contact us

Use the form on the right to contact us.

You can edit the text in this area, and change where the contact form on the right submits to, by entering edit mode using the modes on the bottom right.​

         

123 Street Avenue, City Town, 99999

(123) 555-6789

email@address.com

 

You can set your address, phone number, email and site description in the settings tab.
Link to read me page with more information.

Screenshot 2023-03-12 at 2.41.02 PM.png

Podcast Episodes

The Juicebox Podcast is from the writer of the popular diabetes parenting blog Arden's Day and the award winning parenting memoir, 'Life Is Short, Laundry Is Eternal: Confessions of a Stay-At-Home Dad'. Hosted by Scott Benner, the show features intimate conversations of living and parenting with type I diabetes.

Filtering by Category: Ask Scott & Jenny

#297 Ask Scott and Jenny: Chapter Nine

Scott Benner

Answers to Your Diabetes Questions…

Ask Scott and Jenny, Answers to Your Diabetes Questions

  • Let’s talk about the benefits of rotating sites.

  • What are the pros and cons of using a temp basal increase versus a bolus?

  • How long does it take for a temp basal increase to start working?

  • Let’s talk about how an extended bolus works.

  • Let’s talk about how temp basal works including how to create a black hole.

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - PandoraSpotify - Amazon AlexaGoogle 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
Hello everyone and welcome to Episode 297 of the Juicebox Podcast. Today's episode of Ask Scott and Jenny is brought to you by the Contour Next One blood glucose meter. This is the blood glucose meter that Arden has been using for coming up on getting closer to year and a half now. Absolutely fantastic. Wonderful. Actually, let me tell you why. First and foremost, in my mind the Contour Next One has remarkably accurate testing demonstrated proven accuracy with the Contour Next One meter, and Contour Next One test strips tell us that the smallest error range demonstrated by the Contour Next One meter system was determined to be 95% of results met. Right? That's like plus 8.4 milligrams per deciliter, or plus or minus My gosh, there's a lot of information here. Hold on a second. Wow. I might not be smart enough to tell you about this. I'm reading it and I'm not sure if I'm smart enough. Hold on a second. Anyway, the things really really accurate. But Contour Next One wants you to know that I'm going to read it again meter system was determined to be 95% of results met plus or minus 8.4 mega boy versus reference for glucose values under 100. per deciliter or above 100%, respectively. For subject fingers testing is Alright, listen. I think here's what you're gonna need to go to Contour Next. one.com read it for yourself. See if you have better reading comprehension than I do. You know, me, I just dumb things down. I know the Contour. Next One is incredibly accurate. I've seen a lot of testing, it comes right up at the top of every chart I've ever seen. And you know what? A listener just reached out to me like 10 minutes ago. No lie on one second. But this is an ad. Hmm, this is what the company was looking for when they throw in with me. really concise ads like this. was like it's gonna go with the episode. Hey, Linda reached out right? She's telling me about a little bit of about the podcast asked me for somebody to come on if I could. But but in the middle of her note said, let's see what she say, Oh, I wanted to let you know a tidbit about the Contour Next One app. So the app that goes along with the Contour Next One, it works with voiceover users on iPhone for the blind and visually impaired. Isn't that great? Thank you, Linda for telling me that. Okay, well Contour. Next One, if you know, they're still advertisers, next week, after hearing this go to Contour Next one.com. There's links in your show notes and Juicebox podcast.com. The meter is incredibly affordable, covered by many, many insurance companies. And Arden is just having a great experience with it. As Am I let's put it this way. The Contour Next One is a million times better at being a blood glucose meter than I am at reading an ad about the Contour Next One blood glucose meter following that. Okay, listen, this isn't ask Scott and Jenny. I don't want to give it away. But I leave a little bit of like preamble Jenny and I talk sometimes before you get to Harris. And Jenny brought up something about a Reilly link for loops. So I left that in. I thought that was interesting. We talked a little bit about site rotations. And you know the importance of being prepared. We will even remind you to change your smoke detectors at some point and then we're going to get into some basal insulin talk. It's a little more deep dive. And that comes from questions from you guys. 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 health care plan. We're becoming bold with pencil.

Ask Scott and Jenny are questions directly from you the listeners that Jenny and I answer Jenny, of course, is Jenny Smith, who works at integrated diabetes.com. And you can always go there and check out what Jenny does. You know, you could you could pay Jenny and she'll help you with your diabetes. She's She's good like that. It's her job. You know, I mean, it's not like you, like weird or anything like that. Jenny is a contributor to the podcast. For those of you who have not heard this before, and she's just absolutely amazing. So check her out. Jenny Smith had integrated diabetes.com Let's jump right in.

Unknown Speaker 4:36
Hey, no.

Unknown Speaker 4:37
Hi.

Scott Benner 4:38
What happened your Riley link died died like gone.

Jennifer Smith, CDE 4:41
Yeah, like this morning for 13. So my Oscar he's got a cold and he woke up coughing this morning at like 430 so I went in and gave him some cough medicine, some water and whatever. And I noticed that I always have my like Riley link and my pot my phone right next to my bedside. table and I noticed that my Reilly link was like the green light was not solid It was like green. Green.

Unknown Speaker 5:09
Little Blinky.

Jennifer Smith, CDE 5:11
Like, that's not right, you're not supposed to be doing you know. So I turn it off I turn it back on and then there was no green light. And then now I have like this, like I just I I unplugged everything to like try to plug it back in. I like did all this like trying to figure out it's like this flashy Christmas blue, green, blue, green, blue, green, blue, green. And like, That's not right, as I go to the website and look at you know, like Riley link like errors on the get Riley link. And the only things that I can find, seem to indicate that I have if I have like a solid blue, and it stays on that the board might be dirty. So it says to unplug the battery, clean the battery thing out, well, I don't have like one of those little air can do it with. And I don't have an old toothbrush. They've all been like in somebody's mouth in the house. And so I'm like, screw it. I don't have time for this. Today, I will just use my PDM and figure it out later. I think I have a feeling that it's just that it's just gonna work because I I took the old battery from my Medtronic, Riley link. And I plug that in, and I get the same response. So I have a feeling it's the Riley or that it's actually the motherboard that it's has nothing to do with the battery or the connection. I think something's dirty. So I don't know. I mean, I just ordered it in. April. I don't know if I should send a message to Jeremy and be like, Hey, I haven't I've only had this like six months, would you replace it? Or if I should just go ahead and buy a whole new one.

Unknown Speaker 7:00
So

Jennifer Smith, CDE 7:01
this is what I get for not having a backup.

Scott Benner 7:03
I was gonna say in a very unlike me fashion. About two months ago. I just ordered another one. And I thought if I never it's sitting right over there in a box. I thought if I never take it out of the box, I guess I don't care. And then every time hers acts a little wacky, I'm like, ah, I don't care if this breaks. I have another one. Right?

Jennifer Smith, CDE 7:24
Exactly. And right now it doesn't look like there any holdups as far as like getting another one quick. So hopefully I can just get one and get up by next week again.

Scott Benner 7:39
I got a note from a woman this morning, it said that she moved to loop because of the podcast. And then oh begged me to do a follow up. She's like, I need a best practices podcast for loop. And I was like, Yeah, well, as soon as I know what the best practices are. I'm happy to tell you what they are. And I think I'm close by the way we are. We're in a good spot. Hey, I just finally, after a long time of trying. I finally got Arden to try a different site. Okay, the one thing

Jennifer Smith, CDE 8:14
what she what she had, what had she been using?

Scott Benner 8:18
Arden was thighs. And she's belly canula pointed towards her belly button. And she does not like me. No, no, no, no, no. Like, you know, if you said like, Hey, you should try your arm. She looks at you. Like you said, Hey, you know what we should do? Let's shave your head and your head bald, paint a face on the back of your head and make you walk backwards. Right? Right. Like really looks at you weird. Because when she played softball when she was little, and it was on her arm, she could feel the pod wiggle around when she threw her arm. So she got in her head at a young age. That that's not good. Yeah. And Arden is really, for all of the amazing things that she is. Every insertion of every pump is treated like It's never happened before. Even though when it's over, she's like, it doesn't hurt. It's she it's hard to put into words. But as it's clicking, she just tenses Oh, my god until she's almost at a ball. And then when it gets to the fifth click, if it doesn't happen, she goes. There's a little shake it. It's It's It's not funny, but it is yeah. So she's just like, it's she's just incredibly the Dexcom she doesn't do the thing because there's no click. Yeah, I know. That's what it is. It's her. It's her hearing the clicking and it's ridiculous. And she knows it's ridiculous. Like if you had her here, she tell you. I know. It's not a real fear. But my goodness. So. So what she's done is by keeping the same couple of sites, she's a little numb to the insertion, right? So it feels different on a new site. And but I got it To finally I mean by the by God or I don't know what I might have like, I might

Jennifer Smith, CDE 10:05
have thrown Mercer a read for.

Scott Benner 10:08
So she spun the pod on her belly 180 degrees the canyon was going the other way now. And it works so much better because her her thighs were really like we don't have propped up. Oh, no, I don't know, they just don't work well, like like, because we try all different places I never have

Jennifer Smith, CDE 10:26
my thighs have never worked.

Scott Benner 10:28
So better blood sugar is not on her thighs. And I told her, she's like, well just use my belly. And I was like, you only have two spots. And even when I say to her, like very up and down, she moves it like a quarter of an inch. Right? Like our night a little farther than that. Yeah. So anyway, I got her to move. And finally, it was not without some tense moments, but it's done now and her blood sugar's are way better. So

Jennifer Smith, CDE 10:54
Wow. So you can speak to the benefit of rotating site. Yes.

Scott Benner 11:02
This is gonna seem disjointed. But Jenny and I jump back to talking about the Reilly link for a second. And the bridge we got back to it with wasn't interesting. So this is me telling you little more about Riley link. And then we jump in ask Scott and Jenny. At the very least you haven't had it that long.

Jennifer Smith, CDE 11:19
I haven't. And that's the thing. I mean, if I had had it, like two years, I wouldn't even ask, I would just order a new one. But I haven't had it for very long. And I feel like I mean my other one, the one that I have had for Medtronic, the battery still works, I can still turn it on. It still connects, it works perfectly. And I never replaced that one. So and I've not done anything different. Like I'm not like cleaning out attic spaces with whole bunches of dust in my Riley lane. Collect all the dust you can you know, I like

Scott Benner 11:51
sometimes just stop swearing. I actually, you know, we had a smoke detector that started like chirping. And I just was like, you know what the thing seven years old? Like, I just throw it out and put another one up. You know, I

Jennifer Smith, CDE 12:04
actually recommend replacing them every three years.

Scott Benner 12:06
Yeah, so I had just done a bunch of the other ones in the house with these. There were these two that were like, they were going strong. And I was like I'm writing these out. And then when they started because you know, as an adult, what's the worst thing is to spend money on stuff like that, right? Like, I always tell people the worst part about owning a house is that I once had to have a tree cut down. I had like, like, there was this day that I had 1500 dollars in my bank account and a tree. And when the day was over, I did not have 1500 dollars. And I did not have a tree and that I had less than when I started. Not even like I had a new and improved tree, or you know brakes on my car or even when it was just one of those like the money's gone and the thing is gone. Being an adult is terrible.

Jennifer Smith, CDE 12:50
Yes. adulting is hard.

Scott Benner 12:52
Not fun. All right, you ready? Sure. All right. So it's hard to know where to start when there's this many. So I think the top is probably where to start. I'll go with Stacy who says pros and cons of using a Temp Basal increase versus a Bolus. She says that she tends to do extra boluses if her son doesn't have any insulin on board, but her husband tries Temp Basal as more often. Now, I think this is more of a situational thing. Mm hmm. You know, because there are moments where, and this would feed right into another question. But there are moments where I don't have time to wait for Temp Basal to start, right, right. It's a timing issue. So if it's, if it's after a meal, and there's a creep, right, like, it's just like 85 becomes 89. But there's never an arrow and then 10 minutes later, it's 93. And all that, then maybe I would be like, Ooh, this is so close. Maybe I'll try to tamp it for a little bit to get away. Yeah. But if this was a diagonal up arrow, and it was, you know, 115 to 121 to 130, I would think I need the more immediacy of a bolus correct. So I think that's the

Jennifer Smith, CDE 14:07
right way to think about it. I mean, it's a bolus is going to go in, it's a big depot of insulin right there right now, it's, I mean, it's still gonna take some time to get absorbed, there's a large amount of it at one time to get absorbed. The only caution to that is, especially for those who have really big boluses at a time to begin with, if you just bolused 10 units for a meal. And now it's 30 to 40 minutes later, and you see these arrows going up, and you're gonna bolus, you may, in fact, really not, you may not reap the benefit of an additional extra bolus to offset that on top of the large amount of insulin sitting under the skin already, because it's still absorbing especially if you didn't give enough Pre-Bolus timing, you know, all of those other considerations. So there are, there are lots of variables to both uses. I think

Scott Benner 15:06
I think too, it's what it comes down to a lot of like, again, timing. So if you if you have a quick rise, like you said, but it's happening 45 minutes an hour later, and you Bolus You're so off time now that maybe you'll cut something out of that rise, but you probably most definitely make a low later, right. That's why I like to get as much of the insulin upfront as possible, because at least at least when that battle happens between the carbs and the insulin, you know, you're gonna know there's not a ton leftover afterwards

Jennifer Smith, CDE 15:39
at the end. Exactly, yep. And that's the whole purpose of the Pre-Bolus, as well as more of like that super bolus consideration is up front loading of insulin, gets the insulin connecting with the sugar that it needs to connect with to get used. So in the back end, there's less of it.

Scott Benner 16:01
I'm sorry, I know you couldn't hear that. But that's okay. I was getting a phone call from my doctor's office. And for some reason, it came through my computer too. Could you repeat that really wanted to reach you, I'm a guy bounce through everything I own just oh, my gosh. But But would you say that again? I apologize.

Jennifer Smith, CDE 16:20
No, I was just, I don't even know exactly what I just said, Ah, oh, yes. So the larger amount up front, it's, you know, if you if you do a big Bolus up front, and you do it with more, just because you see a rise, or if you initially do like a Pre-Bolus in your front loading, or you do that super Bolus concept, where your front loading with a lot of insulin with the meal as well as the bazel behind it, you've got more action in the beginning for the insulin to connect with the sugar and to prevent that rise so that in the back end, majority of that insulin should be kind of used up that back end impact isn't as heavy. So

Scott Benner 17:09
I think the bigger response to Stacy's question and by the way, Stacy did not get her question as first because she bought a bunch of gear from the merch store today. Just because hers was at the top. But But I think the answer is it seems like early on, you probably had success with your Bolus, your husband had success with Temp Basal. And now you both think it's a tool that works best for you. But the truth is, in certain situations, it's one or the other. It's not like it's not like one. It's not like two tools that do the same thing. And you prefer one and he prefers another? I think that it's there are two different things because of the timing aspect. And this rolls right into another question. Another question that I'll let you here in just a second after I tell you again about the Contour Next One blood glucose meter. Okay, so I did a pretty poor job at the beginning of telling you that it's really accurate, but it's super accurate. You can go to Contour Next one.com to see how they figure that out. It also has something called Second Chance sampling. This prompts you to reapply blood if the first sample is insufficient to take a reading, it helps to avoid lancing a second time. And more importantly, maybe wasting valuable test strips works terrific. Other top features of the meter that you can add events to your readings. You can record events such as diet activities, medication, also add photos, notes, or voice memos to help put your results in context. Hmm, now we're talking right? voice memos, photos. So wait, I could take a picture of a plate. Oh, now you're getting that right, and put it into the app and say this was the meal I had. This is how much insulin I used this but my blood sugar was when I started watching see what the Bolus does how it works. Next time, got some Delete on their smart alerts, you can get alerted when your blood sugar levels are at a critical high or a critical low level with the Contour. Next One. It's very cool the way it does it was sort of colors and lights and everything you'll see. You can also easily share your results with your doctor in person to before your checkup, you are getting a lot out of a tiny little meter accuracy, alerts, reminders, an app that you can interact with, it'll actually help you with your blood sugar's And best of all, this meter is teeny tiny, but not too teeny tiny. So it's not a pain to carry. And it's not a pain to use Arden and I love it. Go to Contour Next one.com where the links in your show notes. Were the ones that you'll find at Juicebox podcast.com. People wanted to know about how long it takes for a Temp Basal increase to start working. And even though I told him like, Look, we've I feel like we've answered this a bunch of times but it'll it'll but right up nicely with this question. So Let's start with the idea of I bolus insulin. And it takes whatever 15 or 20 minutes to start working for, you know, whatever your your your truth is five minutes, 30 minutes. That's going to, of course, vary depending on your hydration, how high your blood sugar is, like all these different ideas. So okay, so let's just say it's 15 minutes. And that's a pretty consistent thing for you. But what if in that same scenario, my blood sugar's 95. And I suddenly do a Temp Basal increase? How long do I see before it starts impacting? I know, you're gonna say 30 minutes to an hour, probably right? Or even longer?

Jennifer Smith, CDE 20:40
Well, it's, it's interesting, because, you know, as we started with the Temp Basal increases a slower creep up in dosing and amount of, of more right of more insulin. So as soon as you increase by using Temp Basal, you do have to wait for the next pulse of bazel that the pump is going to deliver out for it to incrementally adjust that up. So with the next pulse of bazel, that comes out, it's going to be boosted up in the temporary amount you told the pump to increase by, but that pulse, then that initial little extra pulse is still going to take time for that larger amount in it to get noticed in the circulation and to start impacting the blood sugar. So as you do a temporary bazel increase, you may get more, if I'm talking about just Omni pod, in general, the pulses go out as point 05 pulses, right? So the more or the higher your basal rate is over the course of a one hour time period, the more point 05 pulses, you get to deliver a bazel. So if your bazel is normally at point zero, or point five or point six, you get 12 pulses over the course of an hour, right? If you do an increase to that point six, and now you're getting 1.2 units an hour, you're going to get more pulses over the course of an hour to drive that temporary increase that you've told the pump to provide to you. But it's still going to take time for each one of those pulses to get circulating. As far as absorption. So it's, it's kind of hard to define exactly when you should start to see an impact. But I would say some of its dependent if you've got a load of insulin, again, from a bolus sitting under and you're doing a temporary bazel increase. Sure, you might see in in, you might see a change in blood sugar faster, especially if you're doing a really huge temporary basal increase. If you're doing just this minor little temporary bazel increase, and you don't really have any insulin on board at all, it's probably going to look like it takes a lot longer for that temp increase to make an impact.

Scott Benner 23:01
Interesting, because I think this is one of those scenarios where people really do want a concrete answer. And I don't know that there is a concrete answer. I find that when especially when I'm speaking and so you're in really in front of people who are, you know, really trying to figure out something new. They there's always someone who's like, how long how much when, you know, my head, listen, you know, I can, I don't know,

Jennifer Smith, CDE 23:26
the definitive cut and dry and there is no definitive cut and dry

Scott Benner 23:29
exactly how long would I do a Temp Basal increase while I started seeing an impact? And the truth is, you know, so situational and personal and, you know, where's your site, get a good site, you got a bad site, got an old site, get a new site, like there's so much going into it. The other thing that I wanted to mention here that I find shocking, and, and not because I would expect people to know because anybody would tell them. But I don't want to insult anybody, but it seems like a common sense thing. The amount of people who believe that a basal rate is put in once every hour, like if your basal is one unit an hour it like that they think at like 12 o'clock, you get a unit and then one o'clock you get again, that if you really stop just for a second Think about it. That doesn't make any sense. But I guess it does, if no one's ever explained it to you like why and unfortunately

Jennifer Smith, CDE 24:20
at pump training, it isn't often explained to how that bazel rate is delivered. I think it's it's expected as an underlying under understood but not specifically stated. You know, yeah, it's just not it's not commented on unfortunate. In fact, it kind of also relates to an extended bolus. I don't know how many people I've had asked me or kind of explained me Why give this extended bolus. And I gave 50% now and then I did the other one in two hours. So you know, but then I cancelled it an hour later, so I didn't really get any of that that extra drove that I extended for two hours. I'm like, Nope, that's not how it works. Yeah. As soon as you're up front part of that, let's call it a dual wave where you get some now and some extended. As soon as you get that your pump starts delivering in drip, drip, drip drip over the amount of time you told it to extend it, it's dripping in that second part of the Bolus. told it. You need it longer.

Unknown Speaker 25:23
Yeah, right. Yeah, no, it's

Scott Benner 25:27
if you extend to Bolus, and I know this isn't the first question, and let's just use round numbers, that's understandable. Using 10 units, and you want 50% up front and 50% over two hours, then five units goes in, when you push the button, and the other five units gets broken up evenly over those extended amount of hours. It's, it's, you know, it's whatever that ends up being, if it's point two, five every 15 minutes, or I don't know what it ends up being, I'm not doing the math on it right now. But he just breaks it up evenly over the over the amount of time you tell it to extend it out over. And I don't know, I guess for a lot of people, that's just not something that anyone's ever brought up to them, and they can be confused about it. I've been talking about temp basals like, you know, the idea like I got a message the other day, somebody's like, you know, I just realized that what Scott says about like turning off bazel sometimes to catch like a, like a real drifting low work so well. But they were talking about that they can only do it for a certain amount of time they figured out or they'll close the highlighters. It's great. They're figuring it out.

Unknown Speaker 26:28
Yeah.

Scott Benner 26:30
When I was in Kansas City, I was up on stage. And I said something that I'd never said before, because I was like, Look, think of turning off your bazel as creating a pothole in the future that your blood sugar is going to hit. Right. And then someone from the audience said a black hole and Oh, that's so much better. Like let's say that. Okay, so, you know,

Jennifer Smith, CDE 26:53
good. Yeah, I think better one because

Scott Benner 26:55
it's because it's just a complete, it's a vacuum, right? So, so you've got this layer of, you know, one unit an hour of Basal and so on, that's, that's exists in you. But if you shut your bezel off for an hour at noon, and say it takes an hour for your bazel to go out of you, that means around one o'clock, there's going to be this vast nothingness of bazel right and so if you had a drifting blood sugar, and it hit that black hole, it would all of a sudden it would be weightless, right? It wouldn't have anything pulled the gravity would be going down and then you can hit that spot and stay level. And I so like I got done saying it and I celebrate a little bit and I could see a person down front looked at me and I'm like, I just thought of that just now. So I'm it's a good example and I'm just happy with myself. Just give me a second.

Unknown Speaker 27:47
A little celebration, we're gonna move on it's gonna be fine.

Jennifer Smith, CDE 27:52
You know, we should have we should have those little What are those? Those little popper packages, right where you can like pull apart, like, explode like whenever you go to your kind of your conferences, you should bring those along. And if you have those, like aha moments, you should pull one it surprised the audience. You're like, I

Scott Benner 28:08
just had a moment I think the surprise would be they'd stopped coming. They'd be like, this guy's like, doing Gallagher up here. It's gonna it's gonna break a watermelon since there's an old reference, nobody's gonna get.

Unknown Speaker 28:20
I get it.

Scott Benner 28:21
Jenny really does get it doesn't she? You know, she gets education. Jennifer actually holds a bachelor's degree in human nutrition and biology from the University of Wisconsin. She's a registered and licensed dietitian, a certified diabetes educator, a certified trainer on most make some models of insulin pumps and continuous glucose monitoring systems. She's an active member of the American Diabetes Association, American Association of diabetes educators, and Team Wild. She is also a contributing author for diabetes sisters. What isn't Jenny? What isn't? She? I don't know. If he even likes cooking, did you know that? Alright, luck. Now I've basically just read you like what they write about genuine integrated diabetes. If you want to hire go there, look for that information and click on email, Jennifer. There's also a link in the show notes of this episode, where you can email Jenny directly. She really is terrific. I appreciate her coming on. What else do I appreciate? I think you know, I'm gonna say the Contour Next One blood glucose meter. Give it a try today, at least go check it out. Please use my link if you do. If you can't use the link that's in the show notes or Juicebox podcast.com. Right on just type in Contour Next one.com into your browser. How about a little bit of an announcement about where I'm going to be upcoming in case you want to get some tickets and show up and be like, yo, that's Scott, the guy from the podcast, you can do that. On February 16. I believe that's a Sunday for the greater Dallas type one nation event. If you want to find that without googling, you can go to my Facebook page and go to events or go to Juicebox podcast.com. Scroll to the bottom and click on events. There's links there so that's the greater Dallas type one nation I'm only doing one hour there that They not the whole Juicebox Podcast extravaganza like you're gonna get on February 29 in Georgia at the type one nation event. You guys are really gonna love this one. I'm doing an hour on my own and then a second hour, you know who comes to join me? Jenny Smith in that cool Jenny's gonna go off do her own thing. I'm gonna do a little talky talk, and then as mine and she's gonna roll in, we're gonna do a q&a together. Now, that's exciting. If you're in the Atlanta area, forget me. Honestly, meeting me is quite a letdown. But Jenny Hmm. That's what you're looking for. That's at the Georgia Tech hotel and Conference Center. Actually, I'm sorry. The one in Dallas is in Irvine. The Irvine Convention Center is at Irving. I don't know what you guys say in Texas. It's spelled Irvine, it might be said Irving. shimmy OSHA Maazel. I don't know. After that on March 26. Speaking of shimelle show Maazel in Appleton, Wisconsin, Tickets are available now for that too. That's a three hour build with insulin talk on a Thursday night, I think 530 to 830. Straight through great conversation q&a with me all about stuff you hear on the podcast, if you're out in Appleton, Wisconsin, or somewhere nearby, or you have a sled dog, and you can get to it, really would love to see you there. Those three events are all jdrf sponsored events. Very cool for them to have me out. stuff in the future. I don't know if you can get tickets for yet. Maybe you can maybe you can't touch by type one in May the end of May, in Orlando, Florida. And on August 22, to type one nation event in Richmond, Virginia. I am currently talking to people about doing something in October somewhere I won't mention yet. Might be a couple of them coming in October. But anyway, these are my events. I hope you can check them out. They're wonderful. And I'm not just saying they're wonderful, because it's me and I believe they're wonderful. Other people say they're wonderful too. So I obviously I think they're wonderful. Because, I mean, what I really show up and say something that I thought like, Ah, this is just okay. It would be silly. I am not you. I don't know me that well. But I am not getting on a plane flying somewhere to do that's just okay. We're gonna deliver the goods when we show up. Okay, you're gonna leave with some info.

I'm comfortable saying that. A because obviously, I have a narcissism that allows me to do that. I'm kidding. For those of you who will now leave reviews and says, this guy's really narcissistic. He even says it on the podcast, how wonderful of you to pick up on that. Those of you who don't seem to understand sarcasm, and the but the real reason I can say that is because I just got back from Oklahoma, and I saw messages online, one of them was really touching. It's like a vlog a vlog for you older folks is when people blog, but with video, you get it vlog. It's really Oh, anyway, and this person put a vlog out that was just touching about the talk that I gave. So I'm there to motivate. I'm there to inspire. I'm there to answer as many questions as I can to try to set you on the ideas of the podcast. And of course, to take an incredible amount of selfies that make me feel self conscious. That's why they call them selfies. Thanks very much for listening to the Juicebox Podcast this week for leaving the really cool reviews that you guys left on iTunes recently, the social media posts, you know, that I see on Instagram and Facebook, for your participation in the private Facebook group where people are trying to help each other both adults and parents of children with type one, I really just appreciate the support overall. The reason I bring that up is because when I go out to these public events, I meet a lot of different people, different ages, different situations, different agencies, different goals. And I can tell you that when I leave, a lot of these people are better off than when I got there. And when you see some of their situations, it's hard to it's just hard. Not everybody's having the same success. So to be able to go around the country and find people who wouldn't find a podcast. And to be able to help them or get them started or move them in the right direction is an incredibly and this is overused by people all the time, but as an incredibly humbling feeling. And the fact of the matter is that I would not be in that situation, to meet those people to potentially help them if it wasn't for the success of the podcast. So every time you tell someone else about it, and the lore of the podcast grows and it gets more downloads that motivates people to ask me to come out and talk. So for the really good feelings I've had recently meeting people in person, and for the private notes that I've received afterwards from those people after they see improvements in their health, I thank you for them. I thank you for myself. I really appreciate the listen. And I did a pretty good job of ending this episode on a real bummer. So let me say something happy at the end. And it's personal. But still, my son is still home from college. He actually goes back in a couple of days. And I was sitting at my desk late last night, getting this episode together a little bit, getting ready to edit it today. And he came in and he sat with me for a little bit. We got talking about a bunch of other stuff. And he asked me what I was reading. And I was reading an email from one of you. And it's lovely and personal. But my son got to see what I do, which was very nice. He doesn't know really, you don't I mean, like, he knows I have a podcast, he knows it's about diabetes. But he got to hear from a person who said, some really kind things about the podcast, and I think he was proud of me. So that was really nice. You guys did that to keep sending the emails, keep being bold. You're all going to do fine. It's going to get better if it's not going better. And if it's going great sky's the limit. Keep going. I'm proud of all of you. I'll see you soon.

Please support the sponsors - Contour Next One

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



The Juicebox Podcast is a free show, but if you'd like to support the podcast directly, you can make a gift here. Recent donations were used to pay for podcast hosting fees. Thank you to all who have sent 5, 10 and 20 dollars!

Donate

#291 Ask Scott and Jenny: Chapter Eight

Scott Benner

Answers to Your Diabetes Questions…

Ask Scott and Jenny, Answers to Your Diabetes Questions

  • How do you teach kids to feel their lows?

  • How do you help a type 1 who has an addiction or eating disorder?

  • What are good practices about addressing lows when you're sick and how do you administer a micro-dose of glucagon?

  • How do you bolus for pizza?

  • Bonus! Listen to Scott reading and singing How the Grinch Stole Christmas!

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - PandoraSpotify - Amazon AlexaGoogle 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
friends, neighbors, countrymen, lend me your ear. This is Episode 291 of the Juicebox. Podcast, a super sized ask Scott and Jenny with how many ads? Zero? That's right, baby, we reached the end of the year. So instead of ads at the end of the podcast, a little Christmas cheer.

Here's what we're gonna do today and ask Scott and Jenny, we are going to talk about, I'm looking well, you would think I could read my own writing, especially notes that I've taken in the last hour. Well, this is a letdown.

Unknown Speaker 0:44
Okay,

Scott Benner 0:46
we're going to talk about micro bolusing, glucagon, like around the flow. So there's going to be a tiny bit of conversation around being sick. Similar to what you just got in the episode about illness, but it's more about many glucagon boluses. So we're gonna deal with sick lows, like how to deal with sick time lows. We're going to talk about how Jenny speaks to people about addiction, and

Unknown Speaker 1:13
you eating disorders.

Scott Benner 1:16
We're going to talk about how you can discuss with young children what feeling low, feels like. So maybe if they don't understand that they can learn and Jenny's gonna describe her pizza bolus. Plus just regular Scott and Jenny goodness.

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 health care plan, or becoming bold with insulin. Okay, so here's a question from Trina that I don't know if there's an answer to but I'm incredibly interested. Maybe you're just going to say there's no answer to this. But she's not Trina says she has a fairly newly diagnosed seven year old. That can't recognize being low. Uh huh. And somebody else comes in and says, You know, I, you know, I have a daughter who doesn't feel low to ardens always felt her lows at, you know, I could tell by what she would say to me, I could I could probably tell you what her blood sugar is by her response, you know, from 65, to 60, to 55, to under 50. I know. But is there a way to teach people to feel low? Like that? Doesn't? I don't feel like you could? And if not, then what are the reasons why some people feel it and some people don't? Or is there not even a reason for that.

Jennifer Smith, CDE 2:57
It's not uncommon for younger kids, to not really be quite aware of what their body is signaling and telling them, I mean, outside of like, like a big gash cut that they get in the backyard or something or like, Oh, my God, I'm bleeding, you know, or it hurts, you know, pain sensations are typically felt by all people, right. But from the low sensations, kids are usually not very good with how their body is doing, you know, unless they're like, Oh, my God, I've got a toothache or my ear really hurts, you know, and even little, little kids, like, you know, under the age of, I would say, three, an earache is typically like their rubbing their ear or their like, they don't want to lay down on that side. So as a parent, you can kind of tell, as far as I mean, a seven year old, technically should be coming into some body awareness. Being able to send some things, but as a, as a parent, you might need to discuss some of what the common symptoms are, you know, maybe they don't know how they're supposed to be feeling if their blood sugar is low. And maybe when it is low, saying, Hey, you know, do you? Do you feel kind of shaky? Or do you feel sort of, you know, like, you can't really, you can't really do math, I mean, by the age of seven kids or kids know how to add and subtract at least the basic numbers like, you know, 20 and last, right. So in that sense, maybe it's not a symptom, but maybe something you teach them is, hey, do you know what two plus two is? Yeah. And most kids of the age of seven, should be able to sit out for pretty quickly, right? If they can't, maybe that's something you teach them to think okay.

Unknown Speaker 4:49
to press to?

Jennifer Smith, CDE 4:51
I don't know what it is. And I mean, since we've got sensors, kids nowadays can actually visually see And they can start to associate a value with something in their body. That's not quite right. You know, asking them, does your tongue feel kind of funny? Do your lips feel kind of tingly? You know, when you put your hand out? Does it kind of shake a little bit? Or do you feel sort of like, you know, topsy turvy on your feet? Sometimes it takes talking to kids about what they could be feeling to get them to start paying attention.

Scott Benner 5:30
Yeah, that makes sense symptoms. I think that I think that makes a ton of sense. Actually, please, you said something in there that just made me think we're expecting them to say I'm dizzy. But they may have no, they may have no context for dizzy. So maybe you take them at a time when they are absolutely at a good blood sugar and spin them in a circle a couple times, then go, Hey, if this ever happens, if this feeling ever happens, let me know.

Jennifer Smith, CDE 5:55
And we haven't spun you around like a twist the

Unknown Speaker 5:57
right? Yeah,

Scott Benner 5:58
you know what I mean? Like, if we haven't spun you and you feel like this, let me know. Or I think that's a great idea like, and I would caution when you try to teach them these sensations. Maybe don't tie them to diabetes, because then it's possible. They could make them up at some point to like, teach them the sensations. Don't mention the diabetes, and then just tell them hey, if you ever feel like this, we want to know, right? You don't want to do the I always used to say to my wife, like when we were first billing, we first had Cole, if he fell over, she would like go at him and say, you know, like, you know is your leg hurt? And I'm like, don't put thoughts in his head. You don't mean like, you know, you hit your head? Are you hurt? Well, then you're like, well, I guess I am yet. You know, like, so you can put that thought into someone's head. But that's a great, I did not think we were going to have an answer for that this podcast is excellent. All right, let's go. As the end of season five comes to a close, I want to take a couple of moments throughout this episode, the Thank you. There are 508 ratings for the podcast on iTunes today. And I took some time to jump around iTunes all over the world. And in maybe six to eight other versions of iTunes, like Australia, Canada, there are amazing reviews for the podcast. I'm so touched by all of them. And I appreciate all the time and effort that it takes to put them up. They're really thoughtful, and heartwarming. And I definitely think they go a long way towards helping other people find the podcast. So every time I say to you guys, please help someone else find the podcast. Just know that I appreciate it, that you're doing it. And it's work.

You know, I saw somebody talking about something online the other day, let me see if I can figure it out. I might have a question for you, Jenny on the second. Awesome. Well, I am going to hit this first though, because then how do you? How do you help people who have type one, and also have an addiction? So let's see. And let's keep it to a drug addiction, you know, is there? Are there things that those people can be doing when they make the decision? Like, I have to do better with my diabetes? Like how it seems like such a crazy thing. But at the same time, any kind of addiction could mess up diabetes, obviously, I think, you know, drugs, and alcohol would probably be worse. But even if you had like a food addiction that would throw off managing your type one a lot like how much do you end up having to talk about that with people?

Jennifer Smith, CDE 8:51
I would say that it's more the anger that you brought in food as a piece of it. While it's not I mean, addiction isn't there's a lot of disordered eating. That comes in with diabetes, because our management is from the get go very centered around food, intake food and you do food and you become food becomes almost a control piece. For many people with diabetes. As I think it's good, it's right to kind of categorize it in with drugs and or even alcohol. Those are pieces that we end up talking to people about but not really managing that piece for them. And so far as our explanation about things like for example, alcohol, right as an addiction. Alcohol can have major impact on blood sugar control, and what happens within being drunk right Your ability to mentally decide things and make appropriate choices and what to do. And even, you know, if you were high or drunk or whatever, and you were even changing your pump site, you could totally inaccurately do that. And you could have a major problem. Right. So I mean, those are pieces that we, we do bring in as far as discussion. We encourage people to continue with their, you know, their therapy, if they are in most of the people, I would say 98% of the people that we work with, who have either had an addiction, or a managing an addiction of some kind, already have a therapist that they're working with. Yeah, I have not personally work with anybody that has a known issue, and hasn't had somebody that they're getting help with from it or for it. But I think that's a big piece of it, it's also from the standpoint of their therapist, or who they might be working with, that person also needs to understand the diabetes component to it, because it needs to be brought in to the overall picture of discussion. You know, the diabetes is a stressor, and that's going to be part of how they manage the raw.

Scott Benner 11:22
Yeah, I so I don't know if you saw recently, I did a, something I called after dark drinking addiction edition, excuse me. And it was a piggyback off of a conversation you and I had and we talked about how to Bolus for alcohol. And then I said, You know what, Jenny, I'm gonna get like a professional drunk on here to talk about this, right? And actually, the funny thing is, is that, uh, the person, Maya, who ended up being on the episode, two different people in her life, who listened to the podcast, separately of her, contacted her and said, Oh, my God, it's your turn to be on the juice box. He's like, she's looking for somebody. Scott's looking for somebody who knows how to really drink and take care of their diabetes. It's your turn. And she sent me a message. And she's like, I don't know how to feel about this. But apparently, I'm the professional drunk you're looking for. And I was like, gotcha. So she came on, and we had a really honest conversation about how she manages. She's a person who drinks she's not a she's not a blackout drunk. Do you know me much, but she drinks a lot more than probably most people do. Like, you know, she's at least having a couple of glasses of wine a day at her meal. And she is a person who finds a lot of pleasure going is she described going to like, out to a lake and tubing around and drinking a case of beer and that kind of thing. And she talked about all how she did it. super interesting. When I asked her what she thought the most dangerous part about drinking with diabetes was, she said, it was about making a bad decision with insulin when she was too drunk correctly. And she was like, that's my biggest fear. She's like, I figured out the rest of it. Like, I'm not super afraid of falling asleep. And getting too low. Especially because she has, you know, she's got good technology too. But already, but she said I would think the biggest concern and it's funny, it's exactly what you said, like, what if I make like a grave mistake and give myself too much insulin? That's really that there's a lot of consistency in that.

Jennifer Smith, CDE 13:17
As you listen to that episode, actually, because that sounds It sounds very good. And I'm always I love to, I love to learn it, you know, more even. Yeah, no different insight Exactly. Because it helps me to help people better. Well,

Scott Benner 13:34
the next one we're booking right now is with a legit waken Baker, I found a 26 year old kid who smokes every day and has diabetes, I'm gonna have him come on and talk about that. And as we're sitting here talking, I think I know somebody I'm going to reach out to about addiction, see, if I can't do one with them to maybe they could add some more context than you and I are going to be able to be free. Because even as you're talking about it, I realized that everything I thought to say, was conjecture. I have no real life experience whatsoever. Like I can imagine what the problems might be, but I don't really understand what it's like to be addicted. So. So the answer to that one here for Ana is that I think we're going to try to do an after dark episode about this and get you more answers. Awesome. Cool. We've done some of you are asking questions that are already listened to listen to more of the podcasts are already out there.

Unknown Speaker 14:30
Go search. There's more on there.

Scott Benner 14:33
to them. I don't really label them that well. I want to wish everyone a Merry Christmas. Happy Hanukkah. Happy New Year, wonderful holiday season. Hope all of your dreams come true. Hope you find some time to relax. May you find time to be with your friends and family. And just reboot, you know, let your brain go limp for a couple of days. So you can reach out And I hope during all this eating and celebrating that's going to happen over the next couple of weeks, you keep in mind the things that we've talked about so far on the podcast, because I think they're going to help you. It's flu season. And this person's asking about something I have absolutely no experience with. How do they micro dose glucagon? In scenarios where they have blood sugars that are so low that they can't, they can't get them to come back up and the person's may be too sick or can't keep down food? Like what a good I guess not just around glucagon, but what are good practices about addressing lows when you're sick? Oh,

Jennifer Smith, CDE 15:41
sorry, you cut out a little bit. They're addressing

Scott Benner 15:45
low low blood sugars when you're sick, you know, when you're stuck. Yeah.

Jennifer Smith, CDE 15:50
So I mean, low blood sugars in illness are much more typical for stomach or digestive bugs. not as common for like, the cold or, you know, like a bronco infection, those usually spike your blood sugar. So those aren't as common. If the flu includes some digestive issues, then we usually say a temporary bazel decreased to begin with, can help to cut the risk, especially if you're not eating very often, or can't eat more than like a chicken or vegetable broth, you know, or eat a popsicle every, you know, couple of hours or whatnot. So taking your bazel down temporarily, anywhere between 10 to maybe 25%, less is a good place to start. If you have a blood sugar that you notice is starting to trend down and you literally You're so nauseous that you can't take anything in turning bazel down by 80%. So you really only running about 20% Normal bazel for about one to two hours, really cuts off insulin significant enough that it should help that glucose to stabilize, and not get too low in a time where you can't take anything in at all. So those are, you know, some, some adjustments that can be done. Other ones certainly, if you find something that you can sip on even a little bit of like, honey in the cheek, or, you know, cake frosting, I know is another one that's commonly you know, mentioned, maple syrup is a very curvy. So those kinds of things, even in a cheek and sort of massaging can help to get it to absorb through the the like oil area

Scott Benner 17:42
without you having to maybe swallow it and affect iraq feels Okay,

Jennifer Smith, CDE 17:46
correct. I mean, you're certainly not going to get 100% of carb absorption, but you're definitely going to get some carb into the system by just putting it in the cheek and massaging it. So that's another good option. electrolyte beverages, especially for stomach bugs are also a good place that you can get a little bit of carbohydrate. There's one that's got a minimal amount of carb. It's called drip drop, okay, it's an electrolyte replacer you put it in water, I think per serving, it's got like eight to 10 grams of carb. So again, not a lot, but enough that it could help to stabilize blood sugar some. And then, you know, in a scenario where you really may need to use glucagon. If you don't have if you don't have the current and newest back semi, you know the the nasal sort of glucagon that be many dose unless somebody figured out how to do that already. I don't know. But I mean, it's a one, pop it in and it's there. You can't like micro dose it. But there are some rules of thumb for micro dosing the injectable glucagon. Essentially you would mix up the glucagon. The mixed glucagon is good for I believe up to 48 hours after mixing. So if you had to use more of it over the time period of and stomach bugs usually don't last very long, somewhere between 24 to 72 hours at the at the longest. You would mix it up but you're not going to inject it with a glucagon injector syringe, you're essentially going to use an insulin syringe. So for those people who are using insulin pens with needle caps, get a one time prescription from your doctor for insulin syringes. Keep a box around so that you could go ahead and micro dose your glucagon

Scott Benner 19:47
I would say ardent hasn't has been pumping for like ever. And we still have syringes in the house. I always make sure we have some just in case. Yeah, that's all it just needs to be there just in case I need it. So So

Jennifer Smith, CDE 20:00
don't really go bad. I mean, your syringes. I mean, they do have expiration dates on and I always think it's funny. I'm like, is this it's not like cheese

Unknown Speaker 20:10
with a piece of metal on it. I haven't got

Scott Benner 20:14
I have some that are so I had so many at the end of MDI that I gave a number of them away to somebody because I thought in a lifetime, Arden won't use all these, you know, so we held on to a few and they've lasted for a decade, it's you know, but been incredibly helpful when they were needed. So when I so when someone goes to micro bolus glucagon, is it just? Is it a testing thing? Are you just trying it and seeing are you so there's a rule of thumb or

Jennifer Smith, CDE 20:43
there is a rule of thumb, and I'm actually off the top of my head, I don't know, I'm actually looking in my education materials right now. Because it's something that I actually send to people.

Unknown Speaker 20:56
Core ability to squat,

Scott Benner 21:02
you're looking at that, let me say this, the idea of sipping tiny, tiny little sips, while you're sick of you know, something that has a little bit of carbs in it with the electrolytes, first of all, it's going to help you being sick anyway. But it's really no different than when I was talking to someone, a month or so ago, somebody I know, personally, whose child has type one playing ice hockey, ice hockey, and was getting low. And I said, look, I think he should have some sort of a Gatorade and water on the bench. And then when he sees himself dipping a little low, that's the time you take a couple sips of the Gatorade. And then the next time if the arrow levels out, you go back to the water. And maybe you have to go back and forth a little bit to to, you know, kind of bump and nudge with the glucose from that drink, you know, right. And it worked out really well. For him, I think you're basically saying the same thing. If you're sick and your budget is just trying to get low all the time and cutting your basal back's not helping, then you just have to kind of it doesn't have to be a big drink, don't get into a situation we need a big glass of liquid just write a little bits, little bits and little steps.

Jennifer Smith, CDE 22:08
And with nausea, and everything those little sips can sometimes still be tolerated enough that you can, like you said, you can get in just a little bit incrementally, I mean, stomach bug to really help to get in some power that you are bolusing even a micro amount for because it really helps to prevent starvation ketones, and anytime you're ill, you really want to prevent ketones of any kind, because they could even at lower blood sugars. I know we talked about this before, as far as ketones, even with lower blood sugars in a time period of illness, it can lead to decay, even at numbers that look more normal. So if along the line of a stomach bug, you're micro dosing for, you know, a popsicle, that was 12 grams and you only Bolus for three grams of it, it's getting enough little bit of insulin in that you decrease significantly the risk of ketones

Scott Benner 23:09
you do not want to go into DK and if you go into DK or you lose control of it, you got to get to the emergency room. So correct yet don't correct. Especially going into like overnight, like like don't don't you don't mean like it make a decision. My wife wasn't feeling well the other day and I was like, don't wait till Saturday to decide you need to go to the doctor. It's so don't wait till midnight to decide, you know, I don't think I'm doing well then fall asleep and find out you aren't decay overnight. Like, you know, you have to make it sucks being sick. Hopefully everybody and it

Jennifer Smith, CDE 23:41
kind of, you know, blood sugar wise, it kind of also in an illness goes along with Where? Where should you look at the potential for needing something to help prevent a further dip, right? So if you're starting with somebody who's Ill really nauseous, unable to keep things in, or things are coming out kind of like both ends. Not to be gross, but you know, they really can't keep anything in. You mean need to utilize something more than just taking bazel down temporarily. Right? That might not cut it completely. So Then where should blood sugar safely be? We usually say especially for kids, not letting blood sugar get less than like 85 to 90. Only because less than that you're really risking a quicker drop to being a time or a glucose value that you can't really recover from when somebody can't take anything in right, so many glucagon. And there are a lot of really good resources online. I mean, there's one at diabetes in control. There are some from the NIH. Typically for kids, we would recommend if your child can't take anything in literally at all. And glucose looks like it's dropping. It's not like that nice stable, but it looks like it's trending down, we'd recommend that the mini dose mixing it up that vial, push the liquid and mix it up, get your insulin syringe. And using an insulin syringe, it's kind of based on age. So the mini dose of glucagon. Each unit on an insulin syringe is 10 micrograms of glucagon. So that's the conversion. If your child is under the age of two, you would need to units on the insulin syringe, which is 20 micrograms of glucagon. If your child is between the ages of three to 15, you would need one unit per year of age. So one unit of an insulin syringe or 10 micrograms of glucagon per year of age. And then over the age of 16, it's 15 units, or 150 micrograms. And you'd inject it essentially the same way you're going to give insulin. Pinch up injected in AI, we typically still recommend similar to low glucose, you know, we still recommend checking blood sugar every 15 minutes and definitely doing it with a finger stick. Don't just rely on your CGM value, do a finger stick, get an accurate value. And if it's still lower than that 90 or if you're someone listening from outside the states, and you're in millimoles, that's five millimoles or less, then you can give your child a second injection of glucagon and you would actually double the dose from what you gave the first time.

Scott Benner 26:49
Now, are they going to experience any of the kind of bad side effects that sometimes come from glucagon when you're mini dosing?

Jennifer Smith, CDE 26:55
typically not in fact, those symptoms which common symptoms would be nausea and vomiting, which is pretty significant to give that whole entire syringe full of glue good on, which to my understanding is at least what I initially learned was that syringes meant to treat somebody up to 250 pounds. Cheese. So if you've got a little, you know, four year old who is like 30 pounds or 40 pounds, no wonder they're getting such a significant, like, nauseous. With Yeah, we have a micro dosing of it. You shouldn't

Scott Benner 27:33
Arden's emergency one at school up until I think she was over 80 pounds, just that just give half of it if you can, you know, just eyeball it. I mean, if if Wallah seven year olds having a seizure, and you as a teacher who really never wanted to be a part of this can stop the thing. I just want to put it in half of this. Well, you know, good luck and everything. Right. I think you're in an emergency situation that and maybe the nausea afterwards is is the price of doing business, you know, but I just wondered if it came with a micro dosing to Okay, so I had one more question. I don't know if we can get through it in 10 minutes. Sure. But um, what are we okay, well, we're gonna do one more by the way, Arden's blood sugar 77 and stable. Nice job. Thank you so much. Banana bagel, three molano cookies. Oh, my gosh, big bag of grapes have no, I have no idea how many. And a yogurt. I've even come to the idea of I can now put in more food to give her choice knowing she won't eat at all and still hit the but the Bolus, right? So seriously. Alright, so now we're gonna test this right? We are going to answer someone's question here. Gosh, why can't I just see it? I've been looking at it for 10 minutes while we're talking about moving on. And now all of a sudden I've lost track of it. But this person says, I don't know how to Bolus for pizza. So given that everyone's going to be different. Still. I would like to ask you, you're a grown person. I'm assuming you eat pizza sometimes. How do you Bolus for pizza?

Unknown Speaker 29:12
Oh,

Jennifer Smith, CDE 29:14
assuming this person is using conventional insulin pump.

Unknown Speaker 29:19
And we don't know.

Jennifer Smith, CDE 29:21
I don't really see Tam on injections or I'm pumping or I'm you know, using a frezza nasal nasal insulin or whatever you're doing right? I don't know. So let's assume a conventional pump. Yep.

Unknown Speaker 29:35
In that case,

Jennifer Smith, CDE 29:38
the pizza bolus sort of became the term for an extended bolus, right? It was the first reason that we started to use extended boluses or have that feature on a pump. And the reason being pizza is high carb, very, very high carb unless there's somebody making a cauliflower pizza. across, then whatever your pizza is high carb from the grain nature, but it's also really high in fat. I mean, unless you're doing a vegan pizza that has no cheese and sausage and whatever on top of it, your pizza is high fat. And if it's a pizza from a source outside, the crust probably has fat in it, as well as the toppings that you're adding on top of it.

Unknown Speaker 30:19
So

Jennifer Smith, CDE 30:20
the high fat nature along with the high carb component to it really mean that if you Bolus 100%, right now, for pizza, with a Pre-Bolus, as we've talked about before, the benefit of that

Unknown Speaker 30:36
you're going to get low,

Jennifer Smith, CDE 30:39
and then your blood sugar is going to get high. And then it's probably going to stay high for a while. Right. So there are a couple pieces to pizza food management. And let's kind of tie in nachos and you know, fish and chips and like a cheeseburger and fries or a real Italian pasta meal with all the good cheese, sausage and cheese and oil and whatever. Right. So high fat, essentially an extended bolus. And again, it takes a little experimentation to see what type of extension you need. For the most part for pizza type of food, you would use about a 60 or 70%, upfront possibly, and the rest over at least a two hour time period.

Unknown Speaker 31:27
So

Jennifer Smith, CDE 31:28
what you're doing is you're giving insulin up front, but then that extension over about a two hour time period and the back end is grabbing on and hitting the food that's more slowly getting into the system because the fat isn't letting all hundred and 20 grams of that pizza. Get in right now. Right? Some people do a 5050 50% now 50% over two hours that works very well. Um, I think the upfront amount from my experience really is specific to how much is on top of the pizza. You know, if it's your Margarita pizza that has a couple of blobs of real mozzarella on top, but it's not slathered in cheese, and sausage and Canadian bacon or whatever, it's probably a lot lower fat pizza, right then something like the meat lovers, right? So that breakdown of percent now percent over time, kind of goes along with the nature of what you've got on your pizza. But that's that's the gist of pizza. And again, it takes a little experimentation. Sometimes you got to take a hit

Scott Benner 32:49
and learn and then move on from it. Right? I would say so Arden just had a slice of pizza going out the door to a party last weekend. And it was more the way you describe in some ways. So it was a thinner crust, but it had less cheese. Like it's not completely covered with cheese, you know, and I, you know, I come to realize too. I live in a portion of the country where, you know, I'm eating pizza that somebody in the middle of the country might have never seen before to me I'm not it's not Domino's, or you know, some restaurant chain pizza. This is you know, this is a Sunday night real pizza 90 year old Italian man who has, you know, the, the, the recipe for his pizza chained in a box around the killing to get it from him. So, and I happen to live in that part of the country where a pizza like that exists. And so she has this thing, but it does have sausage on it. So I looked at it and I thought okay, Arden's blood sugar's like 105 I believe back then, because she was she was a little on the lower side, because she was spent a lot of time getting ready with a costume party and everything. She's moved around the house a lot. blood sugar's nice and stable. I'm going to have a slice of pizza. I didn't worry about Pre-Bolus. And partly because I thought she might be trending down to begin with wasn't but because it's pizza too. And my idea about these carby things that hit hard. And then last is I kind of just think about it as getting my insulin up front to stop a rise or a spike. So I have so much, I have so much up front, that there's no way for your blood sugar to spike. And then as time goes away, I can take insulin away and let what's left over from the big push at the beginning act as the bazel going through it. And that is one way I do that. The way you just described I do as well. I don't need to read describe it because you did such a perfect job of talking about it. But But another way is, is that like it's just I bring in so many blockers up front. You can't sacked my quarterback. And then later later in the game when you stop blitzing, I send them away, you know, so and so I sometimes get in so much upfront that the it can not only handle the food, but it can be part of the bazel rate going away. And then I take the bazel way I trade I trade Bolus earlier for bazel later to leave the Bolus tail end acting as bazel later, yes, yes. Yeah. Yeah, that's, that's one of the ways I think about manipulating insulin. So

Unknown Speaker 35:31
but then the other component

Jennifer Smith, CDE 35:32
to pizza too, is again, the fat content, right? Like I said, before the Margarita pizza with a couple blobs of buffalo mozzarella on top, probably not high enough in fat that you're going to have that long duration extended high blood sugar for six, eight hours after, however, bringing the neat lovers and you not only probably need the extended bolus, but you probably need a temporary increase to your bazel for hours after right to avoid the sustained high. So again, scenario to scenario you may have to decide what your strategy is going to be. But those are the typical ways to manage pizza would have grabbed another slice,

Scott Benner 36:11
then I would no longer have been thinking about a bunch up front and no more back now I would have been as soon as she had the second slice, I probably would have bolused thin thin crust pizza, my guesses like 25 carbs, like I probably would have, I probably would have Bolus 25 carbs and probably done zero upfront and the rest out over like an hour and a half. I will as soon as she grabbed another one, I would have started thinking about the future. Yeah, right. But it looked like one and then she was going somewhere. She actually did have to Bolus once while she was at that party. We did not end up taking it away. I did a pretty good job of balancing it. And so while she was there, we had a nudge like a 134. Diagonal up at one point. She did not eat anything at the party, though. Oh, yeah, I think at a certain age kids just stand around and look at each other. So. So you're here I'm here to and then they that's pretty much the end of it. And I did not see Luke doing any gyrations during that time. Like there was no technical way away or way up, you know. So I was in a fairly traditional situation there too, because we'd hit the ball. So well, in the beginning. It just didn't. Luke didn't really have to do anything. It just sat with her base. Alright. Nice. That is really kind of fun when you can see that when you're on an algorithm. But you're like, wow, we did such a good job with the Bolus, like the algorithms not doing anything, you know. Yeah. Wow. That's really like, that's right.

Jennifer Smith, CDE 37:38
You don't see the down or the off the you know, cityscapes kind of thing. You just riding along your leg is looping. Is it working? is it doing anything? No, it's just got me hovering. Nice.

Scott Benner 37:47
We really hit this one. That's crazy. All right. Okay, so hopefully that was helpful. My Eternal grateful thanks to Jenny Smith from integrated diabetes. Don't forget, if you would like to hire Jenny, go to integrated diabetes.com to contact her. Also in the show notes of your podcast app. Jenny's email addresses right there. It also exists on Juicebox podcast.com for this episode. And I know this was ad free, but I'm feeling very festive. On the pod Dexcom dancing for diabetes. companion medical makers of the in pen. All the sponsors that supported the show this year. Happy New Year. Merry Christmas. Thank you so much. And now I'm going to try something that may or may not go well for the holiday season. We're about to find out.

This is for all of you who listened with your children. And for those of you who may still be children. Somewhere inside the Grinch by Dr. Seuss. Every who down in Whoville liked Christmas a lot. But the Grinch who lived just north of Whoville did not. The Grinch hated Christmas the whole Christmas season. Now please don't ask why no one quite knows the reason. It could be perhaps that his shoes were too tight. It could be his head wasn't screwed on just right. But I think that the most likely reason of all may have been that his heart was two sizes too small. But whatever the reason, his heart or his shoes, he stood there on Christmas Eve hating the who's staring down from his cave with a sour grinchy frown at the warm lighted windows below in their town. For he knew every who down in Whoville beneath was busy now hanging a Holly who reef and they're hanging their stockings he snarled with a snare. Tomorrow is Christmas. It's practically here. That he growled with his Grinch fingers. nervously drumming. I must find some way to keep Christmas from coming. For tomorrow I know all the who girls and boys will wake brighten early. They'll rush for their toys. And then oh the noise. Oh the noise noise noise noise there's one thing I hate. All the noise noise noise noise they'll stand close together with Christmas bells ringing they'll stand hand in hand and those whose will start singing far who for $1 who don't? Ray welcome Christmas Come this way. Bar who for a DA who don't raise well gum Christmas Christmas Day. Welcome Welcome, fall Who? ramas welcome welcome Doctor Who does Miss Christmas Day is in our grasp. So long as we have hands to clasp foul Who's Who? For who? And they'll sing and they'll sing and they'll sing, sing, sing sing. And the more the Grinch thought of this who Christmas sing, the more their Grinch thought I must stop this whole thing. Why for 53 years I've put up with it now. I must stop Christmas from coming. But how? Then he got an idea. An awful idea. The Grinch got a wonderful, awful idea. I know just what to do. The Grinch laughed in his throat. I'll make a quick Santa Claus hat and the coat. This is stopped number one, the Grinch claws hissed as he climbed to the roof. Empty bags in his fist. Then he slid down the chimney. A rather tight pinch. But if Santa could do it, then so could a Grinch. He got stuck only once for a minute or two. Then he stuck his head out of the fireplace flew where the little who stockings hung all in a row. The stockings he crunched are the first things to go. And he slithered and slunk with a smile most unpleasant around the whole room. And he took every present. It was quarter of dawn all the who's still a bed. All the who's still a snooze. When he packed up his sled, packed it up with their presence, their ribbons, their wrappings, their sniff and they're fuzzles their tree anglers and trappings. 10,000 feet up. up the side of Mount crumpet. He rode with his load to the tip top to dump it. Poo Poo to the whose he was Grinch Lee humming, they're finding out now that no Christmas is coming. They're just waking up. I know just what they'll do. Their mouths will hang open a minute or two. Then those who's down in Whoville will all cry boo hoo.

That's a noise grin The Grinch that I simply must hear. He paused and the Grinch put his hand to his ear. And he did hear a sound rising over the snow. It started in low then it started to grow. But this sound wasn't sad. By the sound sounded glad. Every who down in Whoville the tall and the small was singing without any presence at all. He hadn't stopped Christmas from coming it came. Somehow or other it came just the same. And the Grinch with his Grinch feet. Ice cold in the snow stood puzzling and puzzling. How could this be so? It came without ribbons it came without tags. It came without packages boxes or bags. He puzzled and puzzled till his puzzler was sore. Then the Grinch thought of something he hadn't before. Maybe Christmas he thought doesn't come from a store. Maybe Christmas perhaps means a little bit more. And what happened then? Well, in Whoville they say that the Grinch is small heart grew three sizes that day. And then the true meaning of Christmas came through and the Grinch found the strength of 10 Grinches plus two. And now that his heart didn't feel quite so tight. He whizzed with his load through the bright morning light. With a smile to his soul. He descended mount crumpet surely blowing hoo hoo on his trumpet. He wrote into Whoville, he brought back their toys. He brought back their floof to the who girls and boys. He brought back their sniff and their trailers and fuzzles brought back their petard cuz they're daflores and muzzles. He brought everything back all the food for the feast and he himself, the Grinch. carved the roast beast. Welcome Christmas, bring your cheer. Cheer to all who's far and near. Christmas Day is in our grass, so long as we have hands to grass. Christmas Day will always be just as long as we have we welcome Christmas while we stand, heart to heart and hand in hand

Please support the sponsors - Contour Next One

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



The Juicebox Podcast is a free show, but if you'd like to support the podcast directly, you can make a gift here. Recent donations were used to pay for podcast hosting fees. Thank you to all who have sent 5, 10 and 20 dollars!

Donate

#282 Ask Scott and Jenny: Chapter Seven

Scott Benner

Answers to Your Diabetes Questions…

Ask Scott and Jenny, Answers to Your Diabetes Questions

  • Are growth spurts a gradual increase or all at once? Strategies for evening spikes.

  • Any tips for being bold with insulin with the Medtronic 670G pump in auto mode?

  • Let’s talk about tricks for Loop, being flexible and learning from your experience.

  • Let’s talk and compare Control IQ, Basal IQ, Medtronic 670G and Loop.

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - PandoraSpotify - Amazon AlexaGoogle 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 Ask Scott and Jenny on the Juicebox Podcast is brought to you by companion medical makers of the in pen. To learn more about in pen, go to companion medical.com or click on the links in your show notes, or Juicebox podcast.com. Are you wondering why I want you to visit companion medical.com? Well, that's simple, because in pen is America's only FDA cleared smart insulin pen and app system. When you get to companion medical.com, you'll discover that in pen combines an innovative diabetes management app with a Bluetooth enabled pen injector. This will simplify the constant tracking monitoring and calculating required for insulin therapy within Penn MDI users are able to live life less complicated. Welcome to Ask Scott and Jenny. These are the episodes where Jenny Smith from integrated diabetes services. Now Jenny, you may know has had diabetes for decades. She's a pump trainer. She's a CDE. She's I think once she went to the moon, I don't remember exactly, but she's done a lot of different things, right? She's also a nutritionist. Listen, she's everything you want. Why are you arguing with me? No, you're not arguing me. And anyway, Jenny and I. We answer questions from you guys. They're left on the boat with Vince on Facebook page. I asked for them every once in a while. I do it real slick. I go like this. Yo, does anybody have any questions for me and Jenny? And then people leave questions and then we answer them. Anyway, today we're going to talk about growth spurts, the 670 g from Medtronic loop tips and a little bit about control IQ. What do you think of that? Hmm? Okay, then. 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 health care plan. or becoming bold with insulin.

Laura says kids and growth spurts Is it a gradual increase or an all at once change? Is that something that you notice they need more of all the sudden that she gives her example toddlers for him was five, still close to some still close to the same ratios? ISF and bazel. From when he came out of honeymooning. I know he's gonna hit a growth spurt soon. And I guess she's looking for like, How do I know when it happens? And what do I do? And I think this falls under the auspice of those of the idea that I just want somebody to tell me how much or when, like, you know, do you mean like, give me a number or an idea? And I don't know that there's a specific answer. I have a general answer. But I wonder what you think about and what you see.

Jennifer Smith, CDE 2:59
Yeah, and my answer is probably similar to your general answer, honestly, there's not a, there's not going to be a specific like, you're always going to see 25% more insulin needed, right. I mean, it could be over several growth spurts that you notice, gosh, he always need like an extra point one added or an extra 25% or whatnot. But it's, it's not that cut and dry by any means. one specific time though, that most parents with kids with diabetes, and parents of teens with diabetes will notice the heaviest impact of growth. With a surge for only, you know, a short amount of time is evening, where their kids go to bed, they've had things really nicely contained. And all of a sudden they get these like spikes. Almost as soon as the kid is snoring, like their head hits the pillow, they're snoring, and up it goes they've been at this beautiful 111. And up it goes and they fight it and fight it and fight it. And it could be an all night fight depending on how strong the growth surge is. And in those instances, it's okay, let's try it. I usually encourage people to try first a temporary bazel increase rather than shooting it with like a dose of three units of insulin and then chasing the drop down. Attempt bazel increase, you know, that might be significant. Maybe it's 50%. Maybe it's 100% more for a time period. See where it levels off? When does it start coming down? You can always shut off attempt it is all right. So and then if you learn from that, let's say two nights in a row, you start to see this surge on the second night when it gets going. You hit that Temp Basal again, similar to the night before if it controlled Well, if it wasn't quite enough, and you still fought a high pump it up even more. But then once that growth spurt is sort of reversed They may need not as much like as the Temp Basal you are giving to offset the rise. But their overnight needs may definitely go up, you know, they were at point to their growth spurt needed a 50% increase overnight for that time period. And now instead of being at point two an hour, now they're at point three or point three, five. And that might be where they sit for a time period until another growth spurt happens is

Scott Benner 5:28
that going to be because there's more body mass, like you've actually grown? There's more of you, or

Jennifer Smith, CDE 5:34
potentially or just the changes that right? I mean, in little kids, especially little kids, I sometimes, you know, with mine, especially my almost three year old, sometimes he wakes up in the morning, and I'm like, you grew right? You just like, all of a sudden, he just let you look bigger, you look like your cheeks are slimmer, or you know, he just looks bigger. And, you know, so sure it can I mean, it wasn't technically overnight that he just shot off. But those, you can suddenly kind of see it and people who are attuned to their kids, especially parents, with little kids who you're following so many more things than just which truck they want to play with, you know, staring at them constantly. And, you know, I mean, with diabetes, you pay attention to so many things. So you could like I said, you could see a tremendous need in a spur period, and then it levels off, but it doesn't come back down to where they were before the growth spurt. Right?

Scott Benner 6:32
I have to say, I think the idea of looking for physical clues is brilliant, because I know our son, his calves would get thicker. Like all of a sudden, you'd look at him and his calves would be out of proportion with the rest of his body larger. And then sure enough, he would get taller. It was almost like his body was like, okay, we're getting ready to do this. You know, like, and it would store things in certain places or something would get bigger sooner. It was just really it never failed as he was growing and I have to say to door jamb that you don't mind drawing on with a pencil is great as you have children, a few people have younger kids. I'm sure you're doing this, but it gets really fun. A decade later, when you're like stand there for a second, you know, and and you get to see how they move up. I would say the answer to this question to me, is the core of the of the podcast, right? Oh, hold on a second. Arden needs a little help with their balls for a second.

Unknown Speaker 7:26
That's okay.

Unknown Speaker 7:29
What is six times

Jennifer Smith, CDE 7:30
we don't use the door jamb we use a my mother in law when our first was born bought us this like measurement tree, and you put it on the wall and kind of pop it in. And same thing, same idea, you just push the hash marks on to the tree as the child grows. But the nice thing is that we've used one side of the tree for Oscar and the other side of the tree for Conan. So we can see where they both are. And it's kind of fun to now be able to see where was Oscar? And is Conan meted out the same? Or is he getting bigger faster? Or are they growing about the same? It's kind of fun? It really

Scott Benner 8:08
is. I have to say my wife has told me without a doubt if we ever sell this house, she's like, you have to pry that board off the wall and replace it for the new owner because I'm taking it with me. And I was like, Okay, yeah. So anyway, what I was going to say is that I think this is one of those questions that if you just caught me, if you texted me real quickly and asked me this question, I would say to you, this is why the podcast is terrific. Because you are running into an insulin need. And it's saying to you, I need more insulin, give it more insulin. Try not to worry about why just it does. And when's it gonna start? When's it gonna stop? I don't know. It does kind of suck. I'll tell you like, you know, because after four or five nights of this, and it goes away on that six night when you're finally like, I trust this is going to happen, jacking up bagels and bolusing and everything. And then it turns out, the growth spurts over now you're waking up somebody at one of the morning going, hi, would you like a chicken sandwich in the banana? It's a it sucks. But it works well for those six days. And in my opinion, it's better than being high for six days and just saying, oh, it'll come back again. Right. You know, I just think that's how I would handle it.

Jennifer Smith, CDE 9:15
Correct. And anything, you know, you bring in a good point, in just the comment of when it comes back again, because it will little kids grow and grow and grow and grow and even teens, you know, up to a certain point, girls grow for less time than teen boys do. I mean, teen boys can grow up and into even like 18 to 20 years, some boys. I mean, most often majority is done by like 18 years. But most girls are pretty done growing up by about 16 years old. You know, they look

Scott Benner 9:53
so much older than the boys even when they're 1314 like in that range toe,

Jennifer Smith, CDE 9:57
right. So you know know that In the nature of all the testing and the things that we've talked about in the other podcasts and the figure out the bazel, and figure out the ratios and all that kind of stuff, it's it's not a number that's gonna sit there until they're well into their adulthood, when maybe a variable component of their lifestyle changes, where they will need to make an adjustment. Kids needs change. That's the simplest way to say kids needs change. So don't think you're crazy. If you go for a couple of weeks, you're like, I got this. It looks like it's working magically. And then, like, professionally, I get these emails. They're like, I thought we had this all figured out. It was all working beautifully. And now the last three nights, this is happening again. I'm like, Okay, well, we need to adjust. Right.

Scott Benner 10:47
So Jenny answers those emails by how do you think we stay in business? It's gonna keep it's gonna keep changing. But But no, I genuinely think that's a great answer for that. Okay. Richard says, any tips for being bold with insulin while using Medtronic 670 gene auto mode, you basically can't adjust the bazel other than temporarily turning on the target of 150 bg instead of 120. And it auto calculates bolus based on carbs, BG or a combination of both. It won't do a correction bolus, unless you tell it your BG is above 150. It adds up to great time and range stats for me range being 70 to 180. But I'm spending a lot of time at the upper end of that range. And I'd like to be closer to the 120. I know Arden and Jenny are Potter's but I think Jenny's colleague, Gary uses 670 g maybe? Well, Richard, I don't know how comfortable I am with everyone knowing so much about our lives. But But I am going to have, I finally have some insight into this automated pumping thing. My brain is starting to almost get all around it. But Jenny is going to go first because I've never seen the 670 g before.

Jennifer Smith, CDE 12:03
Yeah, so the 670 G. M. I said it's hard to sit too long, if it is a long pause, because I have to, I have to be kind of, you know, good in the way that I explain it. Because the 670 g can be phenomenal for some people knock the majority of people. But for some people, it does work quite well. Who does it work quite well for? If you have a pretty structured life, if you have a pretty typical breakfast, lunch dinner, you always go to the gym between four and 5pm. You know, it can be a really good system for holding you a lot more stable, it does do a really nice job, for the most part, again, in those in that type of a life for the overnights, similar to the other, you know systems that do something like this with the augmentation to the bazel and how it goes up and down. But I can see that the 670 for a good majority of people with the variability of today's lifestyle. It doesn't meet need. And for run really specific group. Women in pregnancy it doesn't meet need because it doesn't target the right blood sugar, at least not right now. Nothing Medtronic isn't working on that, from what I understand future iterations will have lower targets and different things to it. But the current 670 You know, it targets the 120. I would say for most people who are having success with it. They're typically getting an average blood sugar of about like 130 ish, not really 120 even though technically it's targeting that. And this question kind of alludes to that piece is that it's really not allowing any corrections unless you're above a higher number than you really want to be at anyway. Right. Right. And it's only correcting you down

Unknown Speaker 14:07
to 150.

Scott Benner 14:08
Yeah. Okay. So it's

Jennifer Smith, CDE 14:10
never really getting you too that that technical target. The other component to the system is that it's, it's not using your current manually set bazel profile to work off of with its increasing and decreasing of insulin dosing through the course of the day based on glucose change. It's I we kind of call it the secret sauce of whatever Medtronic has figured out in their algorithm. The system a couple of days of manual mode use gets an idea of your average of insulin need and kind of like a sensitivity and your sensitivity to insulin and what it does, then use it Essentially doses your insulin along the course of time in a day, based on what it is seeing your sensitivity look like. So really the only factor that in auto mode 670 is using is your insulin to carb ratio. If you've got it set at a one to 10, you're going to get dosed off of a one to 10 along with where your blood sugar is, and that kind of stuff. But even your ISF or your sensitivity correction factor, that is not what auto mode is using. So, you know, it's kind of a long,

Scott Benner 15:40
but it's a limit. It's, I mean, I guess you'd call it a limitation of the system. But not a limitation. I guess it's how it was designed to work. It's not working the way and I see the problem. If you're at that top end of that range, or 175, and you're heading up. And without intervention, you're going to get to 240. But it only intervenes enough to try to get you from 175 back to 150, then that's where it won't work, right. Don't forget what companion medical wants you to know, they want you to know about the in pen. The pen is not just this beautiful Bluetooth enabled insulin pen. It's also an app that works in Congress in Symphony in think of another word that means like all together between your app, the pen, and your dexcom continuous glucose monitor. The app is going to give you an at a glance, look at your current status, from last dose to active insulin to recent doses. It has a dosing calculator to help take the guesswork out of dosing. That's a huge help for MDI, right. You'll be able to enter your blood glucose and what you intend to eat. And the correct dose will be recommended to you by the Impact app. I come on. If you're MDI, you got to admit this seems it seems like a leap, right? Here's dosing, reminders and reports and temperature alerts, there's a whole bunch of stuff but you'll learn all about it when you get there. When you get to companion medical comm so for those of you looking to take a pump break, for those of you who are already doing injections, and just wish you had a little more judge get out I mean, in pencil way to go. I want to thank them, of course for sponsoring this episode of the Juicebox Podcast. And I will thank them by reminding you to go to companion medical comm to find out more. Oh, there's extra time in pen is terrific. Why are you not trying the in pen, go get in pen today. companion medicals.com or on the links to wait hold on a second get even deeper. Check it out today at companion medical.com.

Jennifer Smith, CDE 17:55
Many people who will complain in auto mode about getting what we call kicked out of auto mode and kicked back to manual. What two scenarios one in the example you give as blood sugar is rising, and the system is micro bolusing. Along the way, they don't call it temp increase, they just call it this micro like bolusing along the way that the system will only micro dose for a set amount of time. Yeah. Before it says Nope, can't help you anymore. And out of auto mode, you get kicked back into manual mode. Okay. So on the opposite end of that if you're like low, and it can only adjust so much in a low time period. So you could get kicked out of auto mode as well.

Scott Benner 18:47
On purpose,

Jennifer Smith, CDE 18:49
you can you can choose to turn auto mode off going back to manual mode, which is I've got a couple of people that I work with who've been using 670 for a number of years already. And they've figured out the tweaks and the tricks and the things which we actually have on our website. I've got a lot of little tips for you if you are using the 670 These are some of the little nuances and this is how to like do it better essentially. But some of the people I work with just when they see a higher blood sugar and they know that this system isn't gonna adjust it as well. They just go back to manual mode, they add a corrective and they take care of it and then they go back to auto mode once the cyst once you're brought back to where you kind of want to be. Yeah,

Scott Benner 19:36
I see with what I see with lupus. I now have figured out two things when it looks like it isn't going to stop arise and how to get out of opening the loop. So as soon as I see that up, then I go Hmm, that's not working. For some reason. I bolus what I think is a significant amount I bolus an hour's worth of her bazel Plus, whatever I think the rise needs to correct. So it'll be sometimes sometimes I'll be like, open the loop and bolus four units, which is, which is a lot of insulin to try to stop. Because what you're really looking at is a 135, diagonal up, which doesn't make any sense to put in for it. But it does if you understand what the algorithm is going to do next. So you're going to open the loop, it's going to go back down to your base, you know, base, I'm going to try to stop the rise anymore, it's just going to go too far. Now, I think it's like 2.4, something like that an hour. So it'll go to that. So I've put in enough insulin to stop the stop the arrow, stop the momentum, bring it back. And then when I get momentum coming back down, I figured out and I can't obviously pass this on to any of you. But I can look at the Dexcom graph and go close know when the court follows it now, right? And so you close it now. And it's almost like, it's almost like flying or landing an airplane without your, without your gauges, I guess like you just look at the ground and you go, I gotta start pulling up right now this is it. And, and it works. I can't believe I can't believe I figured something out about looping, to be perfectly honest, you know, a workaround for it. And it's a workaround, that doesn't cause a problem later. The only way you can get messed up coming out of open loop is if you're if you close the loop, and then go right into a meal again. Because then right, then you'll put in, and this just happened while we were doing this, you'll put in art and just put an ad carbs for a large lunch and had a bagel involved in it. And she said, it didn't give me any insulin because we just came out of open loop. And I was like, That's alright, because I wanted this to be 11 units. So still put in the car absorption is 40 over two hours, 40 over three hours, which by the way, spreading out your carb absorptions stop multiple different stops, it stops it from shutting off bazel because it thinks oh I have to stay on for a long time you trick it. You're smarter than the loop, damn it. And then so you get up 40 and 40. And then I just told her Bolus all 11 units. So now it has the 11 units to work with. It has the absorption times in and then it will make decisions about bazel based off of those other two things. And more importantly, I win Jenny.

Unknown Speaker 22:25
Important. Right? Oh, wait, yeah, Arden wins because she's healthy.

Scott Benner 22:32
I defeated that damn thing. I feel like I beat a robot in a sci fi movie. You know, like, like, it came at me with like a spitting action a torch. And I was like, I'm gonna die. And then it was over. I won.

Jennifer Smith, CDE 22:42
I was just like, I can't move on. Yeah, but that was I know. And why why are you winning? You're winning, because you've watched and you've learned?

Scott Benner 22:49
Absolutely, it took me a while. I am telling you this in October. And when did Arden go on loop? It's got to be like six months ago a while right? And, and people at that time were like, oh my god the boat with insolent guys looping. We'll all have great directions for looping in just three days. And then you all emailed me for months. Like tell me what to do with looping. I was like, I am still. And so when I tell people, it, they're never mistakes. It's always a learning situation. I that's exactly what I did. I hate to say it because I think it sounds a little douchey. But when I don't know what to do with diabetes, I go back to what we talked about in the podcast, I just, I revert back to the basics. And I go, okay, what's happening to me here, and then I apply one of those protip episodes until I know, it's, it's a little strange, because I'm the one that said it the first time but it's a great example of how in the middle of life, you can forget things you know, you know, like just because it comes at you from a slightly different angle all of a sudden, and it doesn't look the same as you expect it to you panic and you go different thing don't know what to do, and it's over. But I just kept applying the tenants of the podcast until I figured out the loop thing. So I am so close to us doing that.

Jennifer Smith, CDE 24:01
You know the same thing. I mean, I learned I've learned a lot over now two years Actually, today is my two year anniversary of using loop.

Unknown Speaker 24:10
This is your loop version started

Unknown Speaker 24:11
on Halloween.

Unknown Speaker 24:14
Yeah, by the way,

Jennifer Smith, CDE 24:17
it was what actually you know, to be quite honest, as most people do, you know, I actually I started in closed loop the evening of October 30. And by like the morning of the 31st I was like

Unknown Speaker 24:31
coupon open loop like

Jennifer Smith, CDE 24:35
so I closed it and it was it was actually really great. I mean, I got a chance to trick or treating with my boys and whatnot. That evening. It was was really cool to be able to watch the system and I would have usually applied like some type of temporary bazel or just plan to like steal candy out of there like buckets as We are treated along the way. And it was really fun that Halloween because I didn't feel the need to pay attention, nor did I get any alerts while we were trick or treating, because Luke was doing a great job. And so I don't I think it was kind of a fun day to have started it. So

Scott Benner 25:23
don't test yourself a little bit, right? Don't Don't

Jennifer Smith, CDE 25:25
Yeah. But again, learning, you know, I learned, you know, like my coffee in the morning, I typically found pre loop I had they have a half a unit of insulin to cover. Well, that wasn't based on carbs. It was just what I had learned to utilize. Right? Well, now in loop, I had to actually go back and figure out how much does that equate to as far as like a carb entry for loop to really cover this? Yep, the right way to offset that like caffeine rise and everything. So there is there's relearning to using these hybrid closed systems, whether it's the six, seven dg or loop or open APS or whatever, there are pieces of things to learn that you weren't applying before. Or maybe you were you just have to learn them in a new way with the system. I

Scott Benner 26:18
think that's that's it. Arden right now is at lunch. She's 75 her blood sugar 75. Here's how the morning when she got up in the morning with a pod that only had a couple of units left in it. So we swapped it running out the door, swap it as she's getting that little bit of a rise from the morning, right. So I see like a 120 is starting to creep up. She was one on one while she was getting dressed all sudden, she's 120. I threw in a unit from the old pod because I didn't want to waste it took off the old pod put on the new pod, looked at what insulin was pending for lube, bolus pending insulin. Then she started we drive into school and I just noticed that I felt the number jumped too much. And I was like open the loop and Bolus two units. So now I'm thinking about pod change insulin right. So we Pre-Bolus two units I comes in perfectly forget to close the loop this morning, I'm running around doing a bunch of stuff we forget to close the loop. So then something hits her where she needs more bazel loops, not closed doesn't work, she starts going back up again. 134 diagonal up at 9am. Now I'm like Oh, she's got to eat an hour and a half. reopen the loop Bolus more 91 diagonal down when she wants to eat. And then you heard the rest. We closed the loop tried to do 80 carbs, it didn't want to it didn't want to give it to her. So I gave him the sweet we set up the the absorption times and gave the insulin anyway. And now she's eating and she 75. And I'm telling you two months ago I don't even know where her blood sugar would be with loop right now it would have been a disaster. But I needed that disaster to happen. So I could wrap my brain around the whole thing really. So I'm very, I'm doing very well with it now. Like I can't wait to see what hurry once he ends up with being three full months of this kind of new space. Alright.

Jennifer Smith, CDE 28:06
And it kind of goes along with I think one of the last times we did a we did a chat like this there was we kind of both talked about like taking a hit. Right. And so I actually for our newsletter for October newsletter, I actually did an article about what you can gain like taking a step back in order to take two steps forward. You can learn from the hits that you end up taking Well, my blood sugar did do great for, you know, this five mile run that I planned. Okay, well, what did you do? What didn't work and plan accordingly for next time you you can learn from taking some steps back

Scott Benner 28:47
hundred percent you have to stop every once in a while you just have to broaden your scope and stand back and see the whole picture. Because you're just telling the fight. You know, it's funny. The it's a completely strange, I thought but I think in my mind, it's the same thing. Phillies hired a new manager the other day, Joe Girardi he was really successful manager with the Yankees for a decade, you know, left there. And it's been out of baseball for a couple of years. And he said, I heard him in an interview. He goes sometimes when you're in it, it's hard to see it. You know, he's like you're in this fight. And you're so focused on winning, or I guess in this situation, you're so focused on your blood sugar being where you want to be, you don't see how it is you're losing or winning. You don't know why anything is working or not working. You're just swinging hands, you know. And so I think that's a perfect scenario. I think you got to step back and just look at the big picture sometimes. All of these things that have been on T shirts for the last 50 years have been there for a good reason. It had everything we just said about 670 G and looping. does it apply to basal IQ as well?

Jennifer Smith, CDE 29:55
I think it probably will apply more to control IQ. Okay. Which is basically like you really is only a predictive low glucose suspend, right? So the system is looking for glucose to be less than 80 within the next 30 minutes. And if the trend in glucose is happening such that that's going to be the case, then it predictively suspends the insulin delivery on a basal level. But the interesting thing about it is that it actually doesn't do only bazel suspension. It also suspends an extended bolus. So if you are using bazel, like you, and you have a trend happening, and basal IQ kicks in, and you've got an extended bolus, your extended bolus will be stopped. And so once these like you kick things back on, you have to remember to go back in and either resume an extension of what was missed, or just Bolus for the rest of what was missed, depending on how long bazel iq was kicked off. So that's a kind of a nuance to that system and control IQ will be, I would say, closest in similarity to 670 G. Neither of those systems are by any means close to looping in any sense, you know, loop open APS, Android APS, I, the the current approved, hike, sort of hybrid clothes are just not, I mean, from the basic information about the research of the control, like you, and the people who have used it in the trials, it seems to do a good job. Again, it's conservative, similar to the six, seven dg in what it does, but some of the factors that it uses to adjust. From what I understand it does use your set bazel in the background to adjust off of rather than its own secret sauce of applying a bazel does use your current sensitivity factor as well as your carb ratio. So that, in my opinion clinically, and like if I was going to use it personally, I think that those are big steps beyond 670. Because it's using some things that is, as we've talked about, if you know that your settings are good, why wouldn't you want a system to work off of what you already know, is working to a degree, right?

Scott Benner 32:27
It seems like these systems are, are set up. I'm sure there are people who have been living their lives in the two hundreds and the three hundreds who are on these systems and think this is amazing, right? It's just not the next level of what can be done. Okay, and I'm assuming they were set up on purpose like that. That's what they were made for. And they're probably doing a really good job for the people that are working for.

Jennifer Smith, CDE 32:46
Correct. Yeah.

Scott Benner 32:53
Huge thanks to em pen from companion medical for sponsoring today's show. And of course, the Jenny Smith from integrated diabetes. Did you know you can hire Jenny, you can go to integrated diabetes.com and then find Jenny. I don't know what you'll do it. You'll figure it out. And then you can email her also right there in the show notes. There's Jenny's email address. That's probably easier. You click on that you send an email. Here's the email says, excuse me. Hmm, I'm composing. Dear Jenny, I heard you on the Juicebox Podcast comma. I love you exclamation point. Can I please give you money to help me question mark, and then you sign your name and she'll get back to you

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


Please support the sponsors


The Juicebox Podcast is a free show, but if you'd like to support the podcast directly, you can make a gift here. Recent donations were used to pay for podcast hosting fees. Thank you to all who have sent 5, 10 and 20 dollars!

Donate