't cause a drop in blood sugar. Again, timeframe is also a difference there. I have noticed the difference. If I've been sitting in like a hot tub. I'm usually on vacation. If we do that I try to have my pat on the back of my arm so I can kind of hang my arm out of the hot tub and not like boil my insulin or anything. But even so just the warmth of sitting in that much, much warmer environment. I have definitely seen my blood sugar come down. So that's it's not odd. Your doctor was certainly not, you know, just blowing smoke. Yeah.

Scott Benner 6:52
For clarity to you're not saying that we don't want to heat the insulin up because it works better. When the insulins warm. You're saying that when your cells are warm, just like we talked about the exercise.

Jennifer Smith, CDE 7:01
So absorption is faster and Yeah, exactly.

Scott Benner 7:06
Okay. I like that one. This one's interesting, because I said to someone recently, I have to find a real like professional like drinker to come on the show and talk about how to Bolus for booze, right? Because I don't know but you live where it's called. You must have to get liquored up to get through the winter.

Jennifer Smith, CDE 7:27
So much. So people probably do.

Scott Benner 7:30
So Jim says what's general best practice considered for bolusing? For booze? I generally don't Bolus with my adult beverages. But what but I'd like your take on this. And then and then Emily came in and said, Yes, I gave up beer for more than a decade because it was so difficult to manage my blood sugar. Lately, I've been allowing myself one beer, but I tend to nurse it. So should I do a Bolus and extended Bolus or Temp Basal? So what are you? I am not a drinker at all, and I don't have diabetes. So I'm out on this one.

Jennifer Smith, CDE 7:59
Yeah, it's very, it's a good question. So in in general, have an alcoholic beverage that has carbohydrates in it, you will require insulin to cover the carbs in it. That's we're not talking about alcohol part of it yet just the carb part of it. So a beer. Most beers in fact, the lighter the beer, like the pale ales and those kinds, they tend to in 12 ounces have somewhere between like 15 and 20 grams per 12 rounds. The darker the beers like the stouts. And the Guinness kinds of things, they tend to actually have less carb, usually only about like 10 to 12 ish grams per 12 ounce. So there's a little card for you, beyond what you'd have to Bolus for. But if you are not a college, beer slam drinker in two seconds to see how long you know how quick you can actually get it down in competition with somebody else. If you're nursing it and it's a social drink. My assumption is that you're probably drinking a beer over let's say 30 Or maybe even 60 minutes. Let's It depends. She brings up a good point. Yes, extended Bolus is absolutely very beneficial there, especially if you're drinking the beverage on an empty stomach with no food with it was that mainly because food would help with the overall just it helps with the absorption that your body is also working on digesting the food and the beer or the alcoholic beverages sort of being absorbed and digested kind of along with the food. So you have less impact of like the alcohol component up front. So you have less tendency to have that drop first, even with a beverage that has carbs in it. But again, in a in a no food environment, just drinking a mug of beer. Essentially an extended Bolus would be a good idea, let's say over 30 minutes even over 60 minutes just depending the other types of alcohol let's say you're just doing something like gin or vodka, or something that really doesn't have a carb component to it. There's no reason to Bolus for it since there's not a carb piece to Bolus for. But does that mean that you shouldn't consider the impact of alcohol at all? No, in fact, conventional pumpers, the typical recommendation that we give is, when you've finished drinking, let's say you've consumed three beers or three, you know, drinks with vodka, that are carb free, or whatever it is, at the end of drinking, the goal is to take your Basal down a decrease of 40% for two hours per drink consumed. So at the end of the night, if you've consumed three alcoholic beverages, three times two hours would be six hours, you would decrease your overall Basal by 40% for six hours. And that helps to decrease the chance of lows, which are the end result of alcohol being processed in the body as a first response of the liver, the livers, that's one of the livers many, many, many, many, many jobs is to process the alcohol out because it's seen as kind of like a toxin, right? So in that same form, then the liver output of what your Basal insulin is supposed to be covering, if not outputting, that drip drip of glucose, that your body is supposed to be being covered by the Basal rate. So if you have lower output, you're not going to need quite as much of that Basal and the alcohol content to then cause low blood sugars.

Scott Benner 11:44
I had no idea. Yeah, and I here's one thing I do know that I can add, even though it wasn't asked, glucagon doesn't help you. When you've been drinking, is that right? Or is it not? It's,

Jennifer Smith, CDE 11:55
it's, it's not as effective, it can be less effective. Yes, because again, the liver is first word, especially if there's a fair amount of alcohol in the system, being one glass of wine. It's very wise if God would be fine, but you know, you've had several drinks and whatever, and you're kind of like tipsy and the glucagon would definitely have an impaired detail.

Scott Benner 12:18
And that's because your your liver is busy with other things, and it's depleted in the glucose. So if people understand or not, glucagon releases glucose from your liver, it's not a magic thing that brings your blood sugar up. It's not it's not Yeah, I don't know if everybody understands how it works. So if you're a power drinker, looking at your friends right before you pass out and saying hey, if I have a seizure, mix this up and stick it in my butt not going to be the only guy and I don't mean in the button

Jennifer Smith, CDE 12:45
all up right, right. It's better to call the better to call the EMTs and you know even in that case, you know, like you brought up earlier with the glucose you know, kind of in the cheek even at that point, something like honey or like a glucose gel if the person is actually carrying something along with them squeezing it in their cheek and actually getting it you just massage their cheek is gonna get absorbed and it'll help the blood sugar you know, faster so those are good options but yes, you know, overall, sure carb needs to be accommodated for in beverages especially if you're drinking the fancy you know, my ties and whatever they are Bahama sunflower, whatever Bahama breeze or whatever. Exactly. A there's a fair amount of carbon those.

Scott Benner 13:33
I think that's from Bahama breeze. I'm such I have probably not Jenny No kidding. I have probably not had the total of a case of beer in my entire life. I just does not occur to me to drink. I don't know why just it's never struck me. Let's talk about the in pen from companion medical, first of all companion medical comm. That's where you go to find out when you get there, there's a little blue thing up in the top right corner says get in pen. If you want to just jump right to the good part, you just click on that. First, I should tell you why you should be excited. If you're an MDI user. This thing is the bomb diggity, you understand. It's gonna help you track your insulin. You know, all that fancy stuff that people with insulin pumps get, you could get that with your pen. Not only that, it talks to your continuous glucose monitor if you have one, and if you don't have one. It's all right. The app still works great. The app, of course is for iPhone or Android. It is completely free. And available right now on the Google Play Store. And on the Apple App Store is it they don't call the App Store, right. They called the iOS App Store. They called the App Store. I think it was called the App Store. It's on the App Store. Let me tell you a little bit about what comes in this app. First of all temperature alerts. It can tell you right it's amazing temperature alerts limit the chance of extreme heat or cold impacting your insulin. And if it happens, the app will let you know Reporting is amazing. The summary of your therapy is spelled out right in front of you. You can share this with care providers or use it as a big picture look to help you make decisions. Do you have trouble remembering to dose your insulin in Penn provides you with an optional dose reminder. Right so you can decide to set up a dose reminder can also remind you to check your blood sugar in pen will not remind you to make dinner. The app has a dose calculator. Now listen, I know a lot of you who are on injections wish you had this because they're on pumps and they're really helpful in pen has it right on the app dose calculator to help you take the guesswork out of dosing. You enter your blood glucose and what you intend to eat. And the correct dose is recommended. It takes an account recent doses to avoid insulin stacking impact it's currently available in the US you can head over to companion medical calm right now to find out if your insurance covers the impact. But even before you get your answer, head to the app store and get the app the apps free. The pen, you know, depends on free, I'm not gonna lie to you. Insurance coverage varies by plan, please visit the get Impend link at companion medical calm to submit your information and find out with a no obligation verification of your insurance benefits if you're eligible for the in pen. Here's a funny one. Because Jenny and I know what we did last week. Jessica, who's another top fan? Jessica, thank you for being a top fan on Facebook says how do we concur? Or how do we handle a fat protein rise? When we know the blood sugar will rise again due to like Chinese food or mac and cheese steaks, burgers, etc? How do we learn how much to give at that second rise? And this one's an easy one for me to answer. I get to say, Go back a month to the pro tip episode about fat and protein. So you probably have heard of an easy answer. Just like yay, we finally got one. We don't have to do anything for Jenny and I just recorded an hour about fat and protein. So we're not going to rehash it here. But you can go find that episode. Jessica will absolutely answer your questions. Let's pull this one might be more like for me. Finally, ask Scott. Oh, yay. Actually, let me say this before I move on. One of the nicest replies in this one that made me feel really good about you know what the podcast does is Jessica said, goodness, you all do such a good job of answering questions that I didn't even realize I had. So oh really great. Like I was like that's that's wonderful. Yeah, that made me feel good. That is awesome. Yeah. So okay, here we go. Scrolling. Megan. Megan says, when you talk about crushing a Hi, can you please give an example in a little more detail. For example, if my eight year old daughter finishes eating 45 minutes ago, had finished eating 45 minutes ago, and she's 220 double arrows up. I either miscalculated the Pre-Bolus, the insulin or both? I love hearing people like they're mimicking the like the words in the pockets really makes me feel like we're getting through to people. How would you determine how much to give? This is Jenny's gonna laugh? Because my answers gonna be so just basic. And if and in how much time? If she's still going up? Would you? How would you When would you determine to give another Bolus, same amount this time, etc. So she's talking about like, how to stop this like a blood sugar flying up? My daughter's let's hear Scott's response. Responses just give her more insulin? How much more? I don't know. But more than you used the first time, that's for sure.

Okay, so this, to me is one of those trial and error things. It's where you have to use the information that you have from the past to make a decision today. And oftentimes, it's information you don't see as valuable. That's why I always tell people, anything that happens. Anything that happens with diabetes is never a mistake. I know things don't go the way you want all the time. But if you you can't step back and go, Oh, I screwed that up, or that really didn't work. You have to break it down and say, Okay, here's what I did. Here's where I put the insulin. And this is how much I did. This is what happened later. That's the information that will tell you next time when my blood sugar's to 22 up how much insulin will stop this. And you know, like and so there is a bit of that Megan, I think that you have to do it's sort of pre work for you know, really kind of breaking down what you've seen in the past now. I can tell you how I do it. But the numbers are there meaningless to other people, right? Like how much insulin I would give Arden to stop a 222 hour show up first of all, Meghan and I don't mean to brag but I don't see a lot of two arrows. But but that I mean might be what you really need to look into like how are you seeing two arrows like how far off were you in amount or timing it could have it should be to arrow should say to you significant miss? Like I really missed somewhere. You know what I mean? Now

Jennifer Smith, CDE 19:59
I can bring in what due to what does two arrows mean? We have a CGM. And you're seeing two arrows. What does that mean? That's a rate of change of at least three points. Plus, per minute. Yeah,

Scott Benner 20:09
it's flying. So

Jennifer Smith, CDE 20:10
it's a quick rise, just to define that.

Scott Benner 20:14
It's at least three. By the way, I know we've all done the thing. We're Dexcom says 215. And then five minutes later, it's like, 227. You're like, whoa,

Jennifer Smith, CDE 20:25
right. Right.

Scott Benner 20:28
Right. So Right. There's two thoughts in here. Megan, first of all, the one is sometimes you know, sometimes the arrows can, you know, throw you off a little bit and I like to look at the pitch of the line. I know that sounds may be strange to people but a a more gentle rising more of like a slope. I describe it as for people have seen the prices, right. It's the it's the, the unity, who the guy goes up the thing and like you're guessing things, and then you know, the fall is little pickup, right? And the whole time you're watching it, you're like, Oh, the little like, is it Switzerland? Is that what I'm thinking of? I almost said Swedish, but that's the Muppets. So it's Switzerland, and he's going up the Swiss Alps, they're in this real steady climb, and you spend the whole game thinking he's gonna stop, he's gonna stop and he never stops, he falls off the edge and you lose. That's what happens when you watch that line to me like that slow growing, but steady upward line that went to me says Pre-Bolus was probably pretty good. Not enough insulin, right? And so because if your Pre-Bolus wasn't really good, you'd be shooting straight up, like, like, and so to me that the line is, the answer is helpful. Yeah. Is it? Is it going up? Quickly, but still on more of a diagonal? Or is it like shooting straight up shooting straight up? You missed on everything? How much more do you put in the back? Like, I don't know how to answer that question. But I would I I've always said on the podcast I start with, when I need more insulin, back in the day, I would Bolus, like what what you would consider to be like life saving foods, like they were going to be eaten. So if I had a juice box that had 15 carbs in it, I'd say to myself, how much would I Bolus for this juice box? If I wanted her Arden to drink it as an enjoyable thing and not drink it as a way to stop a low blood sugar? Whatever that answer is for insulin. I know I can put at least that much in, right because I can cover it real quickly with a juice box. But you're looking at a 220. So in my mind, you're stopping the momentum, you're stopping you're covering a number, you have to account for the amount that's still going to rise before the insulin kicks in, like so you can kind of do that calculation through your head and go Alright, well listen, I think like say 220, a unit of insulin would bring it to 20 back to 90. So I go, Okay, I need a unit for the number. Now. I got to stop the arrows too, right? So I'll stop the arrows that probably going to take a unit. And she's gonna go another 50 points before this thing even slows down because I'm two hours up. That's how I sort of do the math, math math for me. Right. So Megan, I can't tell anybody how much that is? I can tell you the answers more. And I can tell you that you can do it in a way where your safety is how do I catch it on the way back down again. And I think that this is scary for people in the beginning, especially probably with kids or adults who are by themselves. But there's so much to figure out about this. And when you do figure out how to stop one of these things, the information you've learned that leads you to stopping this and bring it back level without a low. It will help you for years. And all other aspects of diabetes. Like when you really understand how to manipulate the insulin and smack that that high blood sugar down. It's It's It's the stuff you'll use forever. I think a gentleman might have a technical answer for this.

Jennifer Smith, CDE 23:58
Oh, well, let me and maybe a little bit more technical, because I you know, from what we all figure out by by experimenting on ourselves, we do. I mean, that's you've figured out many of the things that work for Arden, because of like you said, you do something you see the impact. And next time you're like, Oh, it worked but not quite enough or it worked way too heavy. So let's dial it back or let's dial it up. And while there's not really math there, there is an intuitive math that you're kind of using, right? If you really are trying to use a math to work this issue out. One she's right in considering Well, what was the problem to begin with? Okay, if you're getting a pretty quick rise up, as you said, it's probably the timing of the insulin in the Bolus. My my assessment would also be it's likely that the insulin to carb ratio is probably not quite right either. I mean, if it's still 45 minutes later When the insulin really should be getting active if there wasn't much of a Pre-Bolus To begin with, if it's still shooting up with a double arrow, there was missed insulin there as well. Right? How much one good and very, I guess, conservative way, if you wanted a conservative, you know, look of how to address how much is plugged into the pump. And see what is the pump recommending for this 220 blood sugar. Now, the pump doesn't know that there's a rise still happening, it just sees a solid, like written in rock number, right? And so you can utilize that and see, well, the pump is recommending you know, for a kid, it might be recommending something like point to your thinking will point to God, it's like a drop in the bucket, that's totally not going to touch a double arrow up with a 220 blood sugar. Okay, so intuitively, you know, something isn't quite right there with what the pump is recommending, nor does the pump know that it's still ascending. It's such a crazy climb. So there's where you can learn by saying, Okay, I know what the double arrows mean, the double arrows mean at least a climb of three, possibly more points per minute. So in the next 30 minutes, if you have a double arrow, and you do nothing about it right now, in the next 30 minutes, your blood sugar could be 90 points higher if you did nothing, right. So if you plug that number in as again, a way to use the math that's already programmed in with all of the ratios into your pump to 20 plus 90 Gets you What 310? Yeah, right, if you plug in a 310 blood sugar, and you ask the pump now to say, okay, what are you going to recommend for a Bolus? Now to correct this, you were going to get a more robust recommendation. Right. So that's a conservative way, it's not quite as bold as you would attack it with. But if you're trying to learn, it's a more conservative math way of figuring it out. And learning from it. Okay, you took the extra that the pump now recommended. And now I'm watching and the arrows have kind of angled and oh, it's now plateaued. But this is like that. It's another like 60 minutes that it took, because you took this conservative amount, right? So next time, be more bold, right?

Scott Benner 27:19
Because that can very easily lead to actual stacking. Yeah, so the difference between No, and let's add stacking to our defined diabetes list to that's a good idea.

Jennifer Smith, CDE 27:29
That's a good one.

Scott Benner 27:30
So I, I got some feedback about the podcast once where this gentleman said to me, we the day I said, it's not stacking, if you need it, he said changed his life. But it's not stalking if you need it. So but if you put in, in this scenario that we've built here, if you put in a half a unit, and then wait 20 minutes and put in another half, and then get frustrated, and wait a half an hour and put it in a unit, and now it's fit five, or you know, and next thing you know, you've put in three, four or five units over this hour and a half period, that is that you are going to get low later. But if you actually needed, say you actually needed three of those units. If you took it all up front, right, it wouldn't you wouldn't be stalking you. Because now because the impact of the insulin would be lined up with the with the carbs and what the carbs are doing right now. So the action of the carbs, the impact of the insulin are going to be lined up against each other, they'll get to that fight we talked about, then they'll all kind of dissipated the same time. But But thinking about the idea that insulin you use right now is for later, you keep adding later and later and later it keeps layering over top of itself. Eventually those layers are all going to be on top of themselves at the end of this timeline. And that's where you get low. So I like crashing up front because it also stops stacking it stops slows later. And if you are drifting low after crashing a high blood sugar, they are much easier to catch without loads or rebound highs if you haven't stacked Yeah, if you haven't checked if you stack Absolutely. Now you're stuck guessing how do I feed this insulin and not? Which one

Jennifer Smith, CDE 29:04
is actually which dose was actually causing the drop? So how much do I use to treat

Scott Benner 29:09
yourself a problem is what you've done. Yeah. A huge thank you to in pen for sponsoring this episode of The Juicebox Podcast. I hope you've enjoyed to ask Scott and Jenny as Jenny and I have enjoyed bringing it to you. Don't forget to find out more about in pen go to companion medical.com There are also links in your show notes and at Juicebox Podcast comm I'm going to take the rest of this time to remind you that I have a Facebook page. It's called bold with insulin. It's on you know Facebook, because that's where you keep the Facebook pages. Now there's a public page you can go to bold with insulin but once you're there is also a discussion group right? You got to kind of answer a couple quick questions that get in there so we know who's in there. And there you're going to find listeners from the show just like you talking about ideas about management supporting each other. It's very cool. You should check it out. I'm also on Instagram at Juicebox Podcast the Twitter if any of you are still doing that. Where else I don't know. Pinterest. I'm really I mean, I'm gonna be honest we I don't put anything on Pinterest last thing thanks so much for your wonderful ratings and reviews on Apple podcasts or wherever you listen means a lot I really do like them I say it means a lot a lot. A lot a lot. A lot. I say I say it a lot so I don't want you to think I don't mean it because I really do I say it a lot because I really mean it. I want you to know I also now wondering how many times I can say a lot before the music ends. Oh Joe, jeez, almost forgot. Check out Jenny at integrated diabetes.com Or there's a link in the show notes to her email address but integrated diabetes.com is where you can find Jenny Smith. Let her do the Voodoo that she do on you do a lot

About Jenny Smith

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

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#262 Ask Scott and Jenny: Chapter One

Answers to Your Diabetes Questions…

Scott and Jenny Smith, CDE answer listener submitted type 1 diabetes related questions.

• How do you combat that morning rise?

• How does carb absorption work?

• How does it feel being low?

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

+ Click for EPISODE TRANSCRIPT

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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
This episode of The Juicebox Podcast is sponsored by in pen from companion medical. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And Always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. Welcome to ask Scott and Jenny. In today's episode, I, Scott and Jenny Jenny Smith from the diabetes Pro Tip series and defining diabetes. You know, Jenny, Jenny works at Integrated diabetes. She's a CDE, or registered pump trainer CGM trainer dietitian. She has type one, Jenny is the she's the full pack Jenny's the goat, I think that's what we're saying. Right greatest of all time. That's why she's here on the Juicebox Podcast. So we're doing something new on Fridays, they're still going to be some defining diabetes. But we're going to go back and forth a little bit between ask Scott and Jenny and defining. Anyway, in these segments, Jenny and I will be answering your questions. This all began as Jenny and I were talking about new episodes for diabetes pro tip. And I said, Let's do an Ask Jenny thing. She's like, I'm up for that. I said, you know, I'll ask people on the Facebook page if they have any questions for you. And they did. But the questions were sort of never ending and really good. It's interesting how listening to the podcast is making people think about deeper questions. The day after Jenny and I recorded, I woke up thinking, well, that really went well. I love that we should do more of that, you know. And I got an email from Jenny, you know what it said? Jenny told me we should do that. Again, that's a guy was thinking that too. So we were like, You know what, instead of making this a protip thing that happens once in a while, and we can't just make it one episode. Because there's so many questions in an hour, I think it would just get overwhelming. You'd forget what you heard. I said, Jenny, let's break these up into smaller episodes, so they're a little more digestible, and keep doing them. You know, I'll put up a thread every once in a while and we'll get new questions from people. Jenny was like, that's a good idea. I said, Jenny, why are you talking like that? And then I realized I was texting with her. And she wasn't really talking. I was just making up that voice in my head. Anyway, welcome to ask Scott and Jenny, answers to your diabetes questions. For those of you who think that Jenny and I have practice this ahead, you'll know for certain in a second that that's not true. I did send any of the questions so she could look at them. There's no I don't

Jennifer Smith, CDE 2:31
think I did not. I think I looked at like a couple and I was like, Okay, we'll just attack these as we get to that, because I can't, and it was like, 945 at night, and I was like, my brain has no bandwidth, or reading or Okay.

Scott Benner 2:48
All right. Well, I'm just gonna start what I see is the top right, so I think I can get first names. Lionni asks, she says, I just started listening to the series with Jenny and you in the last month and love it. My question, how do you combat that morning glucose rise, no matter what time of the morning, I wake up, as soon as my feet hit the floor, my sugar spikes, Basal increase causes lows, and doesn't fight the rise quickly enough. I know hormones get released when you get up, but still haven't figured out how to stop it from happening. So I'm not fighting highs all morning and delaying food. Good question. Good question. I have very little to add to this. But I think I should go first because I think it will lead you please. I have Arden's you know Basal program set up for a normal day being alive, getting up at a certain time going and doing something summertime comes along or Saturday comes along and she sleeps in. Now all the sudden her Basal insulin that kicks in at like 630 in the morning, so she can get up for school demands too much at some point. So I wake up a little earlier. And I dial her Basal back for a very long time, usually by 30% Does it most days, if she's trying to get low, there might even be moments in there for half an hour right to shut it off completely, to create, like, like there's so I have to mess up on the loss so that she can. So that's the sleeping in idea. But the reason I bring it up is because what it taught me is that opening your eyes, makes your blood sugar go up. And I know technically that's not true. But I think there's something about being awake and alive and aware and anxious and in a hurry and all the other things that come with being alive and having your eyes open, make you need more insulin. So now you can tell her like the technical reason for all

Jennifer Smith, CDE 4:36
that. Yeah. I mean, you alluded to some of it really, it's like, you know, what we kind of commonly referred to as the dawn phenomenon, right? And while most will say oh, it happened somewhere, you know, starting around maybe three or 4am and continues through, let's say maybe 8am. Most people really see it heaviest. Once they do wake up, it's almost Like the feet on the floor, and my blood sugar is rising, and I haven't even like said hello to my dog yet. And my blood sugar is like skyrocketing, right? And this listener reader poster,

Scott Benner 5:12
essentially, is a listener, but she follows okay for Facebook.

Jennifer Smith, CDE 5:16
Awesome. So both fabulous. So essentially, it has kind of the right idea, we would typically say, go ahead. And if you are, in fact getting up at about the same time, every day, like Arden's example, her normal school day, she's getting up six o'clock in the morning, if that's your typical, and you start to see a rise by 615, the accommodation in Basal is appropriate. But in this setting, perhaps the Basal hasn't been adjusted high, soon enough to accommodate for when the rise is going to start. So you know, if the rise is starting at 615 in the morning, and you have your Basal set to increase at 6am 15 minutes of more Basal isn't going to offset arise in 15 minutes, it's not going to do it, like we talked about in the Basal, you know, setting episodes, you really have to get about an hour lead way before you expect to see a rise or a fall happening in your blood sugar. And so in this instance, again, you'd probably need to do a, an increase in your Basal around 5am. If you want an offset arise that you know is going to happen by six 615 To get started, because then by then the Basal be high enough, it'll stop it from happening, you won't have the spikes.

Scott Benner 6:37
This is an example of like what I'd say about like anything you're doing with Vincent currently isn't for now it's for later,

Jennifer Smith, CDE 6:43
it's for later, right. And if you are getting low, you know, she mentions, well, I've tried the Basal thing and it's causing you to go low, it may be again, the timing, it may be that the Basal isn't adjusted high enough, soon enough. And if you're adjusting it six o'clock to accommodate for a rise 15 minutes later, but then it doesn't need to be high anymore by 8am. By that's why you're low is because it's high hitting you at a point when you now no longer need it to be too high. So it's kind of a mismatch of timing. The kind of the other compensation like you bring up, you know, for Arden's sleeping days for adults who are on their own. And I, I did this, you know, with my pump early on, I figured out the same thing. My work days were very different than my weekend days. Not by much. I mean, I'm not I wasn't a teen, it's not like I was sleeping until 11 o'clock versus getting up at six o'clock. But even if I slept in by an hour or an hour and a half, that Basal accommodation that I had set, it was it was too much. So I actually created weekend or day off profiles. And on Friday night, I would set my weekend profile to start running. And it accommodated for that time of day that was just longer in asleep,

Scott Benner 8:04
I would say to for any pump companies that may be listening, you have to be able to they need to be automated. I agree. Or you can't make me remember Friday night to turn on my Saturday Pro. I had

Jennifer Smith, CDE 8:14
reminders on my phone. Yeah. And then my reminders specifically said it wasn't just alarm going off. It was turn on weekend Basal. On Sunday night, I had an alarm that said turn on weekday Basal. Otherwise, I would forget,

Scott Benner 8:29
of course, people for people who are thinking about it on this level, there's no safety concern with allowing them to change their Basal programs automatically. So my last few thoughts about this are basically Liana, what what, what Jenny's saying is, is that you're throwing a punch an hour after the fights over, you know what I mean? You're putting your insulin now, the extra Basal, but it isn't working right now, all of a sudden, an hour later, when you kind of don't need any more. Now all of a sudden, it's there. She's thinking maybe and by the way, right? You know, this is our guests off of four sentences. The other thing I want to say, right? It's interesting to me like Leanna, she says, I know hormones get released. This is what I always talk about. Don't spend so much time trying to figure out why it's happening. Just stop it. You know what I mean? Like, when the bank robbers coming in the door, we don't try to figure out the psychology of why he thinks it's okay to steal from the bank, someone just really needs to stop, right from stealing. So I get it fixed, then if you want to, you know retcon it and think you know, analyze it, then do it. But don't worry. In the moment you need more insulin when you need more insulin. Okay.

Jennifer Smith, CDE 9:37
And another I guess another accommodation just to finish it to is for people who do have more shift kind of work and let's say as you brought up it's hard to remember to change a Basal pattern and to remember you needed on Tuesday for this shift in this, you know, Friday for this shift in a weekend and a day off and whatever. The other potential accommodation that does work for some people is it You know, by evaluating what the rise is that you get, as soon as you wake up, let's say you always know that you get a 5070 30 point rise in blood sugar, you can actually use your correction factor in an opposite way, then you can say, Okay, if one unit drops my blood sugar by 50 points, and in the morning, I have this consistent 40 To 60 point rise in my blood sugar. But when I wake up, if I take a unit of insulin right now, I should be able to offset that rise, because we know it's going to take about 15 to 20 minutes to get a Bolus working. Usually that rise is going to be seen, if it's going to start it's going to be within about 15 to 30 minutes of waking up in the morning. So if you can take that Bolus to offset with a figured amount of insulin, it's another way to accommodate if your days are very different in when you wake up. So you're over bolusing the morning. So you're over Bolus in the morning without ever playing with Basal. You're just accommodating for the rise that you know is going to be there

Scott Benner 11:04
like that. Okay. Do you need a breath? Yeah. All right. I'm good. Here we go. Jennifer asks what I think is a really interesting question. She says so garden, did she, this must be a brilliant question, right? She says so carbohydrates begin digestion in the mouth and absorption can start in the mouth. But the amount of time that the food actually stays in the mouth before you swallow it isn't that great? Then it goes to your stomach. There's about three hours before it moves on to the small intestines for digestion finishes, and then the majority of absorption happens. So my question is, why do we Bolus for the insulin upfront? Why don't we Bolus heavier on the end so that three hours afterwards to catch it when it's being absorbed by the small intestines? Now? I think there's a this is an interesting question, because I think it's possible Jennifer asks, and answers her entire question. What she needs is someone to come along and tell her she's right. Or maybe right so there's a lot in here. So for food does not spend very much time in your mouth by now. The quickest way to stop a low blood sugar is your chipmunk. You just run around with your nuts. He pocketed your key. Yes. Run around with your nuts in your mouth and looking for a hole. That's what a chipmunks right, saving for a rainy day. Anyway, jeez, this is gonna go off the rails, we need to be more structured than this. But so she's you know, I just the other night, a person who's been on this podcast, you guys haven't heard her yet, but contacted me privately. And she said, I just Bolus eight units. And I meant to do point eight, and I'm alone. And I don't know what to do. And I've drank juice, but my blood sugar is like I think it was in the under 40. And so I started like rattling off like, get some of this, get that get this well the person's like, like keto or low carb or something like that. Like I don't have any of that stuff in this house. I was like, okay, so I was like now I'm like, Oh God, now I'm on the hook. Like I'm really thinking right? I said, Oh, sugar bowl. And she goes, Yeah, I said take a teaspoon of sugar. Just melt it in the saliva in your mouth and keep it in your mouth. Like don't smile, it just keep it there because your cheeks super absorb really quickly. Right? So I guess this is an interesting question. And we'll get to Jennifer's overall question, but how is it when my blood sugar is 50 and it's not falling? And I drink, you know, 1015 carbs of juice? How does it pop up so quickly after that? Where does the majority of that absorption happen? Because I'd imagine that just doesn't even make it to your stomach because you start seeing it hit pretty quickly. Do you know?

Jennifer Smith, CDE 13:44
And well in that in her question, and this kind of bring up component of a meal, right? If you're drinking something like juice, the reason for juice being recommended, or any very simple carb source being recommended as a true treatment for a low blood sugar. Or, you know, the reason that you want to Pre-Bolus if you just decide you're going to drink juice and you're not low is because you do need time, because that is going to work fast. That sugar gets absorbed. In the absence of fats and proteins and fibers and other things. Sugar itself gets absorbed pretty quickly. And it gets it gets absorbed essentially, you know through the whole passage and a liquid sugar source things like a gel or a goo or the juice or even like you said liquefying like in fact, something I learned years ago was if I choo choo choo choo choo, the glucose tablet up and needed almost like liquidity in my mouth and then swallowed it. It was a lot faster and why I came to this probably in those strange moments of low blood sugar where you're like, oh, let's try this and your brain is like floating through mud and like, whatever. But I figured, you know, I figured out what works a little better. So that liquid component to it, it gets absorbed a lot faster. And in a very simple sugar form, it's going to get absorbed through the digestive system much, much faster. Now with a meal, she brings up a good point with a meal. Why am I taking this big upfront Bolus? For food, that probably is going to hit me at least some of it is going to hit me a fair amount of time later, right. Thus, you know, a lot of the reason that they truly built in especially for pumpers, that feature of a combo or an extended or a duel or a square wave Bolus, two pumps, that's why it's there. The problem is that you've been taught how to use your pump, but you haven't really been taught how to use your pump, the insulin works, you've not been taught, this is how the insulin works. This is the component of a meal. This is why the insulin needs to be matched to this kind of a meal. This type of food, you know, together. This is the type of Bolus you might need. I mean, the science behind it is more in depth than the education that's being provided it is. So again, this brings up a very good question and potentially, you know if that's if that's what this person is seeing, then yes, an extended Bolus, if you're using a pump is probably in your best advantage to try to figure out writing down some of your common meals. Seeing what is your CGM trend look like trying to match accordingly. You know, maybe I need 30% of my meal Bolus right now. And maybe I need 70% of it drawn out over two hours to accommodate that kind of digestion.

Scott Benner 16:53
I think I think this this question from Jennifer made me think she's never heard an episode where I do Arden's lunchtime, insulin and Arden's blood sugar's already like 80 Because that's the exact situation where I go, Okay, we're gonna use 13 units now. But it's 0% up front and the rest over a half an hour an hour. Because I need I needed to start happening. But I needed to, I need the impulse out longer shot longer, right? Yep. All right. Yep. For now. I think that answers Jennifer's question. I also wrote down that if this wasn't a regular episode, I would call it floating through mud, because that's the most interesting like analogy I've heard for being low ever, like the idea that you're floating, but very slowly.

Jennifer Smith, CDE 17:33
That's how I feel. When I it's one of the best descriptions that I've like been able to come up with for how I have felt long term because symptoms change for low blood sugar for many people. But I've always had this feeling that I'm sort of like, floating or slogging through mud. Like, I feel like I'm moving exceptionally throw the very slow, but my thoughts at the same time are running extremely fast. They're like they're spinning and spinning and spinning and spinning. But I feel like I'm just the slow like, I'm like the slowest, slowest slot on the planet.

Scott Benner 18:13
For your life, but you're changing your chair.

Jennifer Smith, CDE 18:15
Yeah, yeah, it's just, it's, it's a weird sensation.

Scott Benner 18:20
The way you said that.

Jennifer Smith, CDE 18:22
floating through IDs like that.

Scott Benner 18:25
At the beginning of the podcast, I told you that this episode was sponsored by in pen by companion medical. And I want to tell you a story about how that came to pass. So things don't happen as quickly as you might think. About a year and a half ago, companion medical came to me and said, we'd love to come on the podcast and talk about this new smart pen we have it works with Dexcom. It's really terrific. And it's called in pen. I said, Yeah, that's nice. But I can't have you on the show. Because my daughter doesn't use it. I don't know anything about it. And that means a lot to me. I can't take an ad from somebody that I don't really know. You know what I mean? You guys don't even realize it. But there are people who try to come on the show all the time to push what they do in the world. You know, I'm a physical something, I do this for people. And if I don't have direct knowledge of what they're doing, I don't let them come on here. I don't let people just come here and sell to you. So anyway, I kept talking to in pen. And the more I heard from them I liked but I still didn't have any like real world data to back up having them on the podcast. So I told them if you want to come on, that's great. You'll have to sponsor the whole episode. I want people to know for certain that this is an ad. No mistakes, right? I'm not saying I use him pen or I stand behind it. But if you want to come on and talk about it in pen, do it. Just make sure people know this is like a paid for episode and way back like a year ago. They did just that in episode 174. In the year since then. I can't tell you how many of you I've heard from her like Scott, I heard about impact on the podcast. It's amazing and everyone's telling me about how well what's working for them? And what a great thing it is for them. And not only that, but I'm going to talk past the music here for a second. But not only that, but major props to Omnipod for never saying to me, Look, you're taking ads from us. So you can't do like a pen to. Nobody does that this is a very open community. We're building here on the podcast, and it's very collaborative. It's fantastic. So anyway, you know, Omni pod doesn't stop me from taking other ads, you hear people come on here all the time and say I wear a T slim or, you know, I use a libre CGM. Nobody ever gives me trouble about it. When I set these things up with the sponsors, I was clear upfront, you know, I can't stop somebody from saying they use a product that's not yours. If someone starts saying something about your product that you don't like, I'm not going to stop them. I can't do that. And everyone agreed, which, you know, is great in theory, but it's actually happening in real life, like in real life, none of the sponsors have ever called me sent me a note or anything and said, Hey, we didn't like what that person said there, please, you know, could just stop that. That is never happened on this show. I would never let that happen, which I liked. Because I like this information to be, you know, unfiltered for you. Anyway, in pen came back a couple of months ago, and there said, you know, we really would like to buy ads on the show. Is it possible that you'd be open to that now? I said, I gotta tell you, I've heard from so many of your users such great experiences, I think I would. But let's not just lay an ad in the middle of the episode and clog the whole episode up with these ads, right? Let's do something interesting for my listeners. So what I decided was, I'd like to talk to an in pen user, and then break up their story kind of a mini episode, over a number of weeks. And that's what I'm going to do on these Friday shows these episodes on Friday for a little while, are going to be sponsored by in pen, and you're going to hear from one of their users. Now, I think we found a really cool user with a really amazing job. And I don't think we have the person exactly nailed down yet. So if the wait a second longer to make sure that she's on board, should I even say she I'm not sure. Anyway, I'm pretty sure it's gonna happen. So this episode of The Juicebox Podcast is sponsored by in Penn by companion medical, and for now, there's nothing for you to do, unless you'd like to learn more. And you can go back to Episode 174. And listen to the conversation I had within Penn last year. Coming soon, of course, the story of an impending user and some links, you can click on To find out more. Thanks so much for listening to ask Scott and Jenny. Be sure to go follow the Facebook page bold with insulin so that you can ask a question next time the opportunity arises. And please don't forget that Jimmy Smith works at Integrated diabetes. Not only has Jenny lived with type one diabetes since she was a child, but she holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps, and continuous glucose monitors. All of that is nice. But here's what you really need to know.

I like the way Jenny thinks about type one diabetes management. I love it. Actually, she fits right in with how I vibe. If you'd like to hire, check her out at integrated diabetes.com There are links in your show notes. And at juicebox podcast.com. Thank you to everyone who sent in their question. We look forward to doing this again and again. This is going to go on for a while guys. I have a feeling this is going to be pretty popular. I'm tempted here to sing along with the music until the end of the show. Because I hear from a lot of people that you like that. But privately I want you to know that I believe you're mentally unstable for thinking that and I will not be encouraging this with anything today.

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About Jenny Smith

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

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