#237 Diabetes Pro Tip: Setting Basal Insulin

Diabetes Pro Tip: Setting Basal Insulin

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

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

Scott Benner 0:00
Hello everyone and welcome to Episode 237 of the Juicebox Podcast. Today's episode you know by the title is with your favorite guest, Jenny Smith, Jenny and I are here today to add an 11th entry into my diabetes pro tip series. Please don't let the fact that this is the 11th episode in this series make you think phased array testing probably not that important. If it was they would have moved it up sooner. Not even close. Having your basal insulin correct is the core of everything you're doing with insulin. You can't trust that your Bolus was right or wrong. You can't understand why you got low or why you got high. When your basal insulin isn't correct. Everything you see coming back to you from your blood sugar experiences from your glucose monitors from your meter testing. None of it is actionable. None of it is valuable. If your bazel isn't right. Every time I speak with someone privately we start with basal insulin doesn't matter if you're pumping or injecting, and most people's basal insulin is significantly incorrect. If you're seeing blood sugars that you don't understand, it's easy to see a low blood sugar and think that means less bazel. But that's not always the case. At the end of this episode, I believe you're going to have a firmer grasp of what basal insulin is, how to make adjustments to it and why it's so important. You really need to listen to this one. This is where it all starts. This episode of The Juicebox Podcast is made possible by Dexcom ami pod and dancing for diabetes Dexcom. Of course the makers of the G six continuous glucose monitor on the pod makes the only tubeless insulin pump in the world. And dancing for diabetes is the organization bringing joy to children in Florida and touching people all over the world. With their generosity, you can find out more dancing for diabetes.com dexcom.com forward slash juicebox in my on the pod.com forward slash juice box. My friend Jennifer Smith is not just the CDE. She's a person who has been living with Type One Diabetes for a very long time. Jennifer holds a bachelor's degree in human nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer I'm most makes and models of insulin pumps and continuous glucose monitors. Not only that, but she's my guest in every episode of the diabetes pro tip series. If this is your first one, you have to go back started episode number 210. From there, it goes to 11 and 212 then jumps to 217 1819 diabetes pro tips picks back up at Episode 224. With mastering of CGM to 25 to 26 to 31. And of course, you are listening to Episode 237. This is the 11th in this diabetes pro tip series. And in my humble opinion, it just wouldn't be the same without Jenny. Last thing, actually last two things. First one's easy. You know, I'm gonna say nothing you here on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making changes to your health care plan. Becoming bold with insulin. And the second thing is that Jenny does this for a living. You can check her out at integrated diabetes calm, or her email address is right in the show notes of your podcast player.

A funny thing happened the other day, I felt like we did such a great job of outlining everything that everyone would need to know. And I was so comfortable with it that I started supporting the podcast episodes with like social media posts like Hey, don't forget how important your basal insulin is. And the right the amount of notes that I got that were like, Hey, you didn't do an episode specifically about setting up your basal rates. And I was like I didn't, I felt like we covered it all with what we talked about. But okay, if you want it like so let's add one that's about setting up your bazel testing and getting it right. And I was like, Alright, well, we'll definitely do that if the people are asking for a journey, then we have to deliver.

Unknown Speaker 4:02
That's right. That's what I'm thinking. That's what we're thinking.

Scott Benner 4:06
So, so I wanted I would like to do that. Now, here's how I imagined this. And I'm recording already. So this will probably all end up in episode. I'm assuming there's a super like specific way, because I remember being taught it like, you know, in the doctor's office, like very specific don't eat food for this much time, like make sure to like this whole thing, and this is what your basal rates gonna be. Now, there are times when I think that's antiquated and as much as if you have a CGM, you may be able to figure out your base more quickly. But I'll cover that when we get to my less technical way of doing it. But I really do want to start with what is the accepted medical process for figuring out what your basal insulin should be? Check out dancing for diabetes at dancing for diabetes.com that's dancing the number for diabetes.com you can also find them on Facebook and Instagram. Fantastic organization, you should check them out at the very least get involved if you like what you say. What is the accepted medical process for figuring out what your baseline slash obey? Go crazy, Jenny, because I feel like you're gonna get to talk a lot.

Jennifer Smith, CDE 5:21
The I mean, the accepted, ethical way to do it can also vary. You know, I've heard, I've heard a lot of different but I've also heard enough similarities for you, I guess, our best ethical way to do it within integrated when we start working with somebody brand new. As a first and foremost question, have you verified that your bagels are working well, and bazel evaluation can also be done using injected basal insulin as well. Not in the same way or as extensively as a pumped Faisal rates, right. But you can evaluate the whether or not your basal injected insulin is working pretty solidly to Okay, so both of them can be looked at. As far as pumping, we always start with an overnight evaluation. And the reason for doing overnight testing first is one majority of people, unless you're a shift worker, or overnight truck driver or something, most people are sleeping in that overnight time period, there's no eating, no exercising, there's no food going in anyway, it's like one of the easiest times of day to actually get a bazel test in. Okay, the biggest thing heading into any bazel test is that there isn't any food that's going to be impacting in that bazel time period. And there's no lingering impact of your bullet. So for an overnight test, we aim to say, have your dinner and bolus by 6pm. Because by 10pm, when most people are going to bed, give or take depending on if you're a little kid or an adult or whatever, by 10pm that bolus itself and 99% of that food impact should be gone by 10pm in out kind of the bell curve of effect, right? So from 10pm overnight and into your normal waking time, then we get a true look at what is bazel doing to hold things steady. Now, the other variables in episode about variables too, right? Dude that comes into play with testing. You know, if you are in those couple of days before your period is starting, if you have a nasty cold if you have a lot of exercise because of training or practice or something you don't want to be able to tap on an overnight when any of those pieces are.

Scott Benner 7:54
Right, you know what I wonder, too, is I'm starting to believe that there's a different bazel rate that my daughter needs depending on our site. So I think there's a leg bazel rate for her and I think there's a belly basal rate for

Jennifer Smith, CDE 8:07
that's actually funny I use when I use my upper bulat for my knee pads prior to looping with a Medtronic pump. Okay, I noticed that on my bus, I need about 10% more basal insulin. And so I set up a bazel profile that I call but

Scott Benner 8:32
I could definitely say But

Jennifer Smith, CDE 8:34
yeah, I called it but and I had it 10% higher than my standard tested Faisal rate, right that ran on my other normal sites, which seemed to work the same, you're not crazy and thinking that it could be the case. And it's something I bring up with people too, especially those use Omni pod, which can you can wear it in a lot of different places compared to conventional tube pumps, right. So overnight, the goal of diesel testing then is to have fair stability, and not like this entirely flatline. But the goal is to not have more variants than about 20 to 30 points up or down from where your finger stick value at 10pm is. And the goal at 10pm. One set bolus from dinner and the dinner food is pretty much gone. 10pm your blood sugar you're aiming for it to be somewhere between 80 and 250. I know that looks like a broad range, right? And you're thinking well, gosh, if it was like 150 i'd totally correct that at that time because I don't want to sit at night All night at bedtime, you know, 150 you let it lie. You don't touch it. You don't take corrective. Just let it sit. So if you go to bed at 188 you leave it alone, because the bazel job is to not correct that. The bazel job is to hold you pretty steady. If you're not going to have more than a 20 to 30% variance up or down from that. That means all night long. shouldn't really go more than like, a little bit above 200? Or maybe down to like the 150s? If you started at like 188.

Scott Benner 10:09
Push that then you imagine that the bazel is pretty steady, correct?

Jennifer Smith, CDE 10:13
Correct. If you accomplish that with little variants, but not a lot, and you wake up, let's say at 169, awesome, your bazel, we would hold it, check marked off in our box of records as stable tested, it's good. Let's move on to the next testing period. Now, let's say your bazel does show that it's not right. Let's say that 10pm, one at blood sugar, but by 1am, you're starting to see a drift up. That's significant. And by two or three o'clock, you're like 50, or 60 points higher than you went to bed at? Absolutely, there's something wrong. Now, where do you adjust? That's the next big question. People are like, Well, I was high at two o'clock. So I changed my bazel at two o'clock, so that it wouldn't be high anymore. It's actually it's kind of missing the boat, right? Because where you really want to adjust the bazel is about one to two hours prior to the drift being too high or too low start. Okay, so if you're too high by 2am, you probably need a basal adjustment, at least by 1am. Or maybe midnight, that's higher, so that you don't have the drift up in the next two hours. Yeah.

Scott Benner 11:27
And that's the end for people listening to get confused by that. If you think about Pre-Bolus, and you put insulin and it doesn't begin working for a certain amount of time, either does basal insulin, and you're using much less of it. So to get a real impact from it could take some time for it to build up its efficacy, I guess, right? And then not be able to hold you stable.

Jennifer Smith, CDE 11:48
Okay, correct. Yep. So that circulating insulin level at the great description, it needs some time to bump up or bump down right to the rate that's going to be then effective an hour to two hours from now at that rate.

Scott Benner 12:01
It's the same reason, same reason why when we tell somebody if your blood sugar is super stable at 70, and it's been like that for hours, and you haven't had any food or you know, insulin, and you want to try to bring it up by doing attempt down, you can but if your blood sugar's falling at 70, shutting off your bazel is not going to do anything to affect what's happening right now. Wow. You'll make your blood sugar high, two hours later, right after your seizure.

Jennifer Smith, CDE 12:24
Right. Exactly. Right. Yeah. Or after you had, you know, a 30 grams of a juice box or whatever. Yes, exactly. Yeah. So it's Same, same thing, you know, if you're drifting down, you adjust the bazel down a little bit, fill in the same timeframe, one to two hours prior to that drift, starting, so that you don't get too low, later. Now by how much? I mean, again, this is where it does vary a bit. But usually, you know, if the drift up is somewhere between like, if the like 30 to maybe 60 points higher or lower than you want to be within that time period, and adjustment by point 05 to the basal rate could be enough to make a change so that you're not drifting up or down. If it's more significant drift, and you're really rising like 100 points, you started at 188 by two as you're at 280. That's, that's a pretty big change. Yes. And again, we would probably adjust the bazel at least by point one, maybe even point one, five. Depending,

Scott Benner 13:32
you know, what's interesting is that I know this isn't like any kind of hard and fast rule, or it is, and I've found that by mistake, but I talked to a lot of people with kids, you know, younger children. And it seems to me that the rule of thumb is point one per 10 pounds of body weight with kids. I don't know, I don't know if that ends up working for adults or not. But the more people I talk to, the more I see, like that's what makes sense. And I don't know if it's an anomaly for me. But when you have somebody on a phone call with you, which you know, telling telling you something about themselves. And it's like, you know, I'm doing this and it's not working and blah, blah, blah, and you need somewhere to start like it doesn't you don't even you need somewhere to start. And I always ask like, well, how much do they weigh? And most the time it bears out but then recently I spoke to somebody, it wasn't even close. It didn't matter. The weight was unimportant that that child just did not use the insole in the same way. Right.

I think of bazel in a completely odd way. I think of it like volume. Right, like on a on a stereo. And I just think if you can't hear it, or if the base is not working, turn it off. And if it's too loud, turn it down. And because Arden's using, you know, a dexcom, g six, I, I just turned it up until she gets where I want to be, and then I dial it back a little bit. Is that a bad thing? Am I doing that wrong? Is that is that irresponsible? Which by the way, in the last 10 years has become a word again, I don't know if you know that. You're irresponsible. There was time grammar people would be like, that's not a word. You can't say that. And all the sudden, it's been come acceptable in like the last half a decade or so. So now I feel comfortable to speak improperly again. So you're responsible? Is it irresponsible?

Jennifer Smith, CDE 15:47
irresponsible? Well, I actually use that word with my six and a half year old all the time. So I guess I've been using it more appropriately now. And I thought, yeah, that is irresponsible to do that. Do not do that, you know. So,

Scott Benner 16:03
anyway, I

Jennifer Smith, CDE 16:04
don't think I don't think that that's irresponsible. I mean, you're doing again, and again, in the topic of bazel, specific adjustment, we talking about temporary bazel adjustment, we do that a lot, to dial it up to dial it back to kind of you know, and that's also the concept of looping, right, is that the system works according to what it sees happening to the blood sugar and the insulin that's active in the food that's active, and it may dial things up, and it may dial things back. So that's, I mean, definitely not irresponsible. When you're talking about setting through bazel, though, we really want to make sure that we set the the bazel rate itself in the profile the right way, and you can dial it up, you know, if you want to be truly bold with insulin, you may want to dial it up a little bit more than you think you may need do another bazel test, and then it doesn't work quite well, because now you're ending up lower than you want. And great, just dial it back a little bit in the adjustment that you made. But at least it'll be a better picture. Um, you know, overall, and you can always test over and over again. Most people hate vehicle testing, myself included.

Scott Benner 17:17
Listen, that's I remember getting the sheet of paper handed to me when Arden was two, and they're like, the first thing we're gonna want to do is bazel test. And I looked at the sheet like, Well, I'm not doing any of this, but okay, and you know, looking back, it really should have done it, you know, especially back then when there was no CGM, and you know, none of that stuff, and I really shouldn't have done it. But, you know, no food being digested, you know, no active insulin, like, how am I going to get like a little kid not to eat for five or six hours? And I did eventually figure out that overnight was the place to begin. And you can, to some degree, infer the daytime from the nighttime meaning meaning, you know, if it takes a unit an hour overnight, you're probably not five units an hour during the day, you're probably somewhere near that unit. Right. Right. Right. And it could be I mean, it could be significant i right now Arden is more like a unit overnight and more like two units during the day. Right. So in, but that also will go back and forth. The just, just I will say this, because you you alluded to it earlier, and you were just talking about the idea of bazel testing, like I know a lot of you don't want your blood sugar to be 180 or 200 overnight. But for this test, maybe that's what has to be, I'm really coming to realize that an incredibly flat line one that's 85 for 24 hours a day, is really not reasonable. It's doable, right? And sometimes you'll get it and maybe you'll get it for days in a row if you're really dialed in. But you can't be upset if a blood sugar goes to 160 for 45 minutes and comes back again. It just my blood sugar goes to 160. Like if I sit down to play two pancakes today, my blood sugar is going to be 160 probably for a couple of hours now. different situation, right? And I don't have the other impacts of Type One Diabetes like people with type one, two, and I get wanting to limit it. But everything we've talked about on this podcast for the last number of years, I've seen it intersect with Arden becoming an adult. And so do I think you can keep a 90 blood sugar forever if your kid hasn't hit puberty yet? I bet you can. Right? I think it's super easy. I think that when you get to puberty, I don't think you should beat yourself up if that doesn't happen. And and I can still do it most times you don't I mean, like don't get me wrong. But I don't know. Like it's it doesn't seem as important to me. It almost seems like a video game. Now when I step back, and I watch people online, do it, for instance. And they're like, look at this graph, and I'm like, That's amazing. And then there's part of me that wants to say show it to me 10 days in a row and then I'll get excited right like don't Just show me one in the middle of May and go, Hey, look what I did here. And that's why, you know, on my blog, I tried to put things up that are like, Look wrong, everything went today, Arden say onesies still under sick? You know, I don't know, I just I want you guys to realize that we don't want spikes when we get them, we want to bring them back down again. But if they happen, you cannot run around like you've lost some, you know, game that that's attached to your mortality somehow, you know if your blood sugar is always 200 Yes, but you know if it jumps twice, come on, like ease up a little bit. Okay, right. So how reasonable is it that once I bazel test, I'm actually going to know what my basal rates are. Normally, I tell you about the dexcom g six continuous glucose monitor about the share feature, you know, you can see your kids blood sugar when they're not home. Or you know, if you're an adult, and you'd like your parents still or a friend to be able to see it, you know, sharing files amazing. It's available for Android and Apple and blah, blah, blah. And you should do that. Wouldn't you be great if you could see the direction of your blood sugar and the trend lines and how fast your blood sugar's moving up, down all that stuff that you hear me talk about all the time, hundred percent true, but with the time that's left in this Dexcom ad, I'm gonna say this year, you are listening to the bazel adjustment episode. By now if you're still listening, you must believe how important it is to have your basal insulin correct. And while you can do it without a dexcom It is so much easier with one I mean, oh my god, it's so much easier. Go to dexcom.com Ford slash juice box to find out more about the Dexcom g six continuous glucose monitor. Let me sweeten the deal by telling you this story. It's summertime now Arden's home from school. Last night, she was up facetiming with friends from all over the country. And they were up way too late. So Arden needed to sleep in today. She slept till 130 in the afternoon. And I was able to keep her blood sugar from going below were high. While she slept all of that time away. All that think about that

6am 789 10 1112 one, no food, no intervention, just the information from the Dexcom to help me make decisions about her basal insulin. And those decisions kept her blood sugar between 70. And you know, 120 is where we get I alarm. But honestly, I never saw over about 95 dexcom.com forward slash juice boxes, links in your show notes at Juicebox podcast.com. Get started today. But before you do, let's talk about on the pod, the only tubeless insulin pump in the world, the insulin pump that my daughter Arden has been wearing since she was four years old to 11 years ago. And it has been nothing but the best friend we've ever had in diabetes. last day of school, Arden went to a friend's house to go swimming, had around the pot on last night, need to make an adjustment to her blood sugar picked up her PDM button button button. Just like that No tubing, she's laying in bed facetiming she's not wrapped in tubing, she doesn't have to bounce her controller on her head or stick it in her pants that doesn't exist on the pod was over on the dresser right there. just just just there, just reach over and grab it, push a couple of buttons, give yourself some insulin, take some insulin away, maybe a Temp Basal decrease. I don't know what you're doing. But trust me, whatever you're doing, you want it to be easy, and you want it to be good. And you want it to be wholesome and fulfilling and make your life better. And that's exactly what on the pod does. The best part is on the pod wants to send you a free, no obligation demo, they call it a pack a pod experience kit, they'll send it right to you right to your house. So you can try one on the pod for yourself before you make any decisions. My omnipod.com forward slash juice box or the links in your show notes or Juicebox podcast.com. No more ads, talking about basal insulin the rest of the way.

Other times I bazel test and then I don't have any better of an answer.

Jennifer Smith, CDE 24:05
There might be especially if like I said before, if you're doing some bazel testing, and there are variables at play that you didn't really think to pay attention to in that time period, then absolutely though that bazel test could be not very purposeful. It could be kind of null and void. And this is something I encountered a lot with women. And something I bring up when I work with them to begin with. And in a first visit is one you said you've done beta testing, but to see you know your cycle impact if you have one and two Did you bazel test in that sweet spot of like two to maybe three weeks whether women are on birth control or not. They're sort of like this two to three weeks of sweet kind of plays of management without significant hormone impact. And that's where beta testing used to happen. It needs to happen without the impact of Pre cycle or oscillation hormones kind of coming into play. So if you haven't been tested in those sweet spots, and you're completely wrong, what's happening and what your basic needs are. And once you do have that sweet spot to put into play, and other, this is an important piece that a lot of people ask about too, is great. So then I need to test in these other times, well, that really, you know, what we find is that women mostly need like a 25 to maybe 40% increase in a hormone specific time period of the month. If you know that what you can do is use the Temp Basal, ie How well does this work? And what you can do because the time periods during the day that your Basal goes up or down, physiologically, those times will remain pretty stable. Those shouldn't need to change, it may be that you just need 25% more between 6am and 10pm. Right. So you can plug that into a bazel profile, set it and turn it on or enable it when you need to. But those time periods of the day, they stay pretty stable. Once you've designated Oh, my basal needs go up at 2am. Up, they shift down again at ADM, they're pretty stable until four or 5pm, they might go up or down again. Another piece for bazel testing is that most most people, again, your diabetes may vary. But most people will have about Orwell, most people have one Valley and one peak to their bazel during the day. So let's say they start midnight at point six, it might go up to point eight by two or 3am. Maybe it goes down around 8am 9am to like point six again. And then through the day, it's phase kind of lower, and then it may shift back up into the evening time. Okay, so you kind of had one dip, but one rise through the course of a 24 hour time period. Again, that's most people, not everyone. Most people also have about three to five basal rates through the course of the day or bazel time periods. So, you know, midnight until 6am 6am until 4pm 4pm to 9pm 9pm to midnight, those time blocks. Most people have about three to five different segments of rate need. Through the course of a day,

Scott Benner 27:25
you have to stay flexible too. You can't just say to yourself, look, I've set this basal rate, it starts at 3pm, it ends at 7pm. It always works. And then Thursday comes in at five o'clock your blood sugar starts to drift up, and it won't stop drifting up. You can't lock yourself into that doesn't make sense because my bazel always works. It's not working now. And the reasons you know, I'll be talking about this throughout the years of the podcast, but the reasons are almost unimportant in the moment. The truth is your blood sugar Yeah, yeah, right. You need more insulin, use more insulin. And and I've come to start, I've begun to start saying privately that that the diabetes, your blood sugar, it's requiring more of you. So give it to it. You know, he's telling you something your blood sugar going up is is your body's saying hey, I don't have enough insulin. Don't like wonder why just believe it. You know, like, there's no reason to, I don't know, if you came up to an intersection. And there was a cop standing there with his hand up it says don't go around the corner. There's a guy with a gun there. Just believe the cop and don't go around the corner. There's no reason for you to peek your head around the building. Oh my god, there is a guy shooting there. Like just take his word for it and walk around the block. And so. So when your diabetes is telling you, Hey, I don't have enough insulin, just believe it and give it more insulin. I got this beautiful note this morning from someone who said they were listening to the last episode. And she said, I think she called it like a bat in the head moment where she was just like, oh my god, I'm an idiot. Why am I not using more insulin like like, you know, running around all day looking at her blood sugar going, what's wrong? What's wrong? What's wrong? What's wrong? And she said, We must have said something on the podcast. And she just was like, oh, but sometimes that that happens like because you get so narrow, focused on the things that are supposed to be happening, that you can't break away from them for a second and look at actually what's going on. You know, listen, this is good life advice, too. If you're fighting with a spouse or a girlfriend, and you're saying to yourself, I have the best intentions here. Why is she upset? It doesn't matter. She is you know, so you're doing something wrong. Forget figuring out what it is. You're wrong. Stop or you're wrong. Right. That's it? Yeah, I've given you a number of ways to think about this. Now, when your blood sugar is going up. Give yourself more insulin. As a matter of fact, Jenny my next t shirt is going to say more insulin. That's the next t shirt. I'm going to print if I can ever figure out how to have one absolutely deserves a T shirt. All right. Everybody's always like telling me it's so easy to print t shirts. How can you not figure it out? It's like I'm very busy. Leave me alone. But I'm trying. Anyway.

Jennifer Smith, CDE 29:59
Yeah, I do. That's also a really good point. Because if this is where you could also say, is it a trend now? It Like you said, 5pm, my blood sugar is going up. I don't know why I don't have any active food. I don't have any active insulin shouldn't be going up. I felt like things were pretty good up until today. Great. Well, you know what, tomorrow if it's happening again, the next day, if it's happening again, something shifted. Why? Again, don't play with the why I mean, you can go back and evaluate and look at some things and whatever. But in the moment, you say, you know what, it looks like my blood sugar starting to go up by 435 o'clock every day, and I'm high by six o'clock and I keep adjusting and correcting. Don't do that. Right? adjust it, make an adjustment and go forward. And then you know, what if it shifts back down, right? If a couple of days, you're ending up low, then you shift it back down again?

Scott Benner 30:50
Yes. See, you're you're highlighting something that I've never understood when people say to me how many days till I think it's a trend, and I should change. And I'm always like, Who, what, like by the time you by the time you suss it out three days later, it might go back again, now you've given away three days of your blood sugar at that level, get just learn. Don't ask your wife Are you really gonna wear those pants, like she doesn't like it when you say that to her right leg, Sue, so stop and don't don't do it again, like, my blood sugar went up at five o'clock, I did something about it. Tomorrow, it went up at five o'clock, I did something about it. The next day, I'm not even letting us get to five o'clock, right? I'm just gonna decide, I'm going to expect that what I know is going to happen is gonna happen. And I'm gonna deal with it ahead of time. And if it happens to not go that way, well, then I can dial it back again. But it's so much easier to ramp up your insulin and bring it back than it is to sooner than later.

Jennifer Smith, CDE 31:46
Many times doctors will say, Hey, you know, follow a trend over the course of a week, well, that's five to seven days, then that you have chunked out higher or potentially lower than you want blood sugars, because you're trying to find a trend. I mean, in pregnancy with the women that I work with, we say two days of a trend, we're making an adjustment. And you know what if we need to dial it back again, for whatever reason, we will, but we're not leaving things travel higher or lower. For more than that time period, we will adjust and then we'll adjust again,

Scott Benner 32:18
and for all of you who have ever said to me, yeah, I'm going to handle that the next time I go to my doctor three months from now, you make my brain hurt when you say things like that. Okay, just please do not wait three months to address something even. I just yesterday, had a person who won a giveaway that I did with dancing for diabetes, and they you know, we had a phone call together. And this person, this is great. A person in their 60s who decided to get a CGM and a pump and you know, very excited for themselves. And then she said, You know, I have a doctor's appointment July, I said, No, no, don't wait till July. I said, write an email right now. Hey, Doc, guess what, I'm getting a dexcom g six, and I'm getting an omni pod. Go ahead and send those prescriptions in for me, I want to do that right now. And when we get I'm excited to come to you in July, and I'm going to bring my new stuff with me, you can show me how to do all of it. And I said if you never make it there to show or maybe you figure it out on YouTube or somewhere, whatever. And you know, and and, you know, but or maybe they'll send a trainer to your house. I think that is the appropriate thing to say right? And and but but I was like don't wait till July. So because July is six weeks from now, six weeks from now you're going to tell the doctor what you want. They're going to wait a week because people don't do things right away for you. They're going to send in their prescriptions for you, then you're not going to get this pump for six months. If you get that like start today. Go right now. Be proactive.

Jennifer Smith, CDE 33:38
Yes, with technology the way that it is and electronic medical records and things like my chart and things that you can send back and forth. There is no to not communicate between with a doctor and you know what if you don't get a response from them within 24 hours, you call that office and you ask to talk to their nurse and you say this needs to get to the doctor needs to be saw and it needs to be taken care of.

Scott Benner 34:01
Arden's endocrinologist and I have been adjusting her Synthroid are just taking Synthroid and site ml now and we've we've been making adjustments by email. But what's taking and it's still taking a long time to get it straight. Imagine if I only made the adjustment every three months when I saw her art, it would be like a puddle on the ground. When Arden doesn't have enough Synthroid. She can't pick her head up off of the ground. She just slumped over and she's like, her blood pressure, her blood pressure gets incredibly low. And she looks like she's dying the whole time. And and so once she has more Synthroid, she sits right back up again. It's it's literally like grabbing a marionette bytestrings when she has an Synthroid. But if I had to only make adjustments to her medication quarterly, it might take us two years to get it right. And we might never because she's growing and gaining weight throughout that time.

Jennifer Smith, CDE 34:53
And think of her education in this time period to what would she be getting out of her classes and the ability to perform And any athletics that she likes to do and enjoyment of fun with friends and everything. I mean, that puts a major cramp in any age, whether you're a child or an adult trying to perform in work or whatever. I mean, any adjustment, it needs to be addressed in the here and now not waiting three months to say, Oh, well, Doctor, you can see my is such a child. I've been having a lot higher blood sugar's I didn't know what to do. But I knew I had an appointment. So I waited until I came at that.

Scott Benner 35:30
Yeah. All right, Jenny. We're standing in front of your house. And you had your garden hose in your hand, and your porch caught on fire. Would you stand there with the hose thing? Or the fire coming? You'll be here soon. I don't need to squirt the hose at this porch. Why would I do that? The fireman is coming. He's a professional. I'll let him handle just hold the hose. Get started

Jennifer Smith, CDE 35:49
with my hose.

Scott Benner 35:50
Yeah, why don't I just see what I can get accomplished here. All right. So bringing this all back to your baseline slim, because no one thinks about their basal insulin with nearly the importance that it is I spent the first 10 minutes of a conversation the other day explaining to a person what it was. And after I explained it, I had to explain it again. And and so and you can still hear people go so that's the level here like people on empty out there like so. And I get it like they're newly diagnosed maybe sometimes, or they never got a firm explanation. But we treat basil insulin. Like it's not important. And it's everything. It's it's so much more important like it. Can we say it all the time. Everything starts at bazel phaselis not right, nothing else works coming off of it.

Jennifer Smith, CDE 36:35
Well, and so many people think that bazel job is to bring blood sugar down. Right? Oh, many people I mean, people I've worked with who've had diabetes long term who've come in and you know, I look at their records to begin with and they are confused and annoyed that their basal insulin isn't letting them wake up at a target blood sugar. I just stay high all night long. Well, you're starting the night high. So something I mean, time chunks of the day. Usually where you are now it's because the hours ahead of that. Something isn't right. Yeah, it's not the here and now. It's the what happened before this that got you here. So let's look I wanted my diesel should is here, here and here. And it should be bringing me down. No, that's not fatal job Faisal. dabit. The whole just it if you didn't eat all day long, you shouldn't have much.

Scott Benner 37:24
Diabetes is like a time travel movie. I've come to think of it this way. Right? Like it whatever is happening to you in the moment when the cameras pointed at you has nothing to do with what's in the frame with you. It's not a it's not a murder mystery. It's not somebody stabbing you and going, Oh, this is what's happening right now. It's the guy in Act One, set something down on a table and enact 325 years later that thing is how come you blah, blah, blah, blah, blah. There are things in the past. And there's decisions you're making right now with your diabetes that are going to affect you in three hours, or six hours. And and it's not now so much like it's interesting to how people overreact to the idea of Pre-Bolus Singh originally, because when their blood sugars are out of whack when they're really first starting to get things together, and they're jumping up and down. They're so reactive to everything they see I did something and then this happened. And I always tell people, if you Pre-Bolus and two minutes later, your blood sugar starts dropping that has nothing to do with the Pre-Bolus nothing. That's why when you know when you guys hear me say Arden's blood sugar was at five and I Pre-Bolus there. Because she was stable at five for three hours, the Pre-Bolus isn't going to start working right away. I only needed her to get to lunch 10 minutes later.

Jennifer Smith, CDE 38:38
The only reason it would start working right away is if you physically had that canula in a vessel. Right on it was literally going right into the van tapping into her bloodstream. Right?

Scott Benner 38:48
So in normal situations, which Jenny's bringing up, probably because she knows we actually had a pump. Probably Nick a vein in Arden one and for two days. I couldn't we couldn't get her blood sugar to go above like 50 most of the time, until we finally just changed her sight and everything went back to normal. But that was anyway that had never happened before. That was crazy. For the I'm texting Jenny, like you should have seen that texted Jenny, I sounded like you guys sound but you email me I was like, I don't know what's happening. I wasn't with her. I was in Florida doing dancing for diabetes. My wife's at home going? Seriously. This is what's happening when you leave. And I was like, I don't know how to explain any of this. I said I've looped in Jenny, we're gonna figure it out, you know, but, but anyway, yes. The point is, is that timing of your bazel just as important as the amount of your bazel. And to Jenny's point, for those of you who are thinking that bazel is in charge, you're bringing your blood sugar down. It's not it's in charge of keeping your blood sugar stable. And I say all the time, it's a stupid thing. But do it with me here. Unless you're driving. Hold your hands together in front of you like you know in like the classic, you know, prayer prayer motion, right. Imagine yourself Body function and, you know, sugar on one side and your and your and your bazel on the other side, and they're both pushing each other towards the center. And when nobody wins, right, when your hands don't move to the left or your right, that's a good basal rate, when you start moving towards body function, then your basal is too high, and when your body function starts pushing you away, then your basal is too low, you're trying to just give the bazel enough strength to fight off the background things that are happening in your body. If, right, and when you eat, you know, a reasonably normal meal, that bazel should also, you know, help with your Bolus. But don't expect that if you're going to eat like an entire pizza that your point six bazel rate is going to be okay. Because it's not. And then so that's, that's another thing. So once you get done bazel testing and figuring out your bazel for all your normal times when you're just standing around being you amazing you. That's one thing, what about your basal insulin while you're eating? And those tests have to happen in real life, while you're eating? You have to say to yourself, when I eat a salad with a burger, my blood sugar tries to go up. I wonder what would happen if I did increase my basal rate during that? And you know, I mean, for those you've been listening for a long time

Jennifer Smith, CDE 41:15
or after that

Scott Benner 41:16
we're right, right, maybe it's pizza, it doesn't hit me for 90 minutes after I've eaten it, you know, or any other thing like French fries, or had french fries the other night, it must have made her high like four hours after she you know. So

Jennifer Smith, CDE 41:29
it's not the nothingness is understanding again, that's why we also start with the overnight test it because if you can wake up in target, you are not fighting being too low from excessive insulin dropping you and you're not fighting being too high and having to correct and add insulin in a time that you're most people are insulin insensitive in the morning, right. So we talked about things like adding fat in Yes, your background bazel. If you know it's solid and set to begin with, then you know how to play with that temporary bazel feature to accommodate for long term impact like that, that causes essentially a stress factor, it releases triglycerides into the bloodstream, which causes insulin resistance in the aftermath, it can last as long as 10 hours after eating high fat. So most people need a bazel increase. It's like fat almost causes your basal insulin dose to be reduced by 50%. So if you're running at a rate of 1.0, overnight, and you have this big ol awesome like cheese, meat lovers pizza night, you go to bed thinking man, I nailed that Bolus, I'm going to bed beautiful. I'm like a 103. I'm going to sit here all night, it's going to look awesome. At two o'clock in the morning, you're at 300. And you're like, what the heck, you know, where did this cut, its fat, usually fast starts to impact by about three hours, you get this like drift, and then you get stuck by and you nail it with insulin and you nail it with insulin and you nail it again. And then finally you might start drift down. By the time you wake up the next morning, you could have fought it ahead of time by using a temporary rate adjustment. If you know your bazel to begin with is set Well, you can increase using temporary bazel and offset the impact of that

Scott Benner 43:12
fat. I wonder if I can explain what's in my head correctly. Because when your blood sugar gets elevated, imagine it's 250 coming off of the pizza and you think oh, a unit brings me from 250 to 100. So I'll put it in a unit. That's great. But what Jenny just told you was you're at 150% need for your Basal. So the unit really just keeps replacing the bazel you don't have. So you put the unit in, replaces the bazel keeps you stable at 250. But you still haven't addressed the number. And so then you wait an hour and you go I can't believe that didn't do anything and you put it in another unit. It doesn't do it again, because you're still just replacing the bazel you need a yak up your basal rate and Bolus for the number. And remember, the turning up the Basal at midnight doesn't make doesn't mean it's going to start working really maybe until one or two o'clock in the morning. So what So in the end, let me get very close to the microphone. What you need. And I don't want to oversimplify diabetes is more insulin. That's what you need. You do not have enough insulin. It's your union that T shirt. I'm talking right now. I can't do this podcast forever people more insulin if your blood sugar is high. Hey, if your blood sugar is low, guess what? Let me just go at it right now. Less insulin. There you go. It's not difficult, right? It's difficult to imagine the whole thing, which is what this podcast episode is about. Like we're talking through a number of different scenarios where your basal rate means something. But I think that i think that's it at the beginning here. Jenny explained a more clinical way to do basal testing. I think if you have a CGM. I tell people when we're speaking privately, and they're like, how do I figure out you know, how much more bazel to use? I just go well, you know, if it's a kid and they're like, at point three, I'm like, well turn 2.4 and see what happens. You know, and as they start getting low, Put it 2.35 you know, and it has because your kids blood sugar's sitting at 200. You know, like, with point, you know, point three going in every hour, point four is not going to make them nothing, it just doesn't stand to any reason. Common Sense and diabetes is, you know, just like I tell people all the time, one of the best pieces of technology for managing someone with diabetes is text messaging. It is a absolutely, like pivotal way in how art and I deal with our blood sugar if you don't, if text messaging is a is a diabetes tool, and it the same way, right? Just trying things is a diabetes tool, like give it a shot and see what happens. You know, point four, Okay, now let's see what happens. Not enough. So

Jennifer Smith, CDE 45:46
even for little kids, you know, even the incremental of the smaller rate, you know, the point 05, or the point 025. You know, all of that is an option. It's not an omni pod, but it is an option on the tandem in the Medtronic pump. So that is an option to get smaller, incremental adjustments, depending also on what your sensitivity kind of seems to be. I think the only thing that we didn't really is like the daytime testing, honestly, you know, daytime means that if you really want to know what's happening behind the meal, to make sure that the bazel is doing its job, the meal can't be there, right. So if you wanted to look at morning time, you really have to, for adults, you can skip a meal, because you can deal with that. You can just you can slug it out until lunchtime, and go ahead and eat your lunch and just see what happens in the morning when you wake up. You know fasting blood sugar, you let it sit you don't bolus you don't take caffeine, you don't eat anything. You can have water, herbal tea, or whatever. Don't go for a 10 mile run either. Look at what happened. Oh, kids, I usually say you know what, if you can get them to sleep in a little bit longer, maybe on a weekend, at least you're going to get an idea behind what their normal breakfast time is in that morning time to see did the bazel carry them pretty well, or what I had one mother I worked with, not too long ago. She's like, he woke up and he just started playing with his Legos right away. And he played with his Legos for a long period didn't even care about eating breakfast. I'm like, awesome. Yeah, that was a bazel test. I was like, there was nothing there. no food, no balls, he was sitting and playing with Legos. Fabulous. We've got information.

Scott Benner 47:28
That's cool. That's excellent. Yeah, whatever you can do, just just but do it. Because you need to know. In the end, if you've ever spoken to me privately, what I'll tell you is, in a perfect world, if your Basal is right, your blood sugar is gonna be 90, it's gonna be 85 or 90. Now, I don't expect it to always be that. But that's your goal. And if that's your goal, then it's when you're at 150. It's not correct. And also, when you're bouncing all over the place. If you're one of those people who right now is struggling and your blood sugar flies all over. You may turn your bazel up and get a low blood sugar and think oh my gosh, that's because I turned my Basal up. But it again, it might be about the Bolus you use before. So you know, there's one thing I say all the time. That I think is how you start your Basal rates. First thing you have to do is find a level, just find a stability point hasn't really almost matter where it is just get your blood sugar to sit still. And if you have to nudge with food, to do it, or nudge with insulin to do it, it's fine. Get stable somewhere and start over even when things go crazy here. I'll say that the Kelly I'll be like, Listen, I said we're out like everything's out of whack. Like we got to find a stable points where we can start over again. And you know, you just can't I don't know. It's like It's like trying to catch up. It's like trying to catch up on you know what I mean? Like he you gotta wait till it lands. Anyway. All right, um, do you feel like we've covered it?

Jennifer Smith, CDE 48:53
For the most part, I don't think

Scott Benner 48:55
we have to. I appreciate everyone who reached out and asked about a more specific episode about bazel testing. This was it. I hope you liked it. Goodbye, Jenny. Ah, thank you for listening to the 11th installment in my diabetes pro tip series with Jenny Smith CD. Don't forget that there are links in your show notes to email Jenny or you can go to integrated diabetes.com if you'd like to hire her personally, and have these conversations private like with her. Thank you also to Omni pod Dexcom and dancing for diabetes for being such wonderful advertisers. And sticking with the show weekend and week out really makes it possible for you guys to get the show. And I appreciate honestly how easy they are to work with. You wouldn't see that behind the scenes but they're good peeps. If you just found this diabetes pro tip episode, go back and listen to the rest they start around Episode 210. Also something new you may not have noticed last Friday, I began to post a second episode of The Week called defining diabetes. In the short episodes, Jenny Smith and I will define a phrase from your daily life with type one diabetes. If you're a subscriber, this extra episode will just show up like you're used to seeing everything else, it will just populate your podcast player, you can listen to it whenever you want. Thanks so much for listening. I hope you have a great day and a better week. And a special shout out to all of you on Instagram who share the podcast so much there. It's amazing. Thank you so much. You're helping the podcast grow in ways that you can't even imagine. Before I go, I'd like to share something that I imagine that most of you who have been listening for a while understand. It took so much restraint not to call this episode Jenny's but but I did it. I'm an adult. And I use the diabetes pro tip series because that's what this is. But when Jenny said she made a bazel rate called but I was like oh my god. This episode should be called Jenny's but, or but bazel or Jenny's but bazel I don't know. But I just so hard not to do that.

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#231 Diabetes Pro Tip: Variables

Diabetes Pro Tip: Variables……

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

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

Scott Benner 0:00
Hello, and welcome to the next episode of my diabetes pro tip series with CDE Jenny Smith. This one's called diabetes pro tip variables. The episode is sponsored by Dexcom real good foods and dancing for diabetes, you can go to dexcom.com forward slash juicebox real good foods calm and use the offer code juice box to save 20% of your entire order or dancing the number for diabetes.com. To find out more. There are also links in the show notes of your podcast player, and at Juicebox podcast.com. In this installment of the diabetes pro tip series with Jenny Smith, Jenny and I are going to be talking about variables those things that you know, change, but impact your blood sugar. The stuff you don't always think about, like are you taking a medication? Is it allergy season? Has it gotten warmer outside or colder outside? Do you have road rage? Stick around Jenny and I are going to talk about it all. While you're listening. Please remember that nothing you hear on the Juicebox 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. Can I take a second to share something with you that I believe you have an incredible impact on. I'm talking about the popularity of this podcast. I'm looking right now at the total downloads for April of 2018. Versus April 2019. Back in April of 2018, I was incredibly impressed with how many people were listening to the show. And last month, three and a half times more downloads than the previous year. And as I'm editing this, and getting ready to put this up for you in May, I'm pretty confident that this month will be the most popular ever.

Easily surpassing April of this year, which as I said, is three and a half times more popular than April of 2018. So as we approach the 1 million downloads of the Juicebox Podcast, I have a small favor to ask of you that I really have no right to ask because you're already listening. And I love that. But could you just do me a tiniest favor, find one person who doesn't listen right now who's not a subscriber, a person that you believe would enjoy the show and introduce it to them, show them how to download a podcast app on their phone. Show them how to subscribe. And perhaps you know, just share with them a couple of your favorite episodes to get them started. My goal, of course is to limit the struggles and suffering of other people. You guys know how it felt before you found the show. I'd like it if you could help somebody else to get to where you are now. And with all the ads the asks and the excitement of the 1 million downloads out of the way. I think we should start the show. Hey, everybody, this is Jenny from integrated diabetes services. I understand a lot of you have been contacting me privately, which I think is a fantastic idea for any and all of you who are interested. Jenny, of course, has been doing the diabetes pro tip series with me. This was supposed to be the last episode. But I think unless Jenny has changed her mind, we are going to continue to add to this series throughout the year. Yeah, excellent. Jenny. I'm very excited about that. And today's topic is. So you guys don't really understand how all this happened. I wrote down what I thought were the tenants of the podcast. And I sent them to Jenny. And she put them in a different order and made changes to them. And she's like, I think this is how that this will work. And I was like that's great. And then we were supposed to Oh, well. You know what I was thinking Jenny's? We were supposed to record basically a like a menstruation episode but i think i but i think it fits really well into your idea for today, which is variable. So I think we're going to combine the two of them if that makes sense. You agreed? Excellent. Okay. Why don't you tell people what made you reach to me and, and suggest this

Jennifer Smith, CDE 4:05
the word variable brings in the whole topic of discussion, right? I mean, we're taught from the get go there are three main factors that really you know, you get educated about is impact on your overall blood sugar control. We've got an I kind of call them like the triangle of management of what you're told about to look for effects. Exercise, the medicine, you take and type one of course insulin Sometimes though, with the changes in some of the medicine now for type one use could be other medicines. And then you know, the third one is food. So you got exercise, medicine and food and you know, if you contain all of those, you're going to have diabetes success, right? If you just learned about all those little pieces when they're only three, so you're going to do awesome. Well, that's like baloney.

Scott Benner 4:57
I think there's so many more factors. To consider so many more variables or like icebergs, right? That can kind of come through the course of your day. I mean, some of them, you can sort of head off, you may know that they're coming if you know, to look for them, and that they could have impact on blood sugar. Again, the short list that I kind of came up with just to talk about today, cuz I know, we don't have like, four hours to discuss everything, I think I came up with, like 10 or 12, you know, variables that I could really think, affect most people, and that you really should consider. So, you know, I'm sure that you probably have some variables that you know, just with what you've seen with your own daughter's management, right? Absolutely. And, and to kind of tag on to what you were saying, I found myself this past Saturday at the dancing for diabetes touched by type one event standing in front of people telling them that insulin timing is the seed of the tree, that is your management. And as long as you know, we can always go back to that as the base is the root, right? But then eventually, you know, that seed grows a trunk and the trunk grows, branches, and the branches, grow leaves. And all of these different parts of the tree can affect your blood sugar and will sometimes, but you can't get caught in a problem. And staring at the leaf on the 77th branch and wondering what is that leaf doing to me right now, even though it is doing something to you, it's I like to look back afterwards and say what happened there and try to figure it out. But in the moment, as we say, here on the podcast in the moment, it just means you need, you know, you need to change, yeah, adjust, right, maybe that means more insulin maybe means less. The idea that bazel insulin is insulin too, and we always forget about it, everyone wants to set their bazel. And then think about Bolus, which just doesn't work, you know, you have to think about the timing of all of the insulin. And when one of these bazillions of variables comes into play, some of them being more constant in your life than others. They have requirements. And they require of you to, to resist, right? Like you can't just, you can't walk through a day when you're premenstrual maybe the same way you walk through a day when you're not. Oh, right. And so go ahead. Give me your first one. What's your first good one off your list?

Jennifer Smith, CDE 7:22
Cool. My first good one actually takes into account the three that I mentioned, right? exercise, medicine, and food. Each of those seems like a simple like one topic blurb word, right? It's if I figure out the medicine, but you brought in a good factor, it's the dosing the timing, the consideration of the medication itself. And again, with more medication being added to the list of potential use, especially with type one, you bring in more variable there. And so with the dosing and the timing, it takes evaluation, so that that variable can be I guess, better known for you. Again, you know, we all have your diabetes may vary, right? We all have our n of one life with our insulin that we use, and we learn how to dose it, learn how to time it. So that's, you know, one and then the other two, exercise has a lot of variables to it, you get the blanket statement from a doctor who says, just take your pump off or just, you know, do a zero bazel if you're gonna go and exercise. The world of exercise is not that simple with diabetes, but if anything, there are a million variables within just the topic of exercise if you consider you know, slow movement, like when I take my dog out for a 20 minute walk and he stops me pees in sniffs everything. My blood sugar could drop 50 points from just a dog sniffing walk.

Scott Benner 8:50
sniffing walk not to be confused with the brisk walk

Jennifer Smith, CDE 8:53
with a brisk walk. Exactly. So I mean, you know, things like that are all you know, going to like Disney World to walk around all day, that slow, consistent movement, you wouldn't count as exercise not like going to the gym and huffing and puffing and sweating to death. But it's a variable that in my experience, I've found I need to reduce my Basal about 20% for the full extent of the time that I expect to be at like a Disney park or someplace similar.

Scott Benner 9:23
Can I ask you a question about that? Yeah, we always say that and then we never sort of not not you and I just people in general, we always say like, you know, exercise can bring my blood sugar down. In I don't want to go too deep into it. But why? My question is, when my body starts moving, what does it do that makes my blood sugar fall? Is it using the insulin more effectively? Is it speeding up the like, that's what I want to understand real quick. Those of you looking for a diabetes organization to support should check out dancing for diabetes. That's it, no big sell. I just think you should Dancing for diabetes.com that dancing the number four diabetes.com. I was at their event, a couple of weekends ago, I heard Elizabeth talk about how she started the organization. Her words just made me so proud to be there and to be supporting what she was doing. And I think you would feel the same. Just check them out dancing for diabetes.com. That's dancing the number four diabetes.com.

Jennifer Smith, CDE 10:25
Yeah, so the exercise piece, if you consider I like to refer to it exercises like free insulin, really, it's some types of exercise again, you know, the low slow to moderate intense exercise, you really looking those cells, doors on them have, you know, little locks, right, for the most part, we used to use insulin to unlock the door to get the glucose to enter. When we exercise, the body is sensitized to insulin, and those doors open freely, because your body wants to incorporate the glucose into the cells to get used and to energize the body to keep performing. So if you've got and this comes into the first, you know, topic of medication and the timing, when you're looking at exercise, the timing of insulin is very, very important. And the dose and what you're coming into that x active phase with onboard, that's just it's huge. You know, so if you're looking at going into a five mile slow Temple Run with five units of insulin on board from the Bolus that you just took, think again,

Scott Benner 11:37
sizing, I just spoke to an adult woman this weekend, who still play soccer, and she said, you know, the advice she got from her doctor was to take her pump off, and she said, but then my blood sugar goes sky high, and I can't play. And I don't want to do that. And I didn't have much time to talk to her. But what I said was, I said in a very basic way, that everything I say on the podcast, works for activity, you have to wrap your brain around it. But in the end, if you're using the right amount of insulin at the right time and taking into account that this exercise is going to happen, that's it. And it's simple to say, well, you just turn your basal back an hour before and during or something like that. And that may be the answer in there. But there's an answer in there. And that is you have insulin needs. During the soccer game, you have less insulin needs. So don't give yourself the dog sniffing insulin when you're playing soccer.

Jennifer Smith, CDE 12:32
Right. Exactly, exactly. So yeah. And then you know, so then we, you know, take into consideration the adjustment for exercise, but there is also exercise on the opposite side that may require more insulin. Yes, because of adrenaline seems like you know, those who lift or do a lot of resistance training, or do HIIT workouts, you know, the high intensity interval training, where you've got a little cardio but these really like short bursts of intense exercise in some of my first, I guess, personal informative about intense burst exercise for my blood sugar control was when I was starting to train for my first half Ironman and my training routine had some of the running as sprint Hill sprints, where I'd literally like fly up the hill and then sort of jog back down and fly up the hill. Well, you know, I adjusted assuming that I'd have the similar responses other exercise where I would adjust the insulin and whatever, man I was high. I was like, you know, but adrenaline, you know, research adrenaline is kind of a component there to consider. The weightlifters that I work with, tend to find that they need to dose insulin before a heavy lifting session, they might need to take a unit of bolus insulin, they may need to do a temporary bazel increase those kinds of things. So exercise isn't as simple take your pump off and go and exercise. That's not it.

Scott Benner 13:54
That's the do. No, that's do not die advice. That's advice that won't kill you. It's definitely not going to help you. Right, right. Exactly. And the example that I use over and over again, in my talks in here is the idea of Arden showing up for basketball at a great blood sugar and then running around which makes you think blood sugar would fall but then would go up. And then we figured out that she was competitive and she wanted to win the basketball game. So her gitelman spiked up

Jennifer Smith, CDE 14:22
and difference there you probably found from her game to her practices. Yes. Which is very common for any athlete who is in a competitive anything. I mean, I found that with my running races, I could go out for my nice runs and for my training and have great management knew what I was doing some of my first five K's man, I was astounded at the rise in blood sugar as soon as I got in the car to head out. Yeah,

it was like a drift off. It was like

Scott Benner 14:53
play competitive sports or have been around it this this might make sense to you. My son always echoes this back to me that it's true. He said, it's kind of impossible. They always tell you to practice like you play. And he said, it's kind of impossible to do. Because when you're practicing, the game's not there. Like, right like there's these the same intensity is not there the same desire is not there. You can't You can't duplicate the feeling a feeling like you're going to lose, or let someone down or lose your spot on the field or some something like that is like you can't you can't make that up in your head while you're practicing. No. So your your insulin needs will be different because your brain is thinking differently about what you're doing. Wrong. It's very interesting.

Jennifer Smith, CDE 15:37
Yeah, yeah. So those are, you know, all even the time of day for exercise could make a very big difference for how you strategize adjustment. I know my morning adjustment for exercise is very different than my mid to late afternoon or evening exercise. Very different just based on again, the sensitivity and all of that kind of stuff.

Scott Benner 15:56
So, and Arden, as an example, closes her eyes to go to sleep and her blood sugar goes down. It happens almost instantaneously. So it's not a huge job. But that girl goes to sleep and the I don't know what you would call it the day life. Right? The anxiety and knowing like a release of Yeah, she relaxes. And when she relaxes, her body's not forcing her blood sugar up in the same way. And it starts to drift down. Yeah. Wow. Okay. Jenny, let's on that list. Now.

Jennifer Smith, CDE 16:27
The next one, again, of the three, the third one was the food, right? And we think okay, and we talked about this in one of our other, you know, just master carb counting and you've got it like figured out you've got it totally nailed, you'll be clear and beautiful post meal blood sugars, right? Well, again, I kind of Kanan takes into consideration, type, amount, combination of food, what went into the meal, if you sit down and you eat, like, you know, a three cup jar of peanut, versus a three cup plate of white rice. carbs are there in both pictures. The coverage of them, however, is very different. So those variables that kind of come in with food, we know now, thankfully, in the past, I would say five D, maybe even 10 years, we've become much more aware. and educating people a little bit better about it's not just carbs, it is the fat it is the potential protein. And with some of the I say newer, they're not technically new, they just have gotten a lot more media is things like the Paleo kind of diet or the keto diet, those kinds of path plans or you know, eating habits, they require you to figure out the impact of the food in a different way than just carbohydrate.

Scott Benner 17:49
I know I think I've said here before, but I was with a person eating no carb at a meal. And we went into a restaurant sat down, hi, Vicki, Vicki ate food. I feel like we sat there for a half an hour and talked, we got in the car, we're driving away, and she pulled out her PDM for her ami pod and gave herself insulin. And I was like, what was F word she goes, the protein is gonna hit me. So that's it, that's it. I don't think she ate one carb while we were where we were. So different ways to wrap your head around different things. And I have it, you know, again, I just this is fresh in my head because I just got back from a talk. But there's a slide that goes up that says all carbs are not created equal. But you have to you have to write you have to believe that 10 unit, you know, 10 units away, I cannot talk about grams, 10 grams of rice and 10 grams of watermelon or grapes are not going to impact you in the same way or for the same amount of time. Okay, if you don't know that, then you'll struggle. You know, you can't just you can't just count your cars, put your insulin and eat your food and go away. If it worked like that. Well, then you're and this probably would need this podcast

Jennifer Smith, CDE 19:03
would be perfect for all that's exactly right. Well, and then the other factors, you know, that will kind of, I'll touch on as we sort of go on here. But factors of food impact, you may get many of your common things figured out as I think I said in one of the previous ones, you know, if you figure out the 2025 most common foods, meals, things that you eat, that's like 80% of your management, if you kind of nail those, figure them out from the protein, carb fat impact, awesome. But then we bring in all of these other potential variables, like you mentioned, initially, you know, the menstrual cycle for women. Well, you may have all those wonderful things figured out and then in comes the three to seven days before your period is supposed to start. And if you haven't been told that there is an impact on blood sugar, and you just think that gosh, it must be my insulin or it's a bad site or something crazy is going on, you get really annoyed and confused. And for women, that could happen every single month that you're getting annoyed and confused. And unless you start to track things,

Scott Benner 20:12
you'll remain annoyed and convenient. I try so hard to tell people, I don't want you too. I don't want you to completely forget about the possibility that your insulin went bad, or that your infusion site suddenly stopped working. But if your blood sugar was at all day, and then all of a sudden it jumps to 150. And it won't move. It's probably not your insulin, you know, but you see so many people, they hyper focus on the physical things, they think they can see that they that they can they can believe might be the reason, right? And I you have to be able to kind of look back a little bit and say, okay, it doesn't make any sense that my blood sugar was doing what I expected it to do. Suddenly didn't, why am I thinking of the pumps at fault? Like why am I thinking the insolence of fault that insulin has been working for a day and a half, you know, or that vials been working for two weeks, or whatever it ends up being? You really sometimes just have to think it's probably the stuff I can't see. And then I think and then I always think too, and then don't spend too much time on it. Bring it down, drop it. Yeah. And here's a great variable, say your candle is loose and you're leaking. And you're not getting as much insulin as you believe when you push the button. Still, in the end? The answer is, you're not getting enough insulin. The reason is mechanical. But the idea is still the same. If you were getting insulin, your blood sugar wouldn't be that high.

Jennifer Smith, CDE 21:38
Correct? Absolutely. And when we take into consideration, you know, cycle changes, if you start to track things as a woman, and you do have a cycle, and you're not on birth control that completely, you know, cuts your site off entirely, and you just don't have it anymore. If you're having a cycle, start to track things, because that's a good way to figure out some of that variability that a woman will have has nothing to do with the male at all diabetes management strategy. So if you're a woman listening, and you're within the time period of potentially having a cycle, and you're not postmenopausal, or anything, start to track your cycles and evaluate, usually, for most people, they see a rise prior to their cycles starting, as soon as their cycle starts usually needs dip back down, up until about oscillation for women can be anywhere between day 11. And day, like 18, give or take. That could be another rise in hormones, it's usually shorter, it's only about two or three days. And then things kind of drift back down again, typically before that three to, let's say, five days before your period starts again.

Scott Benner 22:49
So we have this continual roller coaster of hormones through the course of a month. And if nobody's kind of clued you in to pay attention to it, you may just feel like there are variables that you just don't know what's happening. It just seems random if you don't think I'm not aware that that's an impact. And they're, by the way, they're fantastic. I happen to know, trackers like different apps you can get for your phone to track your period with it's it was only a period tracker, there you go. And it was only uncomfortable for me like the third time I asked her Can I see the app that tracks your period real quick. You know, she said she was like, Okay, take it. But it really is spectacular. And in the end again, you need more insulin, you need less insulin, you need the regular amount of insulin, you know, once you recognize that it's happening, and you don't spend a day and a half wringing your hands wondering what's going on and you just stay fluid and do what it asks, then then then it's not a burden anymore. It's just I need more insulin, but our brains get stuck. You know, you and I talked about this before we started recording. But Arden's looping now and I'm seeing with her bazel, that how much more basal insulin the loop can use. And I thought back to when I used you know, I had ardens bazel, before the loop set up at like 1.4 an hour and to double it to 2.8 to me seemed like all the insulin in the world. And now I'm seeing the loop do it too, sometimes four or five, six units, and not for a full hour. But it's still it's I realized I was stuck in the number the idea of the number and that can happen to you too when your period pushes up your insulin needs. And you think that's crazy. Let you know on most days, I use 20 units all day between Basal and Bolus 40 is going to kill me. Well, it's not that day because your needs are different.

Jennifer Smith, CDE 24:35
She needed it. Right. Right. Absolutely. Absolutely. And that I think you bring into, you know, you lightly touched on, like the site or the pump or you know, those as being variables, but they certainly are. I mean, you have to know when to definitely address it as a potential site issue. You know, if you're in the time period of, let's say, your mom or your man and you shouldn't have hormone issues and you've got you been floating along beautiful for, you know, weeks and weeks and weeks. And now all of a sudden you've got this like, high blood sugar, you know, you're usually up to like 140, maybe after your breakfast, and now you're at like, 300. Clearly, that's not normal if another variable isn't there, right? So, you know, you address things you say I'm Hi, let's address the Hi, but why is it happening as well? Could it be the site, check your site? You know, those kinds of things? Could it be the insulin think about, you know, if it's brand new vial, probably not. But if it's a vial that's getting close to that, like, end of life, like it's almost empty, or you've, you know, you don't use very much insulin, so you're getting to kind of that 30 ish days, especially this time of the year and through like fall, where if you keep your open vial of insulin out of the refrigerator, temperature changes will affect insulin. So it's really an important piece to consider, maybe you just need to change the insulin out. So those as you know, potential site issues, the other site issues would be the site itself. Have you used this site over and over and over and over? And finally, it's gotten to the point of just you can't use me anymore?

Scott Benner 26:13
Why would you switch to a new site expected it's possible that you need lesson so and then you needed prior on the old practice? Maybe that sites working better? Correct. And for all my talk about don't beat yourself up about it's probably the pump it's probably the pump once you decide it's your it's your site, it's you know, it's the pump. And nobody bails on a pump site faster than me once I believe it's the site, you know, I'm like, okay, off gone. And that's that, you know, and you if you're newer to this, by the way, this all seems I try to bring this up on small talking about things on the podcast is an exploded view, right? Like you're really stretching things out to see in your regular life. It's not going to take the last five minutes a Jenny and I talked about this for you to make that decision. You know, you've heard me say before, like about cgms. People, like how do you know how you can trust your CGM? Like you can tell. They're like, What do you mean? Like sometimes it's 30 points off, which by the way, you know, 30 points off a 10 year old meter. I don't know why we're believed in the meter before we believe in the CGM, but neither here nor there. My point is, is that if you have some experience with this for a while, you know what's real, and what's a ghost, you know, and you can, you can look and say to yourself, alright, this is clearly the site, this is going, you can look at your CGM and say, I don't think it's possible. My blood sugar has been at three for six hours, maybe I ought to use my meter to see if that's right. And those decisions become very easy over time. You may be thinking, but Scott, you just got done saying that diabetes technology is not perfect all the time. Why would you put the ad for Dexcom? Right here? Are you aloka? No, I'm not crazy. I'm confident. And I love the Dexcom g six continuous glucose monitor. It is of course, at the very core of all of the good decisions that we're able to make moment to moment, day to day, week to week, year to year, we're helping my daughter live well with Type One Diabetes, nothing is perfect. But Dexcom is as close to perfect as you can currently get. The only thing that's ever going to be more perfect. Then Dexcom g six is whatever the next version of Dexcom is. I mean, that's my guess. Here's what you need to do. dexcom.com forward slash juicebox that's how you get started. You want the Dexcom because of its predictive nature, because it can tell you not just what direction your blood sugar is moving in sure it's going up. Yeah, of course it's going down. But how fast is that happening? Am I falling so quickly that I need you know, an emergency infusion of juice or some sort of a carb? Or is it just kind of drifting down? Am I maybe able to watch it for a second see what's gonna happen? Is my blood sugar jumping up right after a meal? Maybe I didn't, you know, use an offense on the things that you're wondering while your blood sugar is doing what it's doing the next context the Wonder out, it shows you it replaces wondering with wonder, like wonder like, you know, fireworks like whoo like that. Our results are ours and yours Of course may vary but my daughter's a one C has been between 5.2 and 6.2 for over five years, largely because of the information that we get back from her Dexcom g six, go to dexcom.com Ford slash juice box to get started today.

Jennifer Smith, CDE 29:30
You know another one that

is this time of the year in consideration of like insulin and viability and all that stuff. Another one that a lot of people don't realize is this time of the year of could for many people bring in the variable of allergy.

Scott Benner 29:48
Okay, how would so right just because because that's almost an infection

Jennifer Smith, CDE 29:54
causing yeah causes kind of like that histamine reaction in the body which causes an inflammatory respond, you know, that's the reason you get all Flemmi. And you know, bleary eyed and like whatever is coming out of you desperately to push out

Scott Benner 30:07
the dust

Jennifer Smith, CDE 30:08
push out the nastiness, right, exactly. I mean, unfortunately, my husband has nasty allergies in this time of the year. He's just like full of sneezing and like runny eyes, and you know, that kind of stuff and it stinks. But when you consider diabetes, insulin needs with this as a stressor on the body, we talk about stress as a variable to allergies could be a stress variable. And so your insulin needs may very well go up in this time of the year. Because of that type of, you know, setting now, if you use some medications to help deal with the allergies, it's always important as a medication kind of component or variable, check the label, or ask the doctor, make sure any of those medications that you may take for, you know, an allergy won't necessarily have impact on blood sugar, some of them have a steroid base to them. And steroids, as we know, will usually raise blood sugars as well. So you could have kind of double impact and medication impacting as well as the allergy itself impacting Do you have pain on your list? plan would be another stressor within that like, kind of body sort of? Yeah, absolutely.

Scott Benner 31:21
People don't think about but I've seen it happen so many times that you can't not trust I saw Arden get hit in the knee with a softball once. And her blood sugar immediately started going up and stayed up. State her insulin needs remained high for days while the pain in her knee subsided. It was a significant pain. Yeah. And so let me ask you if I have a headache, would that push up my blood sugar?

Jennifer Smith, CDE 31:45
It could if it's a if it's a bad enough headache, especially those who may have like migraine issues absolutely could be a variable. Sometimes too, you know with that as as effect. Sometimes if you notice the rise in blood sugar, you take medication to offset the pain itself. If the pain isn't felt anymore, blood sugar's should or could very well come down. And so you do have to be kind of cautious with the adjustment in insulin. If you're doing something to cover the pain, you may find that correcting the high blood sugar drives it down more than you expected, because you're not feeling the pain anymore. So

Scott Benner 32:23
funny. My next question was going to be to say I'm in a road rage situation. And because I'm all dialed into my diabetes, and I've got a dexcom I see my blood sugar goes from 80 to 140. I don't want a bolus right away, right? Because my bazel because that that burst of adrenaline is going to go away quickly. And then my base, my Basal is going to crush that number again, most likely,

Jennifer Smith, CDE 32:45
most likely, I mean, Basal never meant to essentially bring blood sugar down. But once the stressor is gone like that a quick impact kind of thing. Typically, your blood sugar should start kind of coming back down. And if it doesn't, it just means obviously that you are thinking about it and continuing to like dwell on the problems right? You have extra road rage

Scott Benner 33:05
is when

Jennifer Smith, CDE 33:06
you have extra road rage Exactly. Go home and you tell every neighbor about what happened on the way home and you know, you continue to perpetuate the issue. Bolus Ford

Exactly. Yes, exactly

Scott Benner 33:18
is a quick burst of adrenaline the same as a lollipop. In that it is it does hit you but that it can't sustain the rise. Is that a similar idea?

Jennifer Smith, CDE 33:29
kind of similar idea. It's kind of a good way to

Scott Benner 33:32
know something, you know, doctors used to and I I'm sort of against the idea of talking about free foods. I don't I don't really think there's free foods in general. But But I have seen it with Arden and I've always wondered, is the fact that like she put a lollipop in her mouth and her blood sugar went up a little bit and came down is that because a lollipop is a quick hit that goes away? Is it a free food? Or is it because I've got the balance over insulin so wrong that it's able to handle carbs? I haven't like haste to think about that when she was younger. Like Am I really like did that really not have an impact or like, you know how we talked about if you know, I was explaining to people this week and I said look you have to Pre-Bolus you can't be scared of it like insulin works the way it works. It does not work the minute you put it into your body if you Pre-Bolus and two minutes later your blood sugar starts falling the Pre-Bolus did not magically start working you probably

Jennifer Smith, CDE 34:25
were falling already

Scott Benner 34:27
yes you were falling already or you did something hours ago that is impacting now that you're unaware of. And I always wondered about that like when we'd give our like little bits of candy my jet was I just premature like what I just holding up a low that was coming anyway.

Jennifer Smith, CDE 34:42
Could be the factor and that's also a kind of brings up a good point while it's not really a variable but it might be if you consider it. Lows when you treat a low we recommend treating with simple sugar, right? When you treat with simple sugar, that simple sugar is really, its potential impact lasts an hour to 90 minutes. And thus the age old recommendation, if you have a low blood sugar, treat it, it comes back up if you're not going to be eating a meal or a snack within the next two hours, treat or follow up that carb sugar with a snack that includes protein. And the reason was to sustain the blood sugar than because that quick glucose like you just said, it goes in it does its job, it gets things up, but eventually the bazel it's there that's supposed to be right. That's sugar, it will overpower it. There's not enough laughs really, if it's working the way it's supposed to. So yeah, absolutely adrenaline and a lollipop.

Scott Benner 35:46
So the numbers not really the power without the way it's just a simple sugar, you have to give it a protein or a fat to actually add the, the weight to that number that

Jennifer Smith, CDE 35:59
so that knowing something slower digesting you know, if you consider something like you know, keen raw or like a piece of sprouted grain bread or you know, something longer sustaining. It's got the carbs, probably more than the lollipop does. But you're going to get the rise it's going to be a lot slower, but it's also going to be a lot more sustained.

Scott Benner 36:17
Jenny, you're not from where you live. Are you? Like were you born where you live? Like Jenny's? Like I'm from the Midwest. And still, I'm still you said qinhuai as an example of that was really interesting. Oh, by surprise, I was like, Oh, we get fancy Jenny must have been burned somewhere else that moves where she lives.

Jennifer Smith, CDE 36:39
Oh, no, not at all. I'm just you know, I am a dietitian. Oh,

Scott Benner 36:43
okay. See?

Jennifer Smith, CDE 36:44
all the fancy foods I guess I

Scott Benner 36:46
should know about right. I haven't I haven't read your bio in a while. I don't worry. I just I usually do it before the episodes when I'm putting the episodes together. You can well I got me by surprise. If this was a regular episode. I would totally title this episode. Keane was just so you know.

Jennifer Smith, CDE 37:02
Funny,

Scott Benner 37:03
so many people. So many people came up to me this weekend and said, Can you put any more effort into making the titles match what the episodes are about that is like No, probably not just listen, you'll figure

Jennifer Smith, CDE 37:13
you can title it the variable of keywords that

Scott Benner 37:20
attract what's next on your list.

Jennifer Smith, CDE 37:22
The weather. As we consider temperature changes, I've got you so many people in I noticed myself I've got really good friend who notices as soon as March hits. And you know, here in the Midwest, March may or may not be warmer than the winter has been. But she's like, as soon as Marcus, it's like a switch in her body goes off. And it's like, it's spring, hey, let's dial down the insulin needs. And she literally has about a 20% decrease in her basal needs, from March all the way through, like, you know, October ish, when it starts getting a little bit cooler out, then across the board rule. For the most part, the warmer the weather, the more and the more time you might spend in the actual warm of the warm weather. You know what, what is warm weather do it increases the like, your body needs to cool itself off. And so your vessels come closer to the surface of the skin. So you can cool yourself by sweating a little bit more that like increase in in the vascular nature of the underlying tissue brings vessels closer to insulin, and you absorb faster.

Scott Benner 38:31
Plus and this isn't physical but physical in terms of inside of your body. But you probably become more active when it gets warmer to

Jennifer Smith, CDE 38:38
right. Absolutely do more things. I know myself I you know here and my husband talks about it all the time. He hates the winter weather and everything and he's like, let's just move someplace much warmer all the time. So we can always be outside. And quite honestly, if that was the case, I probably would have lower insulin needs throughout the whole year because warm weather comes I'm consistently at the park with my boys or and go and doing my normal exercise. I mean, I don't even consider that exercise that's just part of our normal daily when it's nice outside. So yes, we become more active.

Scott Benner 39:12
When it's nice enough to be active more often outside. I think what Jenny's saying is if you're thinking of relocating to a warmer place, and you feel like you can't afford it, don't forget to deduct your savings and so on. Right, there you go. You might be able to afford more rent because of a go. All the diabetics are gonna live in California now.

Jennifer Smith, CDE 39:33
Right, right. And the opposite of that, you know, the cold weather, you need to stay inside more oftentimes, cold weather means you're eating a little bit harder your food, you know, to kind of sustain and back up or kind of plump up almost. You eat more like stews and things that might be a little bit more protein and fat Laden, just heavier meals in general. I mean, nobody eats well, maybe some people do but nobody eats like a rockin hot. chili, dinner in the middle of July summer. at certain times, no,

Scott Benner 40:05
I get that you're more sedentary in the in the winter anymore

Jennifer Smith, CDE 40:08
more sedentary. Exactly. You may get your exercise, but it may be shorter, you know the, though it's not as light outside anymore in the wintertime. So all of those kinds of things as far as the time of the year allergies, whether cold, warm, they can all be a variable. So I have a variable for you. Is it possible? It's more of a question that you may be able to tell me to shut up? But

Scott Benner 40:33
do some of our bodies react differently to Calculus than others? Like Like this? Might this gives a possible that? Because you're because that candle goes in? Right? It's seen as a foreign body immediately. Do some people see a third day on an insulin pump less effective, but some people can make it longer or shorter? But yeah, okay.

Jennifer Smith, CDE 40:56
Yes, absolutely. And I think that's part of the reason, you know, Omni pod, especially did their 72 hour or up to 80 hours of, you know, exploration, essentially three days on the pod, because the studies have actually shown that longer than three days with a site inserts to impact the absorption at the site. So if you think of the consistent drip, drip, drip, drip, drip, and then these big boluses, I mean, if you don't use a lot of insulin might be two units. For every Bolus, if you are some of the team guys that I work with who are eating, you know, 100 plus grams of carb per meal, and the ratio is a one to three, you've got huge 20 unit bolus going into a site and that site gets, it gets saturated, it can only absorb for so long. So some of it may not necessarily be canula. Some of it may be how long and how much is going in at the site. For the people that are sensitive to different candles, though. It could be the angle, some people do much, much better with the angled type of canula. Other people do much better with the 90 degree canula. I myself found no issue with Omni pod at all. I mean, I was a long time user before I started looping about a year and a half ago. But once I started looping with my Medtronic pump, I actually found the angle candles were horrible for my skin, they did not work. And I found the 90 degree plastic canula also wasn't something that my system seemed to really like. Whereas the steel canula that goes in in a 90 degree angle. It's kind of like a foam tap. You just pop it right in. That's awesome. It is like my go to set now. It's fabulous.

Scott Benner 42:38
Just t slim have steel and plastic. They do. Yeah, I see people a lot talk about the people who struggle on the T slim move to the steel Canyon that sometimes helps.

Jennifer Smith, CDE 42:52
Yep, the one for t slim is called True steel. And the one for Medtronic is called the shorty. Okay, they're both steel, they both they work. Lovely. I would say for most people that I've encountered who have that kanila kind of issue. Yes. And you know, as a variable, those may be things to evaluate and say, I know it's not the darn insulin, I can give an injection with the same bottle of insulin and my blood sugar moves the way that it's supposed to, let's change the site. It's not necessarily the site, it could be the canula, we change the canula. magically, things look better, sometimes we even need to go down in the insulin needs because you're responding better. So

Scott Benner 43:32
I would have to say at this point that when you buy a pump, you're going to get instructions from the pump company about approved sites to use. Keep in mind that the pump company had to get the pump through the FDA process. And every site they wanted to test took more time. And that took away time from them getting it to market for you. So had they decide had they had the luxury of more time, they may have tested more sites and the FDA may have said hey, this data proves that you can use it here too. I'm now not saying anything else about that. Other than you should consider that. Correct. That's all.

Jennifer Smith, CDE 44:15
Yes. And even some of those approved FDA sites don't work for some people at all.

Scott Benner 44:21
Just because it doesn't make them good for you.

Jennifer Smith, CDE 44:23
Doesn't make them good for you. That's exactly right.

Scott Benner 44:26
not approved doesn't make them not good for you. All we always take into account the photograph on my blog that Chris Freeman, the Olympic skier allowed me to use of him wearing his pump on his pictorial. I believe the man has the same body fat makeup of this metal microphone that's in front of me. Yeah, I think

Jennifer Smith, CDE 44:48
many women use jet fighter as well, even though they don't technically have. They've got pectoral muscles. They're just hidden underneath a breath. I

Scott Benner 44:55
love when someone shares like a cleavage picture with their pump on them. My daughter and she's like, never, never. And I'm like, Okay, I'm just saying this lady says it works really great. I can't wait for me.

Jennifer Smith, CDE 45:06
Right, right. Again, all those variables to definitely consider.

Scott Benner 45:12
You know where else variability exists in the foods that people enjoy eating. Some of you, for instance, just rocking it eating as many carbs as you can jacking up that insulin going crazy, but some of you are like, Hey, you know, I would like to have a slightly lower carb option without sacrificing taste or choice. And luckily for you, this is an ad for real good foods and they have just that not only do they have it, but they're offering you 20% off with the offer code juice box. Let me tell you more. First thing you do is go to real good foods calm there's a link in your show notes. But if you type it in your browser, it's all the same. Then you go to their products. Chicken crust, pizza, cauliflower crust, pizza, breakfast sandwiches, both sausage and bacon, and geladas 3d different flavors. Italian entrees have been added. And of course the poppers that everyone loves. Those of you who are already enjoying real good foods, they have a VIP text club list for exclusive offers. All you have to do is text RGF 2474747 to be added. Are you kidding me? You love texting people? Wait RGF 474747 you can do that. But you got to go check them out. Their foods are low in carbs and high in proteins and delicious. It's amazing what they've done. They've taken you know, the treats that you love and made them fit into your low carb lifestyle to amazing without sacrificing taste and I don't honestly know how they do that. It's probably Voodoo. I'm not a very like food sciency kind of guy so I'm just gonna go with it's possible there wizards real good foods comm use the offer code juice box at checkout to save 20% on your entire order. And considering their free two day shipping. That's a great deal. What do you see how it shows up? Like they send you an igloo in the mail or something very cold, chilly. Ooh, where

Jennifer Smith, CDE 47:06
are we talking about location here, I clearly had location for a different reason being a variable, location, being like travel. Travel is a variable. If you notice, changes in your blood sugar. When you are flying or traveling long distance, we usually find that over two hours of sedentary travel will usually require more insulin because of the sedentary nature and the potential bit of stress that travel brings in.

Scott Benner 47:42
We on a three hour flight. We always have to Bolus our two hours into a three hour flight. I never thought of it before. But it's constantly that

Jennifer Smith, CDE 47:50
Yep, yep. So I personally have found that I use about a 20% bazel increase. When I fly I get to the airport I turn the Temp Basal on so that by the time we get on the plane, it's already like circulating at a higher level. I continuing until we get the notice of descent and then I cancel it. And that works really well. For me I do the same thing on long travel and when we lived in DC, and we would drive back to the Midwest to visit family. That's a long drive lots of sedentary sitting in a car, the stress of driving on the road and everything I would need a Temp Basal increase for that. So traveling it of itself can be a variable for those on tube pump. The variable could be the pressurization in flight. Many people find and there's actually some really good I guess, blogs on what people found with the tube pump in flight. So the recommendation now is to disconnect before ascent. Check the tubing Once you're at cruising altitude check if there are any bubbles, purge them out with a priming bolus and then reconnect. Same thing for descent disconnect once you land look at the tubing clear the bubbles if there are any. Some people have noticed that they get a bit of insulin bolus that won't show up in the pump because of pressurization of the pump and the reservoir and everything. Some people find that they've got this huge air bubble in their tubing. And so if they didn't look at it, they would get a huge missed amount of potential diesel or Bolus the next time their pump pumps out and that's something

Scott Benner 49:22
with the change of Evo elevation.

Jennifer Smith, CDE 49:26
Yeah, it has to do with the pressure pressurization within you know, the cabinet. Unfortunately, there's not a lot of In fact, there's nothing that I've seen in any of the tube pump companies that they talk about doing that, but it's something that we know is common

Scott Benner 49:43
to happen to

Jennifer Smith, CDE 49:45
an army pad obviously there is no tubing. I've had a random couple of people who've noticed that in flight they have these lows, having not bolused having not done anything different having sat at the airport for like an hour or two before their flight took off. Again, no boluses or anything, and they are low through the course of the flight. So I potentially I guess it could happen even without the tubing component there. I mean, the pod still have a reservoir. But I've really primarily heard it with tube pumps. I always wonder about

Scott Benner 50:18
you. Some people get like, like, we all most people have the same reaction, right? Nervous upset adrenaline, blood sugar goes up, but you do see sometimes, like people have the complete opposite reaction that you expect from them. And it's that's their norm, right? Or, like, here's one, how come when Arden has a head cold, it's like she doesn't have diabetes anymore. And other people say when I'm sick, my blood sugar goes through the roof. Arden gets sick, her blood sugar goes to 80 and sits there for days. It's far right. And it's just so the other variability that we haven't spoken about yet is you? Are you right? So your response? Yeah, your response to all of these things. So you know, the variables may treat you differently than other things.

Jennifer Smith, CDE 51:04
Similarly, I have my friend, who I have done races with in the past, not recently, but she actually has a considerable drop in her blood sugar once she gets to the race day.

Scott Benner 51:15
Okay, that's it. She doesn't have that adrenaline spike, she had the opposite. I mean, there's adrenaline there, but whatever reason it's causing her to drop. Yeah. And so for Jenny's friend, the the point here is, don't say, Well, I heard on a podcast that you know, when adrenaline hits your blood sugar goes up, and everybody online says it, but mine goes down. Don't don't bang your head against the wall. Just accept it. That's what happens to you and address it accordingly. Correct. There we go.

Jennifer Smith, CDE 51:40
Yeah, exactly. The other travel one was altitude. Many people don't consider altitude. And if you are someone who goes to Colorado skiing or somewhere fancy in Europe, and you go skiing, or whatever you do, you could notice that going to altitude, I noticed it when my husband and I took a trip to Peru, and we hiked the Inca Trail, which is we got to Cusco and we were like, Oh my god, can we just pleat the it like the altitude was like crazy, we felt like we had never exercised before. And my insulin needs go up about 30% for about 24 to 36 hours, once I get to altitude, and then they come back down. It's like my body just needs this like adjustment period. And then it kind of comes back, you know, to my normal. But that's a pretty common one to consider.

Scott Benner 52:32
And that is incredibly common. And even though it is incredibly common. There are three people that I know of right now listening to this that are thinking, I it's the complete opposite of what happens to them. I correspond with people who live in Colorado and are afraid they're going to die because their insulin just crushes them. They use the tiniest bit and if their blood sugar's falling constantly, they don't know why pumps injected doesn't matter. They just the elevation, that altitude just it wrecks them. So yeah, that's their that's their normal, you know,

Jennifer Smith, CDE 53:02
that's their normal. That's right, absolutely. So you know, all those, I guess, all those things to consider. You know, they're all there are lots and lots and lots of variables. What else is on my list? I have

Scott Benner 53:15
Jenny prepared for you people, I hope you appreciate that. I did.

Jennifer Smith, CDE 53:19
I did just because I was like, gosh, there's so many of them, I need to like make sure I get the primary ones that I talked to people about considering, you know, a variable I know we've talked about previously, when we're talking about like being bold with insulin is high blood sugar itself, like extreme high blood sugar can be a variable in how you expect your body to respond to insulin. Typically, when blood sugars are higher than about like that 250 Mark, which, huh? You know, they recommend testing ketones anytime you're higher than 252. Right. So along with that comes the consideration. You've got it all like squared away, you know, your bazel you know, your sensitivity to boluses to correct blood sugars, or carb ratio is all dialed in, and you feel like things are working and, wham, you're high now. And you take your correction and you're like, well, that looks like I've put water in my body. And it did literally nothing. It was sugar. So we've got this like, like this toxic state almost like they actually call it glucose toxicity that comes into play when you've got extreme high blood sugars, where you'll need more insulin than your sensitivity factor would normally cover. And

Scott Benner 54:37
that's what people commonly say, I'm insulin resistant when I'm high. That's the that's the common way that people talk about. So if you have that feeling in your head, this is what Jenny's talking about. Now, from my very non scientific perspective. I learned years ago and we've been talking about here forever, that bringing a high blood sugar down and coming in for that landing that you're hoping for And not a crash, right? it you have to In my opinion, it's a mix of Basal and Bolus. JACK, you don't just, if you're thinking, in my mind, if you're thinking it's two units to get this 300, back to 100. I like to find a good portion of that insulin from Basal. And I don't know why that makes more of a difference, but it certainly does. So

Jennifer Smith, CDE 55:24
it's also a, I call it a, let's say a safer way to also manage potentially, because if you've got a Temp Basal increase, going along with a part of a Bolus that you've used to address that higher blood sugar,

Scott Benner 55:40
the bazel can be canceled, right? You can always bail on Okay, once you see the

Jennifer Smith, CDE 55:44
movement that you want, you can bail on the Temp Basal, whereas if you've taken your rage bolusing you're like, it's telling me all you need two units, man, I'm gonna nail it, I'm going to get it down with like eight units and you like nail? Well, once it's there, you can't get rid of that eight units, it's, you know, whereas

Scott Benner 56:00
you just Pre-Bolus for your next meal, you better eat it at the right time.

Jennifer Smith, CDE 56:03
That's exactly right. So you know, if you do some of it as Bolus, like you said, and some of it is this Temp Basal insulin, you can cancel that town, you may need to cover a little bit, but at least you're gonna drift down better without a huge crash. And

Scott Benner 56:17
also, you can also cancel it and go back to it, which I found myself doing before, right? You're, you know, 300, it's now it's 280 is 250. And then you're like, Oh my gosh, it's two hours down, I'm shutting the bezel off, then all the sudden 220 levels out like, Oh, she left the bazelon. And you put it back on again. But at least you're in control of it to a degree, right. And you and you didn't just put in this giant like, you know, mallet full of insulin that you can't stop. It's hard to walk when you're done with it. Yeah, I want to say too, and this maybe doesn't fit here. But when you find yourself in those situations, I think it's incredibly valuable that when you cause that fall that that the sent in blood sugar, and you have to eat some food to stop. But at some point, I know everybody thinks of that as like some failure. But there's so much to learn from watching the food go in and watching how it affects your blood sugar on the CGM, that that that experience of stopping up drop like that will inform a lot of what you do in the future. Because just like you can see, oh, wow, I was 152 hours down. So I ate this. And I came in at at that knowledge. And I can't really explain to you how in the moment right now how in this example, but it will inform your understanding your greater understanding in a way that will help you in the future. It's absolutely very neat to see how the food affects the insulin.

Jennifer Smith, CDE 57:40
I see. So awesome. Yesterday, I talked to somebody who she worked very hard, you know, with strategy management, we knew something was kind of going on in the evening for her. So we said let's do like an evening bazel test, let's see what's happening truly behind dinner without the dinner, you know, being there. So she did this awesome bazel test, we saw the drift happened that we kind of assumed was from bazel. We, you know, could counter it, but she ended up having to treat the drift down and she didn't want to eat at 10 o'clock at night. So she just treated the low. She had three glucose tablets to treat it. And she thought, you know, all we're getting out of this is the bazel test. So we know where to change things. You know what? So we could actually get the evaluation of what the carb intake she did, how much of a rise did she get with it from it, because there was no other food, there was nothing I mean, the only other food she had in her system was from lunchtime at noon, at 10 o'clock at night, there is no impact of that whatsoever. She had no exercise, we treated the low it came up, we saw how much she can use, I pointed out she's like, wow, we got like more done than I thought we got done. She was so excited that she could actually see. And it was simple sugar, right. So she didn't treat with something that had the fat or the protein that would have later potential impact that you couldn't figure out. It was just glucose tablets.

Scott Benner 59:05
So there's so much to learn to learn if you just step back a little, and widen your vision. And and you know, and you have to get rid of that I failed or this is a mistake or a problem feeling. It's just data coming back like look at it and really accept what it is instead of being upset with yourself. Because you can't because I said it this you know, I say it a lot. But this weekend, I was really pointed with a pretty large group. I said, Every time something goes the way you don't want it to go. And you don't use that as a as a moment to collect the data and make decisions and, and and further your understanding. You wasted that moment. And you're going to have to have it again now because you didn't pay attention to what happened. It's just like, I mean, what's the saying right? Something about history doomed to repeat it right? I don't know the exact thing. Right? All of you who know it now are repeating it in your head in your car. But that's the idea. The idea is it's happening. Learn from it. Don't just read Your hands like I can't believe that happened. That sucks. I bet at this, you know, right. All that's true, but isn't going to help you the next time. So right, cool. Jenny Kiki, anything else? I mean,

Jennifer Smith, CDE 1:00:13
I yeah, I had two other one was something that I think is not addressed. Usually not addressed at all, unfortunately, health factors, I guess that we don't really want people you know doing really it's things like smoking. If you're a smoker, I'm sorry, but you know what smoking can have impact on on on blood sugar and some of the research that's out there that can actually show that smoking can have an impact by causing some insulin resistance, because cooking is it's suggesting inflammatory responses in the lungs,

Scott Benner 1:00:50
that make sense.

Jennifer Smith, CDE 1:00:50
So could have impact blood sugar wise, the other one would be drugs. Drugs can have impact potentially, on your diabetes management. You know, depending on the kind of drug that you're,

Scott Benner 1:01:03
you're telling me that if I'm sitting at home, really trying to figure out my insulin problems, and I'm not taking into account my heroin addiction, I make I'm leaving something out that's important to think about. Absolutely. Which which might be, which might be reasonable like that. I think that people compartmentalize their thoughts sometimes. And you really sometimes don't see where the impact is actually coming.

Jennifer Smith, CDE 1:01:25
Yeah. And as a variable, you may not be considering all of the things that you could be doing for your diabetes management. If you are utilizing a drug and it's, it's really your main like focus, right? Because diabetes isn't going to be a focus for you, then are you gonna say drinking next? Because I have one I

Scott Benner 1:01:40
wanted? Yeah, I'd say alcohol.

Jennifer Smith, CDE 1:01:43
Yep. Alcohol itself drinking, it's a big one that I discussed with, you know, my teens and my college. Because it comes into the picture it does. Learning how to do it safely, is an important thing, because the impact of the alcohol itself, you may have your fancy sugar, you know, juice sweetened beverage, the alcohol in it, however, is going to have impact later on your blood sugar. So what we find is that hours later, if you've had enough alcohol, it could cause a drop in your blood sugar.

Scott Benner 1:02:17
And and not for nothing. But when you're really loaded, you're probably not doing your diabetes, math as well as you probably could be wrong. Oh, is it fair to say maybe have a buddy with you explain to them why you don't just need a sober driver, you might need a sober bazel tester to watch these things just made me think of, because I just did an interview with somebody who's like clinically depressed and has type one. And to watch the cycle of how it hit this person over and over again, was just like, it's crushing, you know, to see, but for them to have to live with. So now I'm thinking, if I'm on a depression medication, is that affecting my blood sugar? Is it making my blood sugar higher? Giving me anxiety more that it's higher end, making me feel more anxious about you having to use extra insulin in what about just the, the, the physiological, and maybe you don't know, but experience of being depressed? Like does that have an impact on you?

Jennifer Smith, CDE 1:03:20
It's, well, depression as a stress, right? So it could be it could go various ways, if the depression isn't being managed with, you know, assistance, whether it's counseling, or use counseling, and medication or whatever it might be, you know, that in effect could be enough of a stress that it is bringing your blood sugar levels up. It depression can also mean that you're just, you're just not eating. So it could very well maybe bring insulin needs down because you're just literally not taking in anything through the course of the day. Now, some of the some of the medication, some of the oral medications will make you feel so much better, which is a purpose, right? That's the purpose. But some of them also increase appetite. If it increases appetite enough, and you're not cognizant that that's what's kind of happening and kind of rein that in, you could have weight gain that could impact your influence sensitivity.

Scott Benner 1:04:19
I'm gonna add a thought to this, because I had a conversation with somebody online, told me something I never considered. So this person was overweight. And eating was more than they wanted it to be. And so when they counted their carbs and went to give themselves insulin, they wouldn't give themselves all the insulin they needed, because it reminded them that they were eating more than they wanted to be eating. I know that's a real interest. You have to wrap your head around it for a second, but they were disappointed in themselves for eating that much. And one of the ways they pretended that it wasn't going on was to use an amount of insulin that a more normal meal would have been Yeah. So there's a lot of things I wrote, you know, as we started this conversation today, I wrote down life because the variable really is life. Right? Like, it's your living, and there are different things happening to you. And whether you're, you know, addicted to drugs, or you're depressed, or you just don't have your bazel, right, or, well, all the things that Jenny's brought up here today, really, it's just, it's, you're alive, and you have diabetes. And so they're going to be variable. So are there any more on your list? You're looking at the

Jennifer Smith, CDE 1:05:28
only other one was a

growth cycle?

Scott Benner 1:05:34
Oh, growth, are you?

Jennifer Smith, CDE 1:05:36
And I think, you know, I mean, that is a it's a broad topic. So I bring it out as a variable. It may need full nother discussion, potentially, but it is it's, and people ask, and I work with a lot of kids, lots of ages. I mean, a little younger than two is my youngest person. And kind of up until like, the 70s is my oldest and but the kids have these variables of growth that just drive parents crazy. Because become, you know, we've got things smoothed out and beautiful in the biggest things I tell people is the needs will change. We'll get them figured out. They'll probably look like they're going along pretty nice and that you know, little Johnny is gonna burn up, you know, a half an inch and so for the next couple of nights, they may get these like, like you said, aren't goes to bed and her blood sugar, kind of like drops off in a growth spurt. Many kids go to bed as soon as their head hits the pillow pillow and they're snoozing, man, it's like a rocket ship to the moon

Scott Benner 1:06:42
blast off blood sugar is the worst part about growth hormone and children is that it happens while you're trying to sleep. That really I have to give Arden her balls really quickly. This one's gonna be easy, though. Because Arden's doing the loop right now at carbs. taco. That's it. Time 10 minutes from now

at carbs taco time, change time to 10 minutes from now, that isn't gonna make sense to you guys yet, but it will one day when Jenny and I talked about that and and Katie de Simone comes back on and tells me all the things I did wrong while I was setting up my Ardennes loop. And how good and how I could have avoided them.

Jennifer Smith, CDE 1:07:35
Yes, I get it. That's great. Cuz that was like laying last little tidbit of variable, which is a total different discussion. I'm glad you're going to have it with Katie. But you should discuss with her the looping variable. Because these all have different if you are using a looping pump.

Scott Benner 1:07:55
Jenny, this is going to come out before I talk to Katie. And so I'll just tell you now and then you guys can all hear it. Now then hear me talk about later with Katie. Every every thought I had trying to set up the loop was wrong. Like like you don't mean Up, down left, right? Like everything. If you asked me, you know, yes, though, I'd say yes. And you'd like to know, you know, I send genic effects. I'm like, I'm seeing this, should I move this up? She go no down. I'm like, how do I get that wrong? It's just it's so so all of us. Right now everybody who's listening. If you're being bold, if you're following along with this podcast, obviously, it works fantastic. And there's no you don't need to change. But if you go to looping at any point in your life, or into a closed loop system, the variables, the settings that allow the loop to think are counter intuitive to what we're all doing. We're not looping, but I am putting myself through this so that I can explain it to you all better. Because if you guys want to move to a closed loop in this future, I think that's not a bad idea. And I want to make sure you understand how to transition from being bold with insulin to being I don't know, bold with a blue,

Jennifer Smith, CDE 1:09:08
or how to maybe let loose Be bold with itself.

Scott Benner 1:09:11
Yeah, yeah, there's a way but trust me, I still only understand that about 65%. But by the time I'm done talking to Katie, and by the way, now that Jenny has been kind enough to say that she's going to continue coming on like this. I don't think we'll be putting them out like three at a time, but maybe once a month, or as often as Jenny can do it. And trust me, we're going to get about that as well. So thank you so much for doing this.

Jennifer Smith, CDE 1:09:33
Thank you.

Scott Benner 1:09:36
Wherever you are right now, I imagine you applauding for Jenny just a slow, deliberate and lovely clapping. That's how I feel every time she's on. Hey, how about that great news. Jenny is going to keep coming back on the show. The diabetes pro tip series is going to go on into the future non stop pro tips. Just for you guys for listening to the Juicebox Podcast. Don't forget to check out Jenny at Intuit. To diabetes.com there's a link to her email right in the show notes. Don't forget dexcom.com forward slash juicebox get started with the G six today, dancing the number for diabetes.com. And of course using the offer code juice box at real good foods calm. I love getting all of your ratings and reviews on iTunes. Thank you very much every time someone leaves a great iTunes review for the Juicebox Podcast. I don't know if you know this or not. An angel is completely unaffected, but I am incredibly happy

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#226 Diabetes Pro Tip: The Perfect Bolus

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

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

Scott Benner 0:00
Hello and welcome to Episode 226 of the Juicebox Podcast. Today's episode is called the perfect Bolus, and it is installment number nine of my diabetes pro tip series with CDE Jennifer Smith. I'm gonna make this episode ad free, but I'll probably give them a mention here and there, you know, not a whole like big sell, but still, I really love the advertisers. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And the Always consult a physician before becoming bold with insulin or making any changes to your medical plan.

If you find yourself loving Jenny as much as I do, and you'd like to hire her personally, you can go to integrated diabetes.com. To find out more. There's also a link to Jenny's email address right in the show notes of your podcast player. And at Juicebox. podcast.com.

Hey, everyone, Jennifer's back. And we're here today to talk about the perfect Bolus. So that already sounds like a topic that everyone's gonna get upset about when they hear but i think but there's a lot of different ideas here. So Jennifer, what I was thinking was, Bolus is different differ depending on situation, right? You might have a high blood sugar a low you might be falling, you might be rising, you might have a new site. There's

Jennifer Smith, CDE 1:39
exercise, you might Yeah, keep going. Right? You may have just exercised you might have you might be ill you might have your period, you may be coming into having your period, you know, your dog might have eaten the other dog next door and like you're dealing

Scott Benner 1:54
with a little bit of anxiety going and there's a different tick, Good dog, maybe your next door neighbor's dog Jennifer, Has that ever happened in your life? So psychologists say that if you make up something like that, it comes from something. I don't believe that because my my humor is so bizarre that I look back sometimes. And I think, but that was something really strange. I just said does that have any real connection to my thoughts? And I've really looked closely because I've been worried in the past. But I don't think that's true for everybody.

Jennifer Smith, CDE 2:22
I got a chocolate lab and I don't think that that's even in there. Totally not in the nature. So anyway. No, it's never happened, thankfully.

Scott Benner 2:31
So you people have already learned the chocolate labs are not carnivorous. At least towards other dogs.

Unknown Speaker 2:39
Pog, Oh,

Scott Benner 2:41
my gosh, okay, yeah. So anyway, so I want to start with I mean, we're just going to pick one, right? Let's say your blood sugar's where you mean for it to be your bezels are in check, they work? Well, you haven't eaten in a while. It's the perfect scenario, the one that they described you in the doctor's office, the first time you're diagnosed, right? Your blood sugar is 95. And you're hungry. And you're thinking, What am I going to do? So? Ideally, we know at this point, now from listening to the episodes, we have to figure out what our length of time for our Pre-Bolus is. Right? But how do we know? How much to Pre-Bolus? And I think the answer always has to be, I can't tell you, Jennifer can't tell you it's situational, but that you'll learn through trial and error. So but let's make this one general, right, it's a it's a nice balanced meal, you've got some vegetables, some carbs, there's protein, it looks like it looks like a plate from a superfriends episode that the government told you how to eat in the 70s. The food triangle, it's called

Jennifer Smith, CDE 3:47
a triangle.

Scott Benner 3:48
So so if you're a nice steady blood sugar, if if my daughter was at 95, and I thought this was a pretty, you know, average meal, as far as what I expect, as far as impact back from it, I might put in all of the insulin, you know, in the beginning, but I also might even say, hey, there's bread in there a potato that might stretch out the action of the impact of the carbs over more time. So maybe I'll put in, I don't know, 50% or 60%, and stretch it out over a half hour an hour just to create, like we've talked about in the past that kind of blanket of insulin to cover the entire impact timeline of the carbs. I think that the thing to remember is, is that there can't be really a set idea for what that means. Like maybe you'll figure out a meal eventually and say it's 70% and 30% over an hour. You might get to that point at some point.

Jennifer Smith, CDE 4:39
And many people do many people who have pretty consistent intake, or like the same things over and over. But the variables would be around that will sometimes change even near more standard figured out meal.

Scott Benner 4:54
Yeah. And so I think so my first my first step, I'm telling you Any good Bolus, that one that has any chance of working, I think it's a nice simple way of saying it has to have a Pre-Bolus. Like you have to start, you have to start getting the momentum of your blood sugar moving down, so that when the carbs start acting, they move up. So so that's that, to me, that's step one. Now, do you talk about or do you in your own life use combination of Bolus and Basal in situations like this?

Jennifer Smith, CDE 5:29
Ah, in some situations like this, perhaps more often, more often what I do and more often what I eat is Pre-Bolus based on some of the meal content, because some of that does. It does work together things like glycemic index. And also, as you brought in to begin with the where the blood sugar starting, is it coming in standard at your target? Are you coming in, but it's already dipping down? Are you coming in, in target, but it's already drifting high. All of that is where you can also look at Bolus timing, and how much Pre-Bolus you may need. So you know, coming in at a blood sugar of 95 with a straight horizontal line the past hour, awesome, that looks great. But the minute you put food in, that, that blood sugar line is gonna start to change a quick after that, if there's not time for that insulin to talk first to begin with, right?

Scott Benner 6:33
Yep, I hear what you're saying too, about, like, understanding the glycemic load of different like foods, if you have something like you know, using Chinese food, such a great example, because it normally incorporates rice, which stays for a long time and hit you hard, and usually some sugar that'll hit you fast. So if there's something sugary in there, you may need a real, you know, push of insulin in the beginning to combat that initial rise. But that initial rise could get beat up by that insulin very quickly. And now what's left over is the, you know, the rice they can linger in the back, right? It's an excellent, good.

Jennifer Smith, CDE 7:08
So yeah, yeah, yeah, I was just gonna follow with Yes, you could, in that instance, then have the potential for meeting both Bolus and bazel. Potential change, and also where we talk about Basal. And most doctors are like, well, Basal shouldn't ever be used for food or covering anything. Well, we've learned very differently, especially with fat. Fat requires a huge amount of bazel change in the aftermath of eating your typical pizza, or, you know, burger and french fries, or mac and cheese that's homemade, or whatever it might be. Oftentimes, you need 4050 60% of an increase in bazel for many hours after that meal, or you're gonna stay stuck high,

Scott Benner 7:50
right? Or you could end up hitting it with so much insulin up front that you think you've avoided that and then three or four hours later, you start rising, and you think it's for no reason. Right? And it's still that fat. Is it still the fat? Yep. So I like a in what I call karbi situations, I, which is not a word, but

Jennifer Smith, CDE 8:08
hyrecar in our world, in our world, karbi is absolutely a word.

Scott Benner 8:13
So with carbee foods, there's a couple different ways I use Temp Basal, and we talked about it before, but in this situation, if I thought a meal was 10 units for sure, but I wanted it to be spread out more Arden's basal rate being 1.4. I might double Arden's bazel for an hour and a half and catch two and a quarter units that way, and then take some of that out of the of the bottom line, right?

Jennifer Smith, CDE 8:37
Absolutely. Because we get a lingering effect from the bazel. And you get less upfront, but you're still getting the whole bolus you determined you need it. Okay,

Scott Benner 8:46
same meal. Jenny rapidfire, same meal, but I walk in the door from work, and my spouse says dinner's ready, and it hits the table. I can't Pre-Bolus I didn't know this was gonna happen. What do you do? And that's where I'd like you to lay out the idea of overhauling for people here.

Jennifer Smith, CDE 9:09
Yeah, and that's over Bolus thing. Essentially, that's a good Super Bolus, as you can kind of be talked a little bit about before, that's a situation where 100% unless that meal is like a plate of broccoli, in which you would never need a Super Bowl, or Pre-Bolus. right in your typical meal that we're saying we're having 100% of Super Bowl, this would be beneficial, where you actually do take a load of insulin that would be your bazel behind you added on to the suggested bolus for what you're going to eat. And then you may actually knock off the bazel behind so you don't go low later, but you've gotten the load of insulin, the push up front, right. The other option that many people do in that situation too is they take the bull and they may actually turn their bazel off 100% for an hour.

Scott Benner 9:56
Okay to also try to spike

Jennifer Smith, CDE 9:59
right in actly so that they're getting a bolus, they're maybe not quite sure if the food in the bolus, even though it's happening at the same time is going to cause as much of a rise. But they're definitely saying, I know I need a lot more because I wasn't able to give that 2030 minutes before this.

Scott Benner 10:14
Yeah. And, and I think of over bolusing in two situations. So the one I don't have time to Pre-Bolus. So in my mind, the way it strikes me is I now need the insulin for the food for the high number I know is going to come because I didn't Pre-Bolus and some to stop the momentum or stop the arrow, right? And so if I thought the meal was definitely six units, but I thought, wow, there's no way this doesn't go to 250. I Bolus the six units. And I Bolus like I'm trying to bring down a 250 at the same time, right? Well, that's again, listen, we're calling these you know, we're calling these this series diabetes protests. So this is like ninja level stuff. Like you don't don't try this on day one. But at some point, right. On day one, don't go I didn't Pre-Bolus I'm gonna double my balls, please. Right. Yeah, right. But as you're figuring things out, that's a great place to do. As you've heard in past episodes. There's a very famous book called, is it pumping insulin?

Jennifer Smith, CDE 11:13
pumping insulin is john Walsh. And he's the one who lobbies for bowling. Yeah.

Good. Oh, you got you know, you call it something else? Yeah, we call it

Scott Benner 11:23
I call it over bolusing. But I don't know why.

Jennifer Smith, CDE 11:27
No, I was gonna say the other. You know, the other concept that kind of comes in here that you'd sort of just alluded to is, where is the blood sugar going to likely be? And that trajectory, you know, assuming that okay, I might be 95 right now. But if I haven't Pre-Bolus, I could easily be to 50 in the next 30 to 60 minutes. Okay, you're taking that value. And it's looking at the trajectory of where it will probably be, and using that glucose value to add on to the current Bolus. So you're avoiding that really high blood sugar.

Scott Benner 12:00
And what I say on the podcast, which people might remember is I just say you have to trust that what you know is going to happen is going to happen, right? So you can't just pretend this will be the time this doesn't happen. You know, oh, I'll get away with not Pre-Bolus thing today, there's, that doesn't make any sense. It might happen once in a while. But that's some random reason from something earlier. That's not you know, that's not

Jennifer Smith, CDE 12:20
me, I ran 10 miles and don't usually ever do that. And now, look at that my blood sugar doesn't.

Scott Benner 12:26
So now another place to use an over Bolus as a Pre-Bolus is a is a place where this the concept in my mind is the same, the situation is different. What if I've been fighting with my blood sugar all day, and I just can't get it down. It's 200. But I know I'm gonna eat an hour, like it's dinnertime and an hour and I've been, you know, pushing and pushing little boluses little bays or anything, I can't make this 200 move for whatever, maybe it's a site not working well, whatever it is, in my mind, I Bolus the meal. I Bolus the number I over Bolus upfront and create a fall that I then catch with the food. So I reverse. I we're going to talk about this in the next episode. But I reverse the way I think about I think most of the time we consider how does the food impact my blood sugar? How does the insulin impact my blood sugar? We don't often enough think about how does the food impact the insulin? Right. And that's, and we've talked we talked about that in earlier episodes where we put a little, you know, we put a little boy's blood sugar into a freefall and got it by eating at the right time. So all we're talking about any of these situations is timing, right? It's the right amount. It's the right amount of insulin at the right time. And if your blood sugar's 300, and you have to eat an hour from now, well, the right amount of insulin is now and you know, it's it is now and you can't you can't just wait and do your 15 minute Pre-Bolus on the 300 blood sugar because you've lost already. Right? Right.

Jennifer Smith, CDE 13:58
And you know, something that that kind of goes along to with the concept that catching catching the potential drop while also sort of avoiding or taking care of a higher blood sugar. in pregnancy with the women that I work with. It's kind of similar, we actually at some point get to bolusing. That's like a split a split meal where you actually load the front of that meal time with the whole bolus. Yeah, but you only actually eat about 70% of the food now. And you catch the drop about an hour later with the rest of the meal.

Scott Benner 14:29
Interesting.

Jennifer Smith, CDE 14:30
So what you get is not a spike, not going above those post meal ranges for pregnancy. But you also catch the drop on the back end and you never go low.

Scott Benner 14:40
Yeah, that's very similar to how I handle days like Christmas or Thanksgiving. The idea that there's always going to be eating. So I all I'm always Pre-Bolus in the next grazing opportunity, right like that's interest

Jennifer Smith, CDE 14:56
you for holidays is I actually knowing I'm coming into a grazing time period that's going to be a lot less than precise, a lot less. And a lot of little nibbles along the way behind any holiday where I know I'm going to be up hours of nibbling and eating 25% increase in bazel. And then again, I Bolus along the way. And depending on where glucose is, I might nudge that along the way, too. Yep,

Scott Benner 15:23
yeah. Okay, so now, what happens if dinners taking a little too long to make, and my perfect 95 is turned into a 90 that turned into an 80 that turned on 85. And now it's 75. And now, now someone's yelling, dinner's gonna be ready in five minutes. I know that for most people that makes them feel like Well, I'm too low to Pre-Bolus. But No, you're not. And and so you have to get some insulin moving. And you'll learn how much you can do over time. But in the in the interim, it's got to be some subtle, right, you're just you're drifting low. I'm not even talking about FedEx computer, somebody we're talking about diagnol down, I'm just this, this blood sugar just is kind of drifting down. Your Pre-Bolus still takes as long as it takes to eat to excuse me as long as it takes to work. So if you're 75 and drifting down, Pre-Bolus thing right now is not going to make you start crashing down. If that does happen, that was a coincidence. That's not you. Again, the insulin didn't just start magically working like that, right? Science didn't change. So you still need a Pre-Bolus. Now I get if it's a it's a big meal, and you're like, well, I can't put in eight units. While I'm 75 diagnose, you're right, you probably can't. But you could put in some 20 20% of it even. And we do this a lot while Arden's at school because we Pre-Bolus 20 minutes ahead of Arden's meal at school while she's still in a class. I'm still Pre-Bolus if she's 85. So if I give an ardent gets a big bolus at lunchtime, that while she's in school, much larger than most any other times in her life, 12 sometimes 13 units right for 145 pound kid. So I might do a zero percent upfront, and the balance over a half an hour. So it's all kind of getting squeezed in. But it's not all going to come on line and be active right away. It might be 20% up front, but you have to get some sort of that momentum happening again, on the on the action of your insulin, your insulin to be pulling down when the food goes in. Right, right. Okay.

Jennifer Smith, CDE 17:22
And that's important even for kids, I think in what you're doing that is important, especially for little kids, where you're not quite sure. I know a lot of the people I parents I work with, what I don't know how much Billy is going to eat, or Susie is a really slow eater or, you know, today's she might love spaghetti and she'll love it for the next three days. But then she hates it and I prepared it and I Bolus for it. And now what's going to happen, right? You, for the most part kids and teens will always eat as you said a percent. Let's say that you always know they're going to eat 10 grams of something, even if you have to change what it is they're going to eat something for you. Yes. So if you can Bolus for that little bit up front, it's giving insulin again, more action before you put food in.

Scott Benner 18:08
And one of the many, many reasons that Jenny is on the show is because if Jenny wasn't here, that would have been the next thing I would have said. It's perfect. You, you parents of little kids, it's a perfect idea. Get something moving, even if it's a little bit, just get something moving, give yourself a fighting chance. And to Jenny's point, there's an amount of food if you look back at your kids meals, they always eat at least a little bit. And by the way, if they really flake out and don't worry if, as in the case of the interview I did yesterday with a mother who said she was so excited, she put the insulin in, grab some like fast food and drove away and the kid fell asleep while they were driving away. Right? You know, okay, that might happen. It's happened to me, but still a little bit of juice, right? You only put a little bit in all you've done is Pre-Bolus a couple of sips of juice, you don't have to worry about the food. The point is, is that the Pre-Bolus is always important. It's it's Listen, if you're crashing down as the foods hitting the table and you're literally 50 and your blood sugar's falling. Okay. That's your Pre-Bolus. Right. Right. Okay, you're now prepared.

Jennifer Smith, CDE 19:14
Because there's already insulin that's causing the crash.

Scott Benner 19:17
Yes. Something whether you meant for it or not. You have been Pre-Bolus by so long, right? So good. So see that put the food in. And as soon as that stops, right, as soon as that down arrow goes away, it is time to get your insulin in. You absolutely cannot then say well, I don't know. I'm 60. And that seems dangerous. Now what's dangerous is that you've put all that food in your body and it's going to start hitting you the other direction happened to us last night. And I had to Bolus I had to make a significant bolus at a 75 diagonal up blood sugar because I was like, well, this is I know what's gonna happen. Let me get let me stay ahead of it right.

Jennifer Smith, CDE 19:59
I'm the hardest about using CGM now, as wonderful 100% as they are, the hard thing is that CGM do lag in times of quick change. And so if you have been diagonally down and you're waiting for, you know, you want to Pre-Bolus, but you're not quite sure, sure, go ahead and eat as. But as soon as you see that horizontal or a bit of a trend up, I guarantee your finger stick is higher in the sij than the CGM is showing you. You're already at a deficit of insulin.

Scott Benner 20:29
Yes. Yes. The deficits an important way to think of it and you. And this is again, something you'll learn over time.

Jennifer Smith, CDE 20:35
Well, yeah. It's a bit like the first month. Again,

Scott Benner 20:39
not on your first day, right? Yeah, listen to all the episodes of the podcast to really absorb everything, go through the pro tip stuff, and then say to yourself, I and then you have to see it, right, you have to recognize it. There's a way for CGM users, you have to be able to look, there's like a bend in the line. It's hard to put into words, right. But on the three hour graph on the Dexcom, the last three dots on the right side, tell a story about what's happening. And you will get to be able to glance at that at some point and say, Oh, this is heading down. This is heading up, I can tell I know what and so it's not day one, and it might not be the first month. But if what most of you report back in your emails is anywhere close to true for most, somewhere in the three to six month range. This all just starts making sense in a way. Yeah. Early on the podcast, I used to talk about it like in the matrix, when Neo stopped the bullets. But that has become such an old reference at this point. I'm afraid right now there's like a 19 year old going to what what are we talking about? Now?

Jennifer Smith, CDE 21:39
I'm old enough. I totally know at

Scott Benner 21:41
some point, at some point, diabetes makes so much sense to you, the bullets aren't even moving, you can just walk in between them. And so you get there at some point, right? Okay, so I'm low, I'm high, I'm falling like in the end, I think you're hearing. It's all about the right amount of insulin at the right time, just like we've been saying over and over again, a new site is a good example of, I'm gonna put this in here, even though it doesn't sort of fit, but it does fit. And so if you put a new site on, and you find that your sites don't work as well, immediately, once you put them on, or you know, you just have a site that doesn't seem to be as reactive as you're accustomed to. You still have to do what you have to do. You might have to do it sooner, you might have to do it more aggressively. And I know you're gonna say But what happens when that site starts working? Suddenly? Well, then it does. But you can't not be aggressive when something like that's going on. Because then you that's how you end up at 300 all day long, staring at it wondering what to do next. Right,

Jennifer Smith, CDE 22:44
right. I think the biggest the biggest piece of that Pre-Bolus message is unfortunately, really learning. And it's a daily relearn in the beginning of starting the Pre-Bolus. Rapid insulin is not rapid. Rapid is a bad word for it, it's a better word than our regular insulin used to be, which they called short acting, and I'd actually call that longer than short. I mean, rapid is not instantaneous rapid, as they tell you it is it takes a minimum of 15 to 20 minutes to really get moving.

Scott Benner 23:24
Yes. If you don't leave this episode, and in general, this series, believing that understanding how insulin works in your body is the core of this entire thing. You are not paying attention. So go back and start again.

Jennifer Smith, CDE 23:36
When you get a slap on the hand. Well,

Scott Benner 23:39
I didn't go to Catholic school, but I mean, if I did, yeah, well see Jenny's like, I know what happens when I don't listen, someone hits me with a ruler. So now I guess the last piece of this right about this perfect Bolus thing, right is in my heart, it's about remaining fluid. Now, you know, a lot of people are going to tell you, you really have to count your carbs correctly, right, which is true. You can't use the wrong amount of insulin like you know, you can't have a 50 carb meal in front of you and only put in 30 carbs and then act like oh, I don't know why this didn't work that but you know from listening for me and for a lot of people have been around type on for a while like you just I don't think about it as much as carbs. I think about it as units. I look at a plate and I think that looks like eight units to me. But if I'm wrong, and I am frequently for reasons that I don't care why, right like maybe it's a bad site, maybe I missed on my Pre-Bolus maybe Arden sick I don't care why but I miss then I readdress immediately, right based on my historical knowledge of how Arden acts I know that if I see a double arrow up after a meal bolus, I screwed something up pretty big. And I go more insulin. That's when you guys are starting to hear this. I'm starting to see you on online like talking to other people that people are just going more insulin. I'm like, Yes, I know. That's one of the podcasts and so But is she diagonal up, well, then maybe I missed by a lot less so a little more insulin, or I'll try to bump it back down again, or try to just try to stop the arrow. But staying fluid is the rest of it. Mm hmm. 100% staying fluid as the rest of it. And I know that I heard someone say this the other day. And I like the way they put it, that the idea of stacking insulin in a glucose monitor world is not quite accurate anymore, like you. But this person kind of went a little farther and said, You can't, you can't really stack insulin, when you have a glucose monitor on because you're seeing that you need more insulin. Right? I thought, Boy, that's a big idea. I agree with it in totally in theory. But most of you are going to be taught when you're diagnosed, don't stack and so on. And what they mean when they say that is don't put insulin in at one o'clock, and then put more in it, you know, 130, because you're gonna get low eventually. And if you're not using a glucose monitor, that very well may be true. But right, you can't follow it. Yeah. But if you can see your blood sugar, the direction and the speed it's moving in, you'd have to be incredibly insane to stack to the point where you'd call it some sort of a low that would make you incapable of responding.

Jennifer Smith, CDE 26:13
And that's where even you know, in the CGM, one that we talked about, I had mentioned using those event markers. And the event markers can be hugely beneficial now that they also show up right on your screen. So you can actually see, where did I put the insulin and you don't even have to go back to your pump to look at that. Or remember, when you took your injection, if you just mark it, you will know when those injections went in, you can follow the trend line and you see, okay, do I need more? I don't need very much more. I need a little bit more or a lot more, right?

Scott Benner 26:44
Yep, I've been this is gonna get away from this. And we'll stop in a second go to the next idea. But I've been talking to college students a lot through Instagram messaging. And if you just heard that and think oh my god, that's me. You're adorable. It could be any number of you. But but but but this one person just had a long, protracted high blood sugar that wasn't coming down. So finally, I just said, Look, you you have to like, crush this number, and crank up your bazel like do a Temp Basal raid for hours, like six hours, let's do 30% more and put in however much insulin you think is going to bring this down. And it took most of the afternoon but they got there. And then just with that idea of oh my gosh, I don't have enough basal insulin. The next day, here comes the 24 hour graph hundred and 30 blood sugar, because they're trying to live with not enough base. So as much as as much as we're talking about the perfect bolus here. Remember, you can't make the perfect bolus if your basal insulin is wrong. Correct, right, you'll never be able to. Because you'll always be replacing bazel that doesn't exist. Or if your basal is too high, you'll be causing lows and thinking oh, this is the bolus when actually

Jennifer Smith, CDE 27:59
it might not. Or if you are trying to really be aggressive with your Bolus thing. Then you're Bolus thing and Bolus thing and then finally Bolus thing too much. And that actually brings you back down. In which case then you might be eating, you're sending yourself back up. The Basal isn't enough in the background. So it becomes a roller coaster.

Scott Benner 28:16
So infuriating is this is going to be and then we'll we'll end up this episode. But if you're bezels, right, and you haven't had insulin or food for a few hours, your blood sugar's like 80 it's sitting right there. That's how you know you have your bazel right, and

Jennifer Smith, CDE 28:31
so be stable,

Scott Benner 28:32
right stable. And so and so if you stability at 140 a little more might have stability at 120 a little more you that's how you can learn to play with it, but I'm just telling you that if it's if it was, you know, as intended, you know, by the heavens, then your blood sugar would be around 85. without food or insulin. It's not always going to be like that. I'm not saying that. But I'm saying if you're that far away from that number, you've got work to do on your basal rates, right. Okay, so we're gonna wrap this one up, and then record the next one right away. Okay. Thank you, Jenny for taking the time to be here on the podcast. Don't forget, you can hire Jenny at integrated diabetes.com. Her email address is in the show notes of your podcast player, and at Juicebox podcast.com. As always, I appreciate the support of the sponsors Dexcom on the pod dancing for diabetes and real good foods. You can save 20% on your entire order at real good foods calm by using the offer code juice box. This was the ninth installment of my diabetes pro tip series with Jenny Smith. There are more coming in the beginning I call it like a 10 part series. It might go longer. What do you think of that? If you're enjoying the podcast, please go to iTunes and leave a rating and review. The Five Star kind are the best where you say nice stuff. The better the podcast is reviewed on iTunes the more searchable it is for new people looking for Type One Diabetes support. Thank you very much. For those of you who share on Instagram, Facebook and privately, I love that you guys are telling your endos and your friends and anyone who will listen about the Juicebox Podcast. It's helping us grow. I appreciate it immensely.

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