#211 Diabetes Pro Tip: All About MDI
Scott and Jenny Smith, CDE share insights on type 1 diabetes care.….
I am thrilled to welcome Jenny Smith, CDE back to the show. Jenny will be joining us for an extended series of conversations that focus solely on the management ideas that we discuss on the podcast.
Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com.
You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Alexa - Google Play/Android - iHeart Radio - Radio Public or their favorite podcast app.
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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.
Scott Benner 0:06
Welcome to the Juicebox Podcast. I'm your host, Scott Benner. And you're listening to the second installment of my series with CDE Jenny Smith. This episode titled all about MDI is just that it's a conversation about multiple daily injections. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, and to always consult a physician before making changes to your medical plan, becoming bold with insulin.
How frequently does someone leave a diagnosis with an insulin pump?
Jennifer Smith, CDE 0:50
I would say never.
Scott Benner 0:55
Johnny Smith has lived with Type One Diabetes since she was a child. She holds a bachelor's degree in human nutrition and biology from the University of Wisconsin. She's also a registered and licensed dietitian, a certified diabetes educator, and a certified trainer on most makes and models of insulin pumps, continuous glucose monitors, and continuous glucose monitors. And besides that, I just really like the way she talks about type one. Jenny Smith is a CD. But she's also a consultant at integrated diabetes, where she helps people who are struggling to figure out their type one, you can find out more about what she does at integrated diabetes.com.
Jennifer Smith, CDE 1:37
Part of the reason for that not leaving a hospitalization or a doctor's office with a pump is because of all of the red tape that you have to sort of go through for ordering and you know, that kind of stuff. I would say the rare case, this is probably 10% of the time, maybe even less, somebody's pretty quick to get the order written by their prescriber. And in fact, I worked with somebody maybe a month ago that her little boy was diagnosed and how to pump within about six weeks. Okay, but that's pretty quick. It's not typically that fast. And
Scott Benner 2:14
most people are going to get diagnosed with Type One Diabetes and leave with either pens, or syringes or syringes, right, yeah. And so whether you are a person who thinks right away, I have to have a pump and you hammer through insurance and get it six weeks later. Or if you're a person who gets told, we don't give pumps to people until you've had diabetes for six months, or any of those arbitrary times that doctors throughout one year
Jennifer Smith, CDE 2:36
or until you're in perfect control, then you can have a pump.
Scott Benner 2:40
You know how to do this so well that you'll never want a pump, we'd be happy to give you one, which will never come. And so some people are going to need to know what managing with just MDI looks like. So multiple daily injections. These people are going to get some sort of a fast acting insulin that they can use it meal times and to try to adjust highs and they're going to get a slow acting insulin, that's going to be their basal insulin. Right, though, so let's start slow with the basal insulin. There's a lot of them on the market at this point. Back when Arden did MDI we were using 11 mir. And we found that we had to split it half a dose every 12 hours. How? How much of that is really good advice about slow acting basal insulin,
Jennifer Smith, CDE 3:28
specifically, that what you found with 11 year as a specific brand or type is very common.
Scott Benner 3:36
Okay? While while you know, the makers of love of beer will say that it is a 24 hour acting insulin. What we find, especially with the smaller doses, is that dosing twice a day or two injections of it works much more optimally because it doesn't carry a full 24 hours. That was absolutely my finding. I think a lot of people find that. So that's the first thing to understand. If you say to yourself, every day is certain time my blood sugar goes up. And I can't understand why I bet you it's about 18 to 20 hours after you've injected your long slow acting insulin. And so the important thing to remember when you if when you make the decision to split your basal insulin is that it might not be a 5050 split. So right say you have your five units or a one unit, it doesn't matter. It doesn't mean you're going to put in a half a unit and then a half unit again, 12 hours later, it might end up being three quarters of a unit or one and then a half later, there's your because your body has different needs at different times.
Jennifer Smith, CDE 4:40
Right. And that kind of goes into understanding the needs of the different age groups. kids and teens tend to have a much more profound increase insulin need in the overnight like literally like as soon as their head hits the pillow kind of thing and through and into the overnight. So splitting dose for, you know, multiple daily injections with the basal insulin, you may have a heavier dose in the evening than you do with that morning time, the heavy dose in the evening carries you through the increase in need overnight as well as the morning which is a little bit higher resistance as well. And then your dose in the morning kind of carries you through the day when you're more active, right? And you likely will need a lower bazel amount.
Scott Benner 5:26
And so all we've really said here, and I I repeat this a lot to people is that setting up your slow acting baseline so when you're on MDI is about amount and timing, right, yeah. We're gonna say this in the next episode, but so make sure you get to that next episode, but you have to balance the impact of the insulin against the action of carbs or body function, right. So it's just, it's about a tug of war between those things. And that again, I'll talk about a little later.
Jennifer Smith, CDE 6:00
And that's we're watching you know, glucose values, especially if you are privy to getting a CGM early on, which I do encourage over I've said it a million times to people that I work with, if I had to decide on a technology piece
Unknown Speaker 6:14
between CGM and a pump. If somebody was going to take one away, I would 100% keep my CGM, right 100% take my pump, I'll figure out my multiple daily injections. As long as I've got the data and the trend of what's happening. I can figure it out. If you were gonna I would 100% agree with you if you're going to say that one thing's more important than the other, which I think is a bit of a, you know, yeah, you're right. I I'm not looking to give one of them away. Well, they're my way Endymion. When you when you lose your pump, when you're using MDI, what what that means is that if you want that kind of like, tighter control, I guess, you're going to be injecting more. If that doesn't bother you, then right on, you know, like, that's absolutely fine.
Jennifer Smith, CDE 6:56
You also actually what my friend ginger does. Ginger Vieira, who I wrote the book with the pregnancy book, which, you know, she long term has been multiple daily injections. She uses CGM, she is not scared to give 12 1620 micro dosing adjustments through the course of the day to keep things tightly managed.
Scott Benner 7:19
And so and i think so I always say the same thing. Here's what you gain with a pump. You don't have to inject all the time. And you now have the ability to manipulate your basal insulin. Yeah, but other than that, there's no more
Jennifer Smith, CDE 7:31
precisely right, we can manipulate bazel with injected bazel. We don't, we don't recommend it. Like we would on a pump, it's difficult to difficult, it's difficult to manipulate. But you can use your precision to do that on a pump. Yeah,
Scott Benner 7:48
the first time I thought about getting on a pump, and I didn't know anything about them, and I went to a pump class at our children's hospital. You know, even back then I didn't realize that, that my basal insulin would just be fast acting insulin given by the pump, but in smaller doses, like, like spread out over minutes and hours, right. And I didn't, I didn't think about that. It was explained to me in that room. And then I thought I could shut it off. Like because how many times I thought, Oh, I wish this level Mir had an off switch right now. Right? Turn it off, she's stable, and she's at but I know she's gonna go down because this, this level here, she's gonna keep working in the
Jennifer Smith, CDE 8:25
bank. And I don't want to feed her three juice boxes just to prevent it right looking for that.
Scott Benner 8:30
I have become adept at manipulating Arden's blood sugar with basal insulin through her pump, but that's not what we're talking about right now. But we'll get to it in a different
Jennifer Smith, CDE 8:39
kind of leaves in it goes very well with MBI because you can manipulate differently even if you are on MDI.
Scott Benner 8:48
And so so I guess the first thing I would just very basic ideas you're injecting you need to pick multiple sites keep rotating your site you can put in so on and over and over in the same spots it's it's incredibly important because you your your spot, your spots will become saturated, you can actually what do they call that when that when you can actually see like bumps under this under your skin from
Jennifer Smith, CDE 9:11
Yeah, it's it's really a either a scar tissue development or potentially fatty tissue under the skin that that light, light bow hypertrophy. Other big, you know, fancy words for it. But really, it's just when you inject in the same place over and over and over and over again, you're damaging the underlying skin tissue. And it can lead to like I said, either scar tissue or fatty deposits, and unfortunately, then the absorption in those areas, is quite variable, quite variable, if anything at all,
Scott Benner 9:46
and you could lose your favorite place and never be able to use it again and walk away. So when your doctor or your nurse practitioner tries to scare you with whatever gin, whatever Jenny just said, they're like, something like that just thinking of myself. Just think to yourself, Well, that sounds scary. what she meant was rotate your sights,
Jennifer Smith, CDE 10:02
rotate your sights, and there, you know, there's so many places on the body to use. I mean, the backs of the arms, the lower back the upper, but the legs, the tongue, the tummy, the sides of your tummy. I mean, you've got a lot of places to use. So I think with little kids,
Scott Benner 10:19
that's always a it's a question with parents, you know, mainly because little kids, there's, there's so little, I mean, Arden was too, right. So it's, it's like it's finding the place on such a little body. And I'm let me veer off for a second to say something that I think people will find valuable, especially parents. I did some quick math, and in the time between art and being diagnosed, just after her second birthday, and when we got her on an omni pod, when she was about four and a half, I think we ejected or, you know, or stuck her fingers a combination of 10 to 15,000 times those years, right? Or a lot. And every time broke my heart in a way that I find difficult to put into words. and years and years later, we had been on the on the pod for years, before we ever ran into a situation where I thought I should inject here just to see if my site is bad, right? So we had had, we were on a just a really great run with with insulin pump sites. But one day, a number of years after we switched from from MDI. I said to Arden, hey, I'm not sure if this site's bad, and I don't want to change the pump if I don't have to. So um, you know, in Jackson, and so on, if it starts going down right away, I'm gonna say the pumps, sights bad. And if it doesn't, then you're just resistant for some reason, we're gonna give you more insulin. So I put it up on the counter. There she is, you know, she's like, six, seven years old. I pull out the insulin, and she's just going along. And I bring out the syringe and she says, What is that? And I was like, it's a syringe. It's a needle, I'm gonna put the insulin and then she goes in then what? And I said, Well, I was thinking of injected. And she was like, Well, well, well, well, well, wait a minute. Like really? Like, what are you doing? I'm not getting a needle. That's not something I do. And I was like, do you not remember these? No idea. no recollection of ever getting a shot ever. So I know, it breaks your heart as a parent. But I don't want to say kids are resilient, but time has a way of, you know, blurring the past. So yeah,
Jennifer Smith, CDE 12:27
absolutely. Absolutely. And that's, you know, even pump sites then, you know, same thing with rotation. Yeah, yeah, they all need to be rotated. And that becomes a, I think it as an as an omni pod. Plus, there are so many more places that you can put that pod. And easier, especially from the kid standpoint, or anybody who has dexterity issues or whatnot. You know, because there's no tubing, there's no tubing, and you can pop it on. And that's even easier than an injection.
Scott Benner 12:59
I've seen people put them backs of arms. Arden wears hers, you know, the left of the right of her navel on her stomach, and you can even and she wears them on her thighs. You can even rotate within a rotation. So you could put it on your stomach canula facing your belly button and then the next day turn it and you know, put it the other way like you can. If you have four spots, you have 20 you know maybe because you can just kind of start moving around a little bit. I've grown grown women who wear them on their breasts like that one. Like I show that every once in a while somebody will kind of like pull their shirt down online. I said it's the Arden arms like I've never done that though. Yeah,
Jennifer Smith, CDE 13:37
yeah. I've not tried that myself. Although, you know, this year, Chris Freeman.
Scott Benner 13:43
I was gonna bring Chris on.
Jennifer Smith, CDE 13:45
He wears he wears it on his chest. Yeah. And I know he also wears it on like his upper back. And I've seen people on many of the like the Facebook, diabetes groups and whatnot. The places that I mean, people wear them on their calf. I've seen people wearing them on their forearm. Now, although not approved site. Again, this is where your diabetes will vary. And you figure out what works for you. But you know, yeah,
Scott Benner 14:13
for people who don't know Chris is a four time Olympian and a cross country skier. And there is a picture that he shared years ago that is to this date, the most popular thing I've ever put on my website. So ladies, you might want to look at why you're clicking on things, but it's Chris without his shirt on. And he has no body fat to speak no, because we're the reason he wears it where he does and my point is he still pumping and using a dexcom and so if someone tells you you're too skinny for this, or I've heard it both ways, so funny. Oh, you're too your kids too chubby for that pump. Your kids too skinny for that pump. I there have been I've heard a million different excuses. But okay, so MDI, so rotate our sites. What are other good practice? is around MBI.
Jennifer Smith, CDE 15:01
Other really good practices, make sure you are changing the syringe, if you're using a pen, really, really important as syringe itself, as well as the pen needle caps. In fact, one of the very, very common practice for people to do is reuse the pen cap. And by reusing, they actually store the insulin pen with the needle cap, screwed on to the pen. Really not a good idea, it can introduce air into the pen. And it can change the way that the pen dialing and actually dose the insulin. So if you are going to reuse the needle cap, I don't recommend doing it. But if you are going to do it, take the needle cap off in between those uses. Always make sure that you're wiping the top of the needle, or the insulin pen itself, you know, with an alcohol swab, just cleanliness. Those are kind of the basics.
Scott Benner 16:01
Okay, well, what about and I realized to go back for a second, you were starting by saying don't reuse a syringe, which never in my wildest dreams even occurred to me, but you're telling me people do that, too.
Jennifer Smith, CDE 16:10
People do that. Absolutely. And, you know, having worked with people across the spectrum of economic setting, just like insulin is expensive. I mean, even though a box of syringes is not expensive, even off of the shelf, it's not expensive without a prescription. Again, it may be something that people are reusing because it's an expense that they could decrease somewhere, right? You know, so if you
Scott Benner 16:40
could avoid that, please do. So I have a question. And here's a good place to put it. I'm probably gonna bring it up again, we talked about pumping. So the quickest story would be that one day I took off Arden's pump, and I saw a little redness under where the adhesive was. And I was quite literally standing in my house, rubbing my hands together thinking, because I was scared Oh my God, is she allergic to this adhesive, and we can't pump any more like my brain was racing. And I'm rubbing my hands together and rub my hands together. And as I was doing, and I thought, Why are my hands so dry? And then I realized I'm constantly touching alcohol. Yeah. And so I do a little research and I find out that in Europe, it is not common practice to clean anything, a site with alcohol. And I was like, Huh, so I stopped doing that. And Ardennes never had that problem again, and my hands don't crack as much in the wintertime. And so is that a lawsuit? decision? Like do you say to somebody clean this with alcohol first, because every once in a while someone's gonna get an infection or why do we teach it and some other places don't.
Jennifer Smith, CDE 17:53
Alcohol itself is not a I guess the best thing that that I can call in layman's terms, it's a degreaser. It literally wipes clean, that area of any freeze any any skin moisture, any lotions, anything that could be on there. It's not antibacterial, okay, it's wiping the area in Sure, right. But the real reason for cleaning the site is just to make sure that you've you've taken care of anything that could be there and as far as adhesive component, it's very likely of course that the adhesive isn't going to stick as well if you've got body lotion on it or if you haven't taken a bath in two days and you're putting it on your skin and your skin has done its normal thing and you've got oily skin so the adhesive isn't really gonna stick as well. What do I tell people, I also do not use alcohol. Oh my gosh, a CDE that doesn't use alcohol swabs. But I do of course have a clean site. And by clean site I make sure that I wash the area. Soap and water make sure that it's clean dry it and that's what I you know apply on top of then you're entirely 100% right? Alcohol is it will dehydrate the skin and used over and over and over especially for kiddos little kiddos who have very sensitive skin to begin with. You're just asking for more. I mean, there are skin barriers if you do truly have a you know, a site problem. But yeah, even for injections though, making sure that the injection site is just clean. I mean obviously if your kids been outside rolling in the mud or in the sandbox or doing whatever they've been doing in the rain puddle, clean the site,
Unknown Speaker 19:47
jacked into it.
Scott Benner 19:48
Do the same thing. I use warm water, clean towel, a clean towel to dry it, let it air dry, something like that. It goes on, you know, schedule your pod change around your shower, you know Get out of your shower. Sometimes, you know, I see some people like, they call them naked showers where they change all their gear, they take it off before they jump in for free or for a couple minutes, they jump out and they do it, then there's a bunch of different ways to do it. But I think the important thing here is to use your common sense, right like to. And that's all I did that day, I thought I'm drying her skin out, and then throwing this adhesive on top of her. No wonder there's a reaction here. Absolutely. There is a wonderful post on my blog about how to treat real severe adhesive allergies, it is one of the most popular posts over the last five years. And I'll link it in this so that people are great. It was written by a mom who devised a infallible plan. And when you see the pictures of the reaction that her poor kid was having, it was an all over body reaction. And she figured out a way for it not to happen and him to keep using this stuff. So that was really good. I remember the first time Arden was in like a thin pair of like yoga pants as like a four year old, and or a three year old or four year old and I wanted to give her a shot in her leg. But we were out and I just was like, I'm just gonna jab the knee right through the pants. And that's what I was like, okay, maybe all these rules aren't that important. And and you know, and so she was like, Oh, my God, what are you doing? And I said, No, it's fine. I brought it up in you know, now I say I've done that in the past and she was mortified. She's like, why would you? I was like, Listen, we were in the mall, you know, like, like, what do you want me to? Because I and here's something I really believe. And I think this is a great place to bring it up. I don't think you should hide when you give yourself injections. No, I agree. I think that not just not hiding. But why in a public place? Would you go to what is arguably the dirtiest, the bathroom to write up a hole into your body?
Jennifer Smith, CDE 21:56
Absolutely. kind of goes along with nursing for women. Why should you have to go to the bathroom to nurse when it's the same thing. It's the comfort level of other people. It's not your comfort level that you're worried about.
Scott Benner 22:13
The Dexcom g six CGM is now FDA permitted for zero finger sticks. That's right, the continuous glucose monitor that Arden has been using forever, does not require calibration from a blood glucose meter any longer. But do you know what it does do? It allows you to see your blood sugar, speed and direction. Are you rising at two points a minute falling at three points a minute, the dexcom CGM will let you know with customizable alerts. And if you're the caregiver or someone who loves someone with type one diabetes, and you'd like to be able to see their blood sugar when they're not with you, that's possible too. Because Dexcom has a share and follow feature that is available for Apple and Android. My daughter's in school right now. We just gave her insulin for her lunch, and I can see her blood sugar. Her blood sugar started to creep up on us a little bit. So I got an alert and we added some insulin stopping arise. The dexcom g six features an applicator that is virtually painless. My daughter says she can't feel it at all. And it's completely automatic. One button push and the sensor bed has been applied. You snap in the transmitter and you're on your way. You can see your blood sugar's on your Apple watch or other smartwatches on your iPhone on your Android phone. You can share it with anyone in the world anywhere. I can tell you without hesitation that the Dexcom continuous glucose monitor is without a doubt one of the main reasons why we've been able to keep my daughter's a one c between 5.2 and 6.2 for five continuous years. To find out more go to dexcom.com forward slash juice box or the links in your podcast player show notes or at Juicebox podcast.com. It's going to be the best decision that you ever made. In 2008, we made the decision to get my then four year old daughter an insulin pump. It's a decision that I wish we would have made years sooner. After seeing everything that was available. We easily settled on the Omni pod that was back again in 2008. Today Arden is about to turn 15 years old and she has been wearing it on the pod every day since then, every day. And as I mentioned in the other ad, Arden z one z has been between 5.2 and 6.2 for five solid years. How do we do that? Well, we start by seeing an insulin pump is more than just a way to not have to take shots. The Omni pod gives you the ability to do temporary basal rates, that's increases or decreases in your background insulin, extended boluses which will help you spread out your insulin over the life of a meal and so much more. The Omni pod has no tubing at all. The pod is self contained. You wear it on your body You control it with a wireless controller. So there's no tubes running through your clothing, and no pump that you have to jam in your bra or down your pants or wherever people have to put their palms that just doesn't exist with the Omni pod. What does exist is the ability to swim while you're getting your insulin bathed while you're getting your insulin and live life untethered. The Omni pod even features self insertion, just push a button. Now I want you to go to my Omni pod.com forward slash juice box. And when you get there, you'll get a free, no obligation demonstration pod sent directly to your house. Check it out and see what you think for yourself.
Jennifer Smith, CDE 25:46
It's the comfort level of other people. It's not your comfort level that you're worried about. Exactly.
Scott Benner 25:51
And so let me tell you, the briefest story. I'm in a restaurant one day with my kids. Were leaving that day. And there's this little girl seriously a little girl injecting at her table. And I stopped at the table, none of my business. I said, Excuse me. I just want to do it. May I say something and they looked up at me in horror, I realized now and I said, My daughter has type one diabetes too. And I want to say good for you for injecting here at the table. There's no reason for you to hide. You're doing a great job, little girl. Last year, I got to do the math. Last year, seven years later, I had to make a phone call about jury duty. And I said, Look, I would like to skip jury duty because I'm the sole caregiver for my daughter, I help her make her insulin decisions. And if you listen, if you'll let me be on my phone while I'm there, I don't care. But if you don't want me on my phone, I need to ask the skip. Right. And the woman says oh, I completely understand. My daughter has type one diabetes too. And I gave her my name. And she says is your daughter's name Arden and I was freaked out. And I thought Yeah, why? And she goes, I read your blog. And I said great. She goes, actually you're gonna find this strange. You've been a real help to my daughter through her life. And I said why? And she said, because you bumped into us in a restaurant, the week a week she was diagnosed, and you told her she was doing a good job and she shouldn't hide. And she's like, and it's been such a big deal in her life. And I was like, wow, oh, touching. I'm gonna get out of jury duty. Right? And, but, but absolute 100% honest story. Like Don't, don't hide, you know, and because Jenny's right it is for other people. It's not for you, and it quietly you'll you feel shame like it quietly will make you feel shameful about what you're doing and you should not be ashamed of accounting type on
Jennifer Smith, CDE 27:50
that at all. It's just like, you know, I mean, everybody wears it I mean, it kind of goes along with everybody wears their pump differently. And there are a lot of people especially Omnipod wares who wear them you know, only in like, unseen locations. Man I like I wouldn't bipod there get decorated with stickers and I used to like color them with markers and now that now that you know we have the 3d printer kind of thing. We don't but I ordered a Wonder Woman 3d print pack snaps. It snaps over the top. It's awesome. I actually got my six year old pick it out because he was like, wow, all those are cool. You have to get Wonder Woman mommy are wonderful. I was like great. I missed that one.
Scott Benner 28:38
But mommy was ours but okay.
Jennifer Smith, CDE 28:41
In fact, one of my favorite places to wear it is on the back of my arm because honestly because it isn't visible. Yeah, not like the other places on my body aren't good. It's just I like to wear it good spot visibly, you know,
Scott Benner 28:54
I would tell you that Arden has in the past seen other people using insulin pumps on the pod and CGM. And it she's not the kind of person who runs around excited about it, but it has quietly given her a lot of comfort. Yeah,
Jennifer Smith, CDE 29:08
yeah. It's always fun to when you run into I call it diabetes in the wild. Like you run into somebody at the grocery store who's like, you know, boldly got their pump, like hanging off their pants or, you know, clip to their jacket or you know, something like that, because I I always reach out I'm always like, Hey, you know, look, you
Scott Benner 29:26
pumps we've all got pumps, and it kind of starts up a conversation and it's, I don't know it just because diabetes is so like, it's such a silent on scene. For the most part. It's just a nice way to bring it to a visible and make it make it normal because when and here's why that's important. I interviewed a singer A long time ago, a Broadway singer named Kelly. And if you go back and listen to Kelly's episode, which I'll link in the show notes, she hid for a long, long time. And it was not good for her. When she finally decided not to do that it was freeing. So I'm saying don't put yourself in a position to begin with, you know, just be yourself and write and this is who you are. And look, I'm not judging you, if you can't bring yourself to do it in public. I'm not saying. But I'm saying if you can do it, do it, you know, you'll be happy with what happens. So, okay, so what are we not? I haven't, I haven't injected insulin in a really long time. So let me tell you one thing that happens to me all the time, every once in a while when I have to give a needle I'm not good at it. tells me I'm not good at it. And so what, what is, like, what should I be doing? Is there a pinch? Is it quick? Is it slow? Like, what's the right way to stick that needle in there?
Jennifer Smith, CDE 30:49
Do it? Yeah, I mean, you know, obviously, the age old recommendation is to pinch up. To put the needle in, when I was initially diagnosed 30 years ago, we were told to inject at an angle almost at like a 45 degree angle. Quite honestly, now the the recommendation is just like most 90 degree pump sets, just straight up, putting it straight in, no angle is needed. A lot of people have questioned to about the needle length, and all of the research and studies that have been done. Regardless of body type, and body stop body size. Even those really, really micro looking needle lengths, they give you the same, the same ability to put the insulin under the skin in the place that it needs to be, which is the sub q tissue, like the that kind of fatty layer for absorption. So pinching up the skin, putting the syringe or the the needle that's on the the pen straight in 90 degree angle, and then just push the insulin in,
Scott Benner 31:59
that I have to keep the needle in for a second or is that a pen thing?
Jennifer Smith, CDE 32:02
That's for the pen. Really, the recommendation is it does vary. I've heard people being told that they're supposed to count to 20. I've heard people say that they're supposed to count to five. When I was initially educated, we were told to tell people count to 10. So that is what I educate with. And it's interesting because if you have ever given a syringe injection versus a pen injection, you will notice the difference if you pull that pen needle out right after and you don't give that count to 10, some of the influent can leak out. Okay. So that's the reason for that count. And whether it's a basal insulin or your rapid acting insulin or a regular insulin. If it's a pen, you do need to do that count.
Scott Benner 32:49
Okay. All right. Um, let's see what you think of anything that I'm not asking you about because I'm at a disadvantage when talking about MDI.
Jennifer Smith, CDE 32:57
I mean, the only I mean, we kind of, you know, bazel insulin, of course, rapid acting insulin, you know, there are multiple of them on the market. And there also is still some use of regular insulin which we called short acting insulin, it had a longer profile of of working in the body than our rapid acting insulins have, it also didn't work as fast. So again, this is where figuring out what your needs might be. For the most part, the rapid insulins on the market, the three age old ones, you know, human log novolog, a Piedra, technically, they're all supposed to work pretty much the same way I can tell you my personal and have one is that human log and Nova log work pretty much the same for me, a Piedra does not I've tried it, it doesn't work the same for me. Then there's also of course, Vf, which is faster acting insulin aspart, which is just faster acting novolog insolence. It does have a faster onset of action, and has, in my experience, having used it for a bit of time, it seemed to have almost a more clean finish to working. It was done and and that was kind of the end of its actual in my bazel was kind of kicking in and doing what it was supposed to do. But you know, determining what again, works for you insurance wise, many insurance plans have a preferred or a tiered kind of both bazel and rapid acting insulin for you to choose. monetarily, if you can go outside of you know, tier one or tier two, most influence are tier two. If you can go outside of that, they'll usually be a tier three and your copay is just going to be more. But if you prefer one over the other, that might be the course of action you have to do. If you can't, then you're kind of stuck using what the preferred is
Scott Benner 34:52
okay? And I'm gonna ask you one question and then we're gonna switch to another episode and talk about insulin. So the one thing I've found That when I talk about Pre-Bolus with people, and you know Pre-Bolus thing is a pumping word, it just means putting your insulin in before your food, right. So you can, you can pre inject you call it whatever you want. But but some, but a lot of times what you'll hear from especially parents is I don't want to inject them twice at a meal time. And I say, look, I understand that, but but if you can't be sure of how much insulin, how much food the child is going to eat, you still need to get some moving first. So if you're on MDI, and you're seeing crazy spikes at your meals, it's because you're not Pre-Bolus thing, I'm guessing, or a lot of other reasons that you'll hear through the next bunch of episodes. But you're gonna have to make that leap in your head like I'm gonna, if I can't trust he's gonna eat all this or she's gonna eat all this, then I need to put some in now, and summon later,
Unknown Speaker 35:49
right.
Scott Benner 35:52
Please remember that the Juicebox Podcast wouldn't be possible without its sponsors for today's episode on the pod, and Dexcom Dexcom, the makers of the G six continuous glucose monitor, and of course on the pod is the tubeless insulin pump that Arden has been wearing for over a decade. You can go to my Omni pod.com forward slash juice box to get a free no obligation demo of the pump sent right to your house. Or you can go to dexcom.com. forward slash juice box to find out more about art in CGM. Heck, you could do both. The next episode of my series with Jenny Smith is called all about insulin. And it's available now at Juicebox podcast.com. are right there in your podcast app. If you're enjoying the podcast, please leave a rating and review on iTunes and take a moment to share the show with someone who you think it can help. Thank you for listening for being bold with insulin, and for remembering that nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise. And to always consult a physician before making any changes to your health care plan.
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#210 Diabetes Pro Tip: Newly Diagnosed or Starting Over
Scott and Jenny Smith, CDE share insights on type 1 diabetes care.….
I am thrilled to welcome Jenny Smith, CDE back to the show. Jenny will be joining us for an extended series of conversations that focus solely on the management ideas that we discuss on the podcast.
Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com.
You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Alexa - Google Play/Android - iHeart Radio - Radio Public or their favorite podcast app.
+ 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 0:06
Welcome to the juice box podcast. I'm your host, Scott Benner. I first interviewed Jenny Smith, the CDE from integrated diabetes back in season one on episode 37. At that point, Jenny and I were just talking about different management ideas. But it was then that I realized how much we agreed about type one diabetes, and the management of the disease. I brought Jenny back on in Episode 105. And we really drilled down about a one sees what they were and what they weren't. After that second interview with Jenny, I decided that one day I would have her back on to discuss all of the diabetes management ideas that come up on the show, I wanted to break them down into small categories, something that was easily digestible, where we'd stay focused on just one idea, I wanted to create something that you could come back to, hopefully learn from, and if you found useful share with others simply. And so with that in mind, I give you the first in this 10 part series, diabetes pro tip for the newly diagnosed for those wanting to start over with Jenny Smith CD.
Please remember that nothing you hear on the juice box podcast should be considered advice, medical or otherwise. And always consult a physician before becoming bold with insulin or making any changes to your medical plan. If you're a newly diagnosed person with Type One Diabetes, or the parent of someone who's been newly diagnosed, what do you think the first things to understand our
Jennifer Smith, CDE 1:49
first things to understand beyond the glucose values are? What does insulin do? How does it work? I think that's it's a huge one that is it's under, it's under emphasized, I guess is the best way to put it. Many people, especially adults who are diagnosed are kind of given a this is your insulin, this is the dose to take and kind of go experiment at home. I feel like that's kind of the way that it is. And I think insulin is a first most important thing to really understand. How does it work? what's what's the purpose of it? How is it supposed to kind of finish working? And what is the effect for you?
Scott Benner 2:37
Okay, and so what are some, like bare bones ways to come up with those understanding. So I think, obviously, if you have a CGM, it becomes different, right? If you have a CGM, you can get yourself at a stable spot where you haven't had insulin or food for a while, and just give yourself an amount of insulin, see how it moves you? Let's talk for a second about like old school, do you still teach people that they need to do bazel testing?
Jennifer Smith, CDE 3:02
in a general way? Yes, I think especially for pumping is helpful in the beginning, because it does in that bazel only time period, it does give you a general idea of how things are being kept with the rate that that play, I do think that bazel testing needs to be more explained, let's say, when we are talking about pumping insulin, though, because there are as you know, a lot of variables that could be at play in that Barrett bazel testing time period, especially like from from a woman's standpoint, it could very much be that it's not the right time of the month to be bazel testing. Right? Right. Right. So all of these variants, or, or a kid or a teen who is a kid or a teen who is really athletic. Right, and there is a consistent effect of activity level. And it may be different on different days, but there could be overlap from a day ago that you had for our practice or a tournament. So bazel testing, as a general idea, yeah, it can be a really good place to start, especially if you think things are really off in a certain place of the day. But is it the end all be all of knowing where your insulin should be? Not 100% of the time and so
Scott Benner 4:28
so what I end up telling people when I speak with them, is that you know, if you're having an issue and that issue could be anything like you're spiking at a meal, or you're you know, drifting high all the time, or you're incredibly high all the time, you know, any of those things. You have to first look at your basal insulin. It's it's absolutely falling away. The first thing I have to apologize to ardens texting me and I believe she's trying to tell me, it's lunch. Okay, so lunch question mark. So Arden has been sick the last couple of days and probably already kind of resistant like to, to her insulin a little bit. But we are ahead of it now. So she's 106 and stable now. But to give you an idea, she woke up at 110. By the time she was getting dressed, she was one to one. He then was this diagonal up, I bolused a unit and doubled her bazel for an hour. And 30 minutes later had to bolus two more units to get her back to this 106. Now, she never got over about 150. But she sees that rise every morning like that, that little bit of a rise. But this morning, I used I'm going to save three units more than I would normally use. Yeah, it's just because she's not feeling quite well.
Jennifer Smith, CDE 5:40
Again, another reason that bazel testing things like this is not it's not purposeful. In fact, I think, you know, a lot of people try to overcome that morning time rise with a bazel adjustment. But what happens then when you wake up at a different time of the day, right? Or you have a variable schedule, so a lot of times I actually tell people, you know what, let's look at what the rise is. Don't correct it. Let's, let's watch the rise. Let's figure out how much of a rise Are you consistently having, you know what, we can offset it with a with a dose of it of bolus. Sometimes that actually hits the mark better than trying to incrementally adjust a bazel behind the scene that could actually change day to day.
Scott Benner 6:26
Right, right. Okay, so now this is um, this is really interesting. Do the 10 way to like tell you what just happened. So this is kind of hilarious, but my wife is here. I'm gonna have to walk away for a second. Yeah, back. Arden's pump only has 10 units left at it. And no and and just and her lunchtime bolus is going to be 12 units. So I just had to do a smaller bolus as a pre bolus still. And I'm going to send my wife over to like swap.
Unknown Speaker 6:56
I'll be Oh no, let me go ahead.
Scott Benner 7:01
The dexcom g six CGM is now FDA permitted for zero finger sticks. That's right, the continuous glucose monitor that Arden has been using forever, does not require calibration from a blood glucose meter any longer. But do you know what it does do? It allows you to see your blood sugar, speed and direction. Are you rising at two points a minute falling at three points a minute, the dexcom CGM will let you know with customizable alerts. And if you're the caregiver or someone who loves someone with type one diabetes, and you'd like to be able to see their blood sugar when they're not with you, that's possible too. Because dexcom has a share and follow feature that is available for Apple and Android. My daughter's in school right now. We just gave her insulin for her lunch, and I can see her blood sugar, her blood sugar started to creep up on us a little bit. So I got an alert and we added some insulin stopping arise. The dexcom g six features an applicator that is virtually painless. My daughter says she can't feel it at all. And it's completely automatic. One button push and the sensor bed has been applied. You snap in the transmitter and you're on your way. You can see your blood sugar's on your Apple watch or other smartwatches on your iPhone on your Android phone. You can share it with anyone in the world anywhere. I can tell you without hesitation that the dexcom continuous glucose monitor is without a doubt one of the main reasons why we've been able to keep my daughter's a one c between 5.2 and 6.2 for five continuous years. To find out more go to dexcom comm forward slash juice box with links in your podcast player show notes or a juice box podcast calm. It's going to be the best decision that you ever made.
Jennifer Smith, CDE 8:48
So all is okay.
Scott Benner 8:49
Yes. My wife sits across the street. Yeah, my wife's gonna run over. She's working from home today. And it really does just go to show. I guess the fluidity that you have to keep around diabetes because Okay, I'm lucky my wife's here today. If she wasn't, I would have to tell you, Hey, I gotta go. But in the end, there's no panic here. Arden's blood sugar's 107. I wanted I wanted to do a temp basal increase of 50% for an hour and a half. And an extended 12 unit bolus for lunch. But she only has 10 units. So instead, I had her set the temp bazel still and do an eight unit extended bolus. So she's still going to have four units. Going when my wife gets there, they're gonna swap that pump real quick. And then she's gonna head off to lunch and be okay.
Jennifer Smith, CDE 9:35
Right. It'll be fine to get early lunch.
Scott Benner 9:37
Yeah, on every other day. It's at 1030 and then on the austerity
Jennifer Smith, CDE 9:41
like what if you get up at five o'clock do breakfast?
Really that
Scott Benner 9:46
sheets 1030 every other day and the opposite day sheets at 1130 and she's out of school by two. Oh, wow. Okay, it's all kind of very quick. I don't know, learning anything but. So so I think Yeah, so anyway, what I wanted to say about bazel is that, I'm sure just like you, I meet people who are having trouble, right? They're either on the roller coaster and they're going to 400. And they're going to 60 and up and down, or, you know, somewhere in that problem, they're high constantly, they're always 180, you know, they can't really seem to do anything about it. And when they get to you, they have all of these theories about why their blood sugar is too high. Right? And I tell them, your blood sugar is too high, because you don't have enough insulin, and it's not timed correctly. And we're going to start with your basal. And they'll inevitably say, Well, what about my insulin to carb like, That doesn't matter. I'm like, you can have a perfect insulin to carb ratio. If your basal insulin is not right, none of this matters, right?
Jennifer Smith, CDE 10:44
That's right. That's why we call basal insulin, the foundation of your management, it really is we, we actually tell people, it's like the foundation of a house. If you have a sound structure that you're building on top of everything you put on top of it will work. Even if the influence of carbon, the correction factor and things are a little bit off. If the bezel is off, those are going to also look like they're not working well. And it becomes impossible to diagnose what's happening,
Scott Benner 11:14
right. And so what I end up saying is that you try to imagine we use round numbers for examples, but try to imagine your bazel is a unit an hour. That's what that's what it should be. But you have it at point five. And then you have you look at some food and you say, Oh, well that food is two units. So you and let's say you're right about that, let's say you're 100%, right, that the food takes two units, you put your two units in, all you've done is now replace the bazel that you needed, right you so you're resistant, you're high, now you're replacing your bazel it's possible those two units will only go towards impacting the problems your basal insulin has, right. And then your blood sugar shoots up and you go, I don't understand, I put in the right amount of insulin, I counted my carbs, right,
Unknown Speaker 12:01
I counted my carbs. I looked at the label and I did
Scott Benner 12:04
everything The doctor told me why didn't this work. And in the end, and you know, through this series that you and I are going to do together, I'm going to repeat a couple of things over and over that I've found to be incredibly helpful. But in the end, if your blood sugar is high or low, you've mis timed miscalculated, or a combination of those ideas. And that's pretty much it, you know that I find that to be the core of it. It's not the first step to me, not being afraid of insulin is the first step. But we're gonna talk about that in a different episode. But I think that it's it's timing and amount. And I think there's a million other things that can impact your life with diabetes. But that's the seed of the tree, right? And you could throw away all the leaves and all the branches and everything that comes off of that seed, if you have that seed timing and amount, you're well ahead of the game. Right?
Jennifer Smith, CDE 12:53
Right. Absolutely. And I would say the that those two pieces actually go very well together as far as not fearing insulin, you know, and not being afraid of using it because I I certainly work with many people who that is a major problem it is I just want to eat 200 because I'm afraid to give the amount my pump is telling me to give or the amount that the doctor told me to give, you know, and I think understanding insulin is the base of that, understanding it and understanding the timing, and the action of the insulin and how it also individually works for you, helps to dissipate that fear,
Scott Benner 13:37
right? I think that I think that if you can keep your blood sugar stable at 200, then you can keep it stable at 180. And if you can do it, you can do it at 140. And believe it or not, if you can do it at 120, then you can do it at 75. And you know and so because the the tools that you use to to achieve that stability aren't different depending on what level your blood sugar is at. It's all the same. It's all the same stuff. Okay, so that's that is that's excellent. So we'll talk about fear in an upcoming episode as well.
I'm newly diagnosed, I go into my doctor's office. Now you are uniquely qualified to tell me this. What do people get told a diagnosis and why do they only get told what is shared with them?
Jennifer Smith, CDE 14:37
I think it there's a wide range of what people are told. I certainly think that the younger the diagnosis, especially for type one, the younger the diagnosis, the more education there is, the more information is provided. adults that are diagnosed I think unfortunately, get the least amount of education again And it differs system to system and provider to provider. But in the beginning, you know, they're taught how to use a glucometer. They're taught how to give an injection. And they're taught that you're going to be taught essentially, the basics of that insulin action. And you're going to be taught carb counting, that is pretty much the gist of what you're going to be taught. And anyone who's been listening to this podcast for any amount of time will know that I call that do not die advice. That's the that's the advice you get so that you don't die. It doesn't keep you healthy. It doesn't help you understand anything, it just keeps you from going home and falling over. Well, and I think another piece of that, too, is it's very, very soon in that beginning is how to avoid hypoglycemia, how to avoid a low blood sugar because insulin causes low blood sugar. And unfortunately, that's where the fear starts.
Scott Benner 15:57
Exactly. And so that's where it's that's where the fear starts, but try to understand it from the clinicians point of view, you are frazzled, I say this all the time being diagnosed with a disease that you cannot cure. It feels like someone just walked up to you with a shovel and smack you square in the face with it and then started yelling, basal insulin, bolus glucometer. This is a test strip and you're like, wait, wait, why? And so the doctor sees that on your face, and can't in I guess in their minds, they don't want to overload you. But the unintended problem is just what you said that you start with fear, then everything starts with fear. It would be a simple sentence, it would be it would be Listen, we're going to teach this to you slowly. I know that seems counterproductive, but it's not. But there's no reason to be afraid. And that's what we're going to learn. Now. The question is, do doctors not teach that because they don't have the time? Or they don't have the knowledge? Like what like, because there are everyone's gonna walk into a different endos office, you're gonna get an 80 year old guy who's been doing this, since people have been boiling their urine, right? And he's just gonna think that if you count your carbs, and inject and go to 300, and come back to 100, that's amazing. And that's that, right? Right. And then you're going to get a guy who's in his 50s, who's just starting to hear about like, other CGM stuff and and and you're gonna get different advice from them, you're gonna get different advice from a, you know, a woman who's been out of medical school for three years and has diabetes. How do you as the patient know what advice you're getting? When you don't know anything about diabetes?
Jennifer Smith, CDE 17:36
That's a very good question. Absolutely. And I think, you know, with today's technology, honestly, I, personally, as people have come to, to work with me, or to work with us at integrated, you know, it's people come, because very soon, they realize they're not getting what they need. It's not quite, they're not sure what they're missing. But they know from researching and looking and googling it, that the information that they've gotten is so just literally the tip of the iceberg, that they're missing so much more beyond and that, you know, that their doctor is saying, well, you have to be in good control for a year to be able to start on a pump. And most parents or even adults are saying, that's not the case,
Scott Benner 18:23
right? Doesn't mean
Jennifer Smith, CDE 18:24
that that's not doesn't make sense. I want to know what I should be doing. I want to know, what is the best for my child or for myself? I want to know, and I think those are some of the things that as a as a newly diagnosed, asking more questions of your provider, even though you may not know exactly what you're asking, when you've googled it, and you've researched and done some of your own searching, and even asked, you know, some people I think more and more people are there kind of they have acquaintances or whatnot, who might have diabetes. And so they, they will ask them, they'll say, well, they're doing this, you know, maybe I should ask about this. And I tell all the people that I work with, you know, what, if your providers not able to meet you or can't answer, even those basic questions at the beginning, it's it's time unfortunately, to find a new provider. It really is.
Scott Benner 19:19
And based off of that idea, I want to say I want to say the same thing to two different segments. So if you're a clinician and you're listening to this, or if you're a person who has diabetes, or is trying to care for someone who does, there's a space that a lot of people get into, they're not given enough information up front. And they're, they're paying attention, right? They want to do well they're paying attention, and they see in consistencies with what's been taught to them in the doctor's office. But because you're the doctor, or because you're looking at a doctrine, you were raised to listen to a police officer, your teachers and a doctor, you're raised to believe that a person in a white coat is infinitely more intelligent than you are. There's no reason to question them. And so when they give you these concrete laws of diabetes, you go home, put these laws into practice, and they don't give you decent results. This is for the doctors, it puts people into such a psychological bad place. It just wrenches their gut, they feel like they're killing themselves or their children. And they don't understand why. And even when common sense things about their diabetes show up, they can't bring themselves to make the leap, because you've told them or not told them anything about that idea. And I will give you a great example. And it's a very simple example,
Jennifer Smith, CDE 20:36
or kind of before your example, you know, it's kind of a cut and dry too. As you know, kind of going with what the doctor said, The doctor said to do this, the doctor said I should take my, my insulin and eat right away. Well, if that's not working, and you don't, if you don't know that, and clinically, clinicians, I think, really do need more information about what really is the real life of diabetes, what's the real life use of insulin and mastering its action and all of that, because clinical book does not mean it meets what happens at home. And when your clients come to you and your patients with their people with diabetes come to you. And they say, this isn't working. I'm following all of your rules. It's not working. And instead of saying, well, you must be doing something wrong because that that happens often, whether as a clinician you want that expression to come out or not, it does you make them feel like they're not doing something right. And you don't give him a way to to help you don't explore with them and say, Okay, I hear what you're saying, I hear that you've tried everything I've thought would, excuse me would work, right? And it's not let's, let's see why it's not working, maybe something is variable for you.
Scott Benner 21:56
And let's have more of a conversation and explain what's happening. So that so the doctor can glean more from what's going on. I'm at the point now. And I'm sure you're there, too. I can look at a 24 hour graph, and make changes in five minutes that improve somebody's life and measurably in 24 hours. I don't know why a doctor can't do that.
Jennifer Smith, CDE 22:16
So I mean, I figured I can yes, some are, some are awesome, but some are not.
Scott Benner 22:21
well enough now to know that, you know, I'm not the brightest person in the world. And I can look at it and go Okay, this is this like this. My example of how powerful the doctors suggestion or non suggestion can be to people is that I was speaking with a woman in her 40s, who had had diabetes for 25 years. I looked at her graph, she was distraught. And I said, you just need more insulin? And she said, Well, no, no, because like I said, all these reasons why it that wasn't the case. And I said No, that doesn't make sense. And in a brief 32nd explanation, over a telephone call, I could literally hear the light bulb turned on in her head and she went, Oh, my God, I just need more insulin. And I was like, right, that's it? I mean, can we go an hour, you know, but But think about, think about that. A well intended, intelligent, educated person who goes to her doctor's visits, and in 20 years, can't figure out why their blood sugars are the way they are, and no one's ever helped her. So what I'm saying to people who are newly diagnosed, or people who have gotten to that point and want to start over, you have to sort of think different, you have to, you know, if you're, if you're in a situation where you're newly diagnosed, and you've gotten some real, like what I call like old timey information, you need to think differently. And if you've had diabetes for a long time, or have been caring for someone forever, and it's not going the way you want, that's the first thing you have to do you have to say to yourself, I must not be thinking like flip it upside down, look at it all the time, I have a friend who every decision they make is wrong. And I once said to them, how come when you have a reaction to something, you just don't wonder what's completely opposite of that, and then just do that. I was like, I was like, right, you're right, you're always wrong, you know, so like, right and, and that's what happens every day you get up, you do this thing with this insulin and this pump and all this stuff, and it always goes wrong, but yet there you are the next day,
Jennifer Smith, CDE 24:19
doing it over and over and over again, which is another reason that I you know, working especially with the women through pregnancy that I work with, that's a piece of the variability that I try to encourage them to sort of work on prior to pregnancy. Okay, you know, because if you can figure out it's why many people with diabetes, eat some of the same things over and over and over again, they have a standard breakfast. I know that it works. I know that I need this much insulin, I knew we need to use a temporary bazel for this much or for you know, whatever extended bolus and it works for me, it's that's the reason because once you figure it out, you're like great. I had Like little magic is magic piece right here and I'm not gonna screw
Scott Benner 25:05
it up. Now I should have this half a piece of wheat toast two eggs over easy and two tablespoons of avocado for the rest of my life. Right? Exactly. Every morning, if that's happening to you, if you're listening, and that's happening to you, I say this proudly, the there are some low carb people who will get upset and I want to tell them right now you can eat low carb your whole life, I don't care. I'm just saying that if you ended up there because you couldn't figure out insulin. You know, if you're if you're eating something you don't want to be eating, there might be a way to manage this. But I tell people very proudly, that at this point, my daughter is 14 years old when I'm recording this. She has had Type One Diabetes since she was two. And for the last five years, her eight one C has been between five two and six, two, with absolutely no diet restrictions whatsoever. Anything you can think of Arden eats and eats frequently.
Jennifer Smith, CDE 25:58
And I bet her more important within that I think we talked about this in the a one c discussion and podcasts. But more important than even the a one C is for standard deviation, the variability, which I would estimate without even seeing her information, I would estimate that her standard deviation is very nice, meaning she's got these little gentle rolls through the course of the day, rather than this major roller coaster because you could have anyone see a 5.4 Yes, but you could have a major, you know, standard deviation. And we will
Scott Benner 26:29
talk about that in coming episodes. You can't run around with your six a one c but be at 300 half the day and 50 the other half of the day that you've just trick the one c test
Jennifer Smith, CDE 26:39
right? On the doctor. Yeah, because again, that goes back to clinician. A one CS is certainly it's a starting place. It is not the end all be all there is more in depth that needs to be looked at with that a one seat. Yeah,
Scott Benner 26:52
we try very hard. Well, you know it. As you go on and listen to these episodes, you'll realize I'm not trying that hard anymore. I figured it out to the point where it doesn't really take that much involvement from us. But Arden's low alarm on her Dexcom is set at 70. On my follow app, it's 120 for the high alarm on hers, it's 130. And so we'll talk about like bumping and nudging later on, but that's my concept is that smaller amounts of insulin as you try to leave a tight range, get you back into that range more quickly. And cause far fewer lows later. Yeah. Give me one second here, we'll take a pause. Okay, um, I'm gonna text Arden, she's now wearing a new pump. I need to know how much insulin delivered from the last Bolus. And then because it's a new pump, and she's literally going to walk right into lunch. Excuse me, I'm going to double her bazel for I was only going to do 50%. Now I'm just going to double it for an hour and a half. And that way, if there's any slow start with that site absorbing and having action I'm just going to do, I'm going to do something that at some point during these, you'll hear me talk about what I call it over bolusing like I just I imagine not just what her needs are now, but the momentum and higher number that I know is coming. In 2008 we made the decision to get my then four year old daughter and insulin pump. It's a decision that I wish we would have made years sooner. After seeing everything that was available. We easily settled on the Omni pod that was back again in 2008. Today Arden is about to turn 15 years old and she has been wearing an ami pod every day since then, every day. And as I mentioned in the other ad Arden's a one she has been between 5.2 and 6.2 for five solid years. How do we do that? Well, we start by seeing an insulin pump is more than just a way to not have to take shots. The Omni pod gives you the ability to do temporary basal rates, that's increases or decreases in your background insulin, extended boluses which will help you spread out your insulin over the life of a meal, and so much more. The Omni pod has no tubing at all. The pod is self contained, you wear it on your body, and you control it with a wireless controller. So there's no tubes running through your clothing and no pump that you have to jam in your bra down your pants or wherever people have to put their palms that just doesn't exist with the Omni pod. What does exist is the ability to swim while you're getting your insulin bathed while you're getting your insulin and live life untethered. The Omni pod even features self insertion, just push a button. Now I want you to go to my omnipod.com forward slash juice box. And when you get there, you'll get a free no obligation demonstrator. pods sent directly to your house. Check it out and see what you think for yourself. I'm going to do something that at some point during these, you'll hear me talk about where I call it over bolusing. Like I, I imagine not just what her needs are now. But the momentum and higher number that I know is coming.
Jennifer Smith, CDE 30:20
Yep. So that's hot change was one thing that I
Unknown Speaker 30:26
was
Jennifer Smith, CDE 30:28
always in in. In the beginning, I was very thankful that I had noticed a difference with my Animas on change that I needed that site to just be like, just saturated with insulin to get absorption sooner. So and I was glad because when I started Omni pod in 2006, I started doing the same thing that I did with my other pump sites, you know, just Temp Basal going up by almost 100%. For about it was usually about an hour to two hours depending on kind of where I was at that point. And if it was, I was having to change that pod, especially if it was before a meal. And I was going to need insulin for that meal with the new pod. I actually, instead of doing it through the pod, I gave an injection, because I just found that a bolus with that new pod site, it never went well. Whereas if I did a Temp Basal increase, I took a bolus via injection for that food that I was going to eat and let the pod get settled in. I didn't have any blood sugar issues.
Okay. Yeah, yeah, it's everybody's strategy is different,
Scott Benner 31:39
right. But I'll tell you what it what it what that tells me is, and again, this is going to be another sentence you hear over and over again, you have to trust that what you know is going to happen is going to happen. Yeah. So if you make a pod change and your blood sugar's 90, you still need to do that. Right? Right. It's okay, hold on, at 5.6 units. So I'm gonna do a Temp Basal increase 95% for an hour, and Bolus seven units. All now go eat as soon as possible. So she's got 5.6 units in from 20 minutes ago or so she's still 102. And so I'm not scared of those seven units. She's going to be eating in five minutes. And look, the 5.6 units didn't do anything over the last 20 minutes. So I'm good. My goal here on this bolus is 75. Diagonal down while she's about halfway through her meal. Anyway, that's again, stuff we'll talk about later. Yeah. Okay. So,
Jennifer Smith, CDE 32:43
um, comfort level with what you know, will happen.
Scott Benner 32:47
Yeah. And because, and by the way, and just these, you have to, you have to have these experiences, like, I'm going to leave this in this episode, so that you know, that things have to happen that you don't expect, because it's data, right? It's, it's I did this and this happened next time, I'd like this to happen. So I'm going to do sooner or later, more or less, whatever it is, I'm going to do, but you can't know that unless something goes wrong. Right, right. And so and so here's a great tip for somebody starting over or who is newly diagnosed. There are no mistakes. There are only experiences that build on for next time. That's it when I see something happen. Instead, you can't get dramatic. You can't get upset, you can't cry, you can't go oh my god, I'm killing her. You can't do it. Right. You say to yourself, okay, bare bones, what just happened here, I put insulin in here. It went up to there. And then it came down and crashed. I bet you If I would have put that much insulin in sooner and spread it out a little bit like I could have created the resistance that that blood sugar needed. Right, right, right. But if you're busy running around, wringing your hands, and just you gave away an amazing opportunity, and I and I will use this as an example. This past weekend, I was helping a mother with a five year old four or five year old boy. And while I was talking to her, this kid's blood sugar went to 300 off of some Cheerios. And we talked for 20 years, that breakfast cereal. Oh my gosh, we're talking about 20 minutes or so. This poor kids blood sugar's at 300 it's not moving. And we're getting ready to get off the phone. She's like, he's hungry. I don't know what to do. And I was like, are you would you like to do something that's gonna sound insane. I'll help you. And she goes, I think I'm desperate enough to try something insane. I was like, great. How much insulin Do you think it'll take to bring a 302 90 and she says a unit? And I said How much do you think the lunch is gonna take? And she said a unit and a half. I was like cool. Bolus two and a half units right now. And she said, She's like, what's gonna happen? We're going to put him His blood sugar into a freefall. And then we're going to add the lunch at exactly the right time. And then with a little bit of fast acting carbs if we need to, we'll bring it in for a landing. I said, I'll never leave you will will text the whole time we'll talk again we have to, so she does it. We get diagonal down to 90 to 75 to 52 errors down to 50. She's texting. Oh my god. I'm like, No, no, perfect. Like, Oh, hold on. I actually texted her a picture of the guys from Star Wars. We're trying to blow up the Death Star, right? stay on target. Like just don't don't flinch. Like don't flinch to 52 down to 42 3200. I said, Okay. Now's the time to start getting the lunch together. And she laughs She goes, Oh, it's already it's just here on a plate. I was like I said when we get the one at given the food. So 182 down kid gets the food 10 minutes later. Now isn't this interesting? we're dropping 10 points every five minutes on the CGM. Then he eats. Then all of a sudden the dropping stops. The arrows are still there. But now it takes longer to get the 170 took even longer to get the 160 and she gets the watch this happen. 150 still two down 140 still two down. I said okay. It's not gonna catch the arrows. Do me a favor, give them a few ounces of juice. She says we don't have juice in the house. And I thought to myself, Oh, I just killed a kid over the phone. Goodbye, wrong number. So she said she says we treat Lowe's with jelly beans because they hit him so hard. I said, that's great. But do you have any liquid in the house that has carbs in it? That's not soda. And she said, we have lemonade. I said that's great. I want you to give him four ounces. Eliminate. So she gives them I said and don't go crazy measuring it. Just give them a little bit of lemonade, right? So she gives him the lemonade boom, goes to one arrow goes to diagonal down the cake comes in I swear to you 75 nice and stable. It's foods been in for a half an hour. And when it was over, she's like, wow, that was nerve racking. I said, Okay, I know that. Clear your head, and then go back and look at the boluses. Look at the time you put the food in and look at the CGM and figure out how that insulin works in him. Because you just had a Master's class how insulin impacts blood sugar and how food impacts insulin.
Jennifer Smith, CDE 37:26
Absolutely, absolutely. And that's, that's the place that as you know, clinicians, they don't have the time to do that. And it's unfortunate is it's unfortunate in the stance that with somebody something like diabetes, type one diabetes, specifically, if you need that hand holding in an instance like that, you need the ability to be with somebody who can say, You're okay, write it out, you're okay, he's gonna be fine. You've got jelly beans, you've got juice, you've got honey, you've got something in the house, you've got a mini glucagon that you could use if you need to, you're going to he's going to be okay, she's going to be you're going to be okay. It's, it'll be fine. But you do you have to use those learning pieces. I think it kind of goes along with a really good friend of mine. Who has had diabetes a bit longer than me, which is 30 plus years. And her her doctor actually gave her kind of a good little hint for numbers, you know, we we start to view numbers in diabetes as good and bad, right? And that comes with that feeling of frustration then, and oh my gosh, I'm like killing myself or I'm doing something bad or whatever. And he said, you know, the numbers are information to just like you said, it is okay, I'm here. Why am I here? You know, what can I learn from this? What can I do better next time? And maybe you analyze it, you know, three hours from now, maybe not in the instant, but it's information. And so he told her, you know, when the number is going to come up on the glucometer you put this test strip in you put your blood on the strip and you tell yourself, I am awesome. And here comes a number, right?
Scott Benner 39:11
Yeah, because they told me what to do next. It can't be a judgment. You can't feel judged by it. You can't let you can't you know, you can't look at it and say bad low you can say not what I wanted, not what I'm shooting for. Right? What makes me what gets me to what I'm shooting for. And you know, it's funny as you and I are pretty much wrapping up this first thought right? Um, I have so many people asking me when they're first diagnosed, what are the things I need to know? And I find around diabetes in general everyone's looking for an amount or a number from you just want to tell me how many minutes I should Pre-Bolus Please tell me how many units I should do if his budget is like this. And I tell them all the time. I don't know figure it out for yourself. And you will write like you have to but I can't give you no one can tell you that a 10 minute Pre-Bolus is going to be what's right for you, in any given situation, let alone all the time. I think it's insane that we think that just because we've set a basal rate of, you know, one and a half units at 2am, that we think that that's what our body is going to need every day at 2am. It's, it's insanity to think that it's just the best we have with the technology we have at the moment. Exactly. And so if you listen to this thinking, someone's going to tell me the rules about what I need to do. And I'm starting with diabetes, we did, we told you what to do, it just isn't what you expected. Right? Right. And so I get that, I understand that it's, it's not a pill disease, it's not take three of these a day, and you have to have food with them. Like, it's not that easy.
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