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

Filtering by Category: Jenny Smith CDE

#660 Defining Diabetes: Black Holes

April 08, 2022Scott Benner

Scott and Jenny Smith define diabetes terms

Scott and Jenny Smith define diabetes terms In this Defining Diabetes episode, Scott and Jenny explain Black Holes.

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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 friends, and welcome to episode 660 of the Juicebox Podcast.

Over the years on the podcast, I've come up with terms that, you know, don't exist in diabetes management. One thing I can think of off the top my head is trust that what you know will happen will happen. It's to me it's a diabetes truism. It's a tool. And some of these terms give you another way to think about an idea. Once in a while on the defining diabetes series, we get off of words that you're like Bolus, I know Bolus, that's a medical word. And we do one like today. Today's term that Jenny and I will help define is black hole. Don't worry, it's all going to make sense soon. Please remember, while you're listening that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan, or becoming bold with insulin. If you have type one diabetes, and are a US resident, or are the caregiver of a type one, and R US resident, please head over to t one D exchange.org. Forward slash juicebox. Take the survey, you'll be helping people with type one diabetes, and supporting the show.

This episode of The Juicebox Podcast is sponsored by us med. US med is the online diabetes supplier that you've been looking for. They have a dedicated 800 number for Juicebox Podcast listeners. And you can call today to get your free benefits check 888721151 For or go to us med.com forward slash juicebox us med wants to bring you better service and better care than you're accustomed to. For today, I think I'd like to do a couple of like my terms, like dictate the pace and black hole, I want to start there. And then maybe we have time, we can definitely

Jennifer Smith, CDE 2:12
your terms. They're not the I don't use but actually my boys talk about black hole, but they're very much referring to black holes in the outer space.

Scott Benner 2:23
Well, so I mean, it's at this point, it's been a number of years. And so I don't even know if you remember the first time I said it. I kind of remember the first time I thought it and it blew my mind a little bit when I realized that a Temp Basal off was creating a void in the future. Right. And that good term for it? Yeah, right, like so. So I guess I guess we're talking, we'll just keep going. The way I see it, and I'm sure the way you see it, too, is that if you're using insulin, if you have diabetes, your blood sugar, as soon as you introduce any carbs, or you know, body functions that push up blood sugar, your blood sugar starts to go up, and it wants to continue going up. It is only stopped by the introduction of manmade insulin. And in my mind, that's a I know, people have probably heard me talk about all kinds of different ways. But you know, you could think of it as the the offensive and defensive line meeting in a football game, you could think of it is, you know, what is that called mimes when they pretend they're up against the wall. They put their hands up right being inside of like the box, yes, I just think of it as equal force from both sides. So the blood sugar is trying to come up. And you need to meet it with enough force to stop it from coming up. But to stop it and hold it at a level that you desire. So some people that might be 80. And for some people that might be 120, doesn't matter. But we've talked about it over and over again, that basil when set very properly. Hold your Joe at that spot, wherever it is, you know. And so I know this, these things might seem disconnected for a minute, but I think they'll it'll come together in a second as we're talking. But I think of that as okay, I know that it exists. If I have that, right. That's one thing I can count on. And then I start thinking about the timing of insulin. And you know, you said all the time as anybody who's paying attention, right, you get a Pre-Bolus your meal because insulin doesn't start working right away. Right? And then you're always very quick to like come by, if I say something about that and say Don't forget basil takes time to start working too. Yeah, right. So if you're on a pump, and you just shut your basil off at noon, you're not going to see the impacts of that at noon. So you could do that right now. You could be super steady or whatever your number is. Shut your basil off and your blood sugar is not going to immediately start going up because beta has been going in slowly over the time. And it takes time for it to begin working. So if your pump is giving you Basal insulin, I mean, how does it break down? And in some pumps, how frequently do you get it in an Omnipod, for example

Jennifer Smith, CDE 5:15
Omnipod, you get a pulse? Well, it depends on what the Basal rate is at, right? Each pulse from a pod is delivered as a point 05 pulse of, of insulin. So depending on what your Basal may be, if it's only point one per hour, you're only getting 2.05 boluses, essentially, pulses over an hour's time. The higher the Basal rate, the higher the pulses so incrementally that adjusts over the course of an hour. Based on how many pulses you should get to add up to your Basal in an hour.

Scott Benner 5:51
So if your Basal is a unit an hour, you're going to get 20 pulses an hour of the point oh five,

Jennifer Smith, CDE 5:58
and divide that into an hour, which is 60 minutes, it could give you exactly how many minutes between pulses. Exactly.

Scott Benner 6:04
Okay. So that, that that the rest of that math, I don't care about the idea that it's going to happen. It's going to wait, it's going to happen. It's going to wait, it's gonna happen. Each one of those little pulses, lives in its own timeline inside of your body. Yes, yes. Ah,

Jennifer Smith, CDE 6:20
absolutely. It's like starting a new if you imagine the timeline, that's a really good example. You know, I mean, even grade schoolers, like my child who's in third grade already knows a timeline or a line of, you know, something in math to break it down. Yeah. So if you say, Okay, over this timeline, I'm getting a dose here, I'm getting a dose here, I'm getting a dose here. And then each of those has its own. If you imagine like a bell curve of action, right, got its own timeframe of start and finish each pulse does.

Scott Benner 6:52
Yep. So if you've been on a Basal drip for hour, I mean, you don't have to be on it for about an hour for them all to be active. And then you shut it off, it would take I know this is audio, but the first point oh, five at the top of the hour, lives its life goes through its bell curve and in dissipates. The one that happens after that starts a little later than that ends a little later than that. But if you just shut your Basal off, eventually, all of those little pulses would live their lives and be gone endpoint and have an endpoint. And when that happens, then there's a void. There is a black hole where there is no longer any gravity pulling down on your blood sugar or pushing down on your blood sugar. I know the gravity doesn't exactly work like that. But it's not the point in my head. It does Jenny. So when I'm thinking about insulin, this is how it works. So, you know, that's where you, you know, you can you hear me say, Well, if you're low now, but not too low, what if you shut your Basal off for half an hour, maybe an hour from now that 70 That's been holding, but not going down might drift up to I don't know a little bit more, right. And you put the Basal back on and you kind of catch it. It's, um, I'm Hope I'm being clear, because in my mind, it's crystal clear.

Jennifer Smith, CDE 8:15
It's, well, you're bringing up a really good point, because I think as people get more, they want to become more aggressive, not an I use aggressive, not as a bad word, but they want to get things in target more often. Right? So we learn how to manipulate and micromanage with insulin. But the biggest piece that you do have to remember is that the timeline of insulin isn't rapid. Rapid is I think one of the sets a horrible name for our insulin today, it certainly works a lot faster than ages ago, thankfully, but it is not a stop it now, it has a now effect on what could happen. Right? You have to remove it with enough time to build up in circulation more or in circulation less to impact the time in the future that you want more or less. So if you are low right now. Do not suspend your insulin.

Scott Benner 9:23
It's not gonna help you need sugar. It's not gonna work fast enough to stop a like a falling blood sugar. Right? My and I appreciate you pointing that out. Because my my thought there was if you're 70 and your hours beyond your meal, insulin, and you know you're not getting any lower, but you really wish you were at five and you don't want to take in carbs. Taking your basil away for 30 minutes. Could be enough. Yeah, but it's not going to also happen in that moment. Like you can't shut the basil off at noon and expect the 70 to turn into 85 you might see a slow drift up over the next hour. Right That's my guess. So right over an hour, and you also those of you who hear this and are like, I'm going to try this one day. Also remember, you can't be shutting your basil off forever. Like if you have to shut your basil off for three hours, you have bigger problems, then a small little nudge might help. And and you want to fix that problem. You also don't want to be without insulin for that long, just No, not a good plan.

Jennifer Smith, CDE 10:24
We usually say no, no suspends, or no disconnections from insulin for or Basal insulin right. Even if you're on injections, and you haven't taken Bolus is all day but you did take your Basal you're not without insulin. So that's a different scenario, right? But completely disconnected from all insulin. We don't want it longer than two hours,

Scott Benner 10:44
right, basically. And that would be in a situation where you're talking about, you know, you have too much to begin with. So you're trying to kind of horse trade, which I'll talk about in a half a second. As soon as I answer Arden's tax play, this hasn't happened on the podcast in a while, because the COVID, where I talked about Hardin, about her food. So Arden is in a situation now where she is in a Chinese restaurant. And she says she is having sesame chicken and white rice. But Arden is also on a steroid pack right now. So we stuff we have her insulin jacked up to work on this. The problem is, is that we're using the algorithms the algorithm is set at a 200% increase right now all the powers jacked up to 200% of its settings. So if she puts in the right carbs for this, it's going to double her meal insulin and probably I'm guessing killer in about a half an hour. So we're gonna,

Jennifer Smith, CDE 11:42
we're gonna, probably not she'd she'd do something, she would do something about

Scott Benner 11:45
it, but it would try to get her. So I'm gonna tell. So what I'm basically doing is I'm telling her to take, I'm telling her to tell it half the carbs of what I think it is. Because it's going to double it. So I think that will make a Bolus that is so

Jennifer Smith, CDE 12:00
you really only need with the steroids. You only really need more basil. It doesn't sound like Bolus does need to be what's increased. It's more just a Basal level, she definitely needs a heck of a lot more.

Scott Benner 12:10
Absolutely crazy. She's on the steroid pack. Her Basal is basically at four units an hour for the last couple of days up from 1.1. But no change in her meal ratio was necessary at all. Wow. So I mean, I don't know. Like, I'm just going with what works at this point, you know, right. So hold on one second. So I've told her that get her back to this. Okay. All right. Now I got to try to find I'm getting too old to skip around in thoughts, Jenny, hold on a second. What the hell were we saying before before she texted

Jennifer Smith, CDE 12:43
talking about insulin, and it's action time.

Scott Benner 12:48
Yeah, don't turn it off. Because we were talking

Jennifer Smith, CDE 12:51
about the timeframe to not turn it off for which was about like, no more than two hours is typically what we

Scott Benner 12:57
write. And I was gonna bring up that if you're using an omni pod specifically, it's always Temp Basal decrease, because you can set an end time to those and it kind of turns back on turns back on. Whereas if you suspend the insulin and you do not remember to turn it back on, your insulin is not coming back on. But my bigger point here was going to be that if you think about, if you think about this, the way we're talking about it, you can flip it around and think about the other way. So I'm just going to kind of go through it again. If you shut your insulin off your Basal insulin off on your pump at noon, and you leave it off for an hour, sometime about an hour or a second, she's saying 19 year, let's just dial that back a little bit.

Jennifer Smith, CDE 13:44
I'm always, I'm always interested in I have a lot a lot. I have a lot of teens that I work with as well. And I am always amazed at the amount of insulin that they take for meal pie. Like I oh my gosh, that's like 80 to 90% of my total daily insulin. Right there in a meal. Oh my goodness,

Scott Benner 14:09
she's about to have white rice and sesame chicken in a in a Chinese restaurant. So I told her to make it 16 I gotta be honest with you. I don't know what's too much. Maybe I don't know what's about to happen. But we'll see. And she's got my car. So not only am I worried about her personal safety, but I'm worried about my card. So so we're trying to be

Jennifer Smith, CDE 14:33
very clear. Text me when you leave the restaurant. Yeah. Oh, gosh.

Scott Benner 14:36
Okay, so anyway, so turn it off at noon. It creates, you know, it takes a while for all those timelines of those little pulses to finish up. And now at some point in the future, probably around an hour, you're gonna start seeing a drift up. That's a that's a ninja level move. But what you're really doing is you're manipulating the insulin to be where you Wanted end to end and, and sometimes to not be where you don't want it. So if you so you probably people have probably heard me talk about even using Temp Basal increases during carby your meals and and that's a good way to like up your basil so that an hour from now you have more resistance, you could do that to meet a fat rise from French fries, you know, you could do that I see Arden's fat rise from fries, and a burger hits her in about 90 minutes after she starts eating. So there's a world where 30 minutes after she starts eating, I can jack or basil up to try to get ahead of the fat rise. Just as simply you can also kind of just, you could you could flip it around and do it the other way, right? Like you could take it away to create a void to create a black hole. You could also add it to give yourself a I don't know, I don't know enough about space. What's something that sucks you when it gets really powerful? I have no idea. But but you can change the power in the future by making decisions. Now, super important to say that I think everything you do right now with insulin is always for later whether it's a decrease an increase a regular Bolus, no matter what you do, it's for later, right.

Jennifer Smith, CDE 16:21
Absolutely. And that's I talked about that a lot with people in terms of adjustment. They might say, well, everything is lovely after midnight, in terms of like basil alone, right? Everything is lovely, as long as I land at midnight where I want to. But last night, you know I or and or I've been floating around at 170 overnight, but it's really nice and stable. Well, good. It's stable, because your basil isn't wrong in this time period. Right? Where it's wrong is in the hours before this, which is impacting this time. And this basil is holding it where whatever happened before. left off. Yeah, so let's address this time period. Right. But the same thing for exercise. Again, I work with a lot of people around exercise and how to manage and manipulate and it's don't adjust right now as you're going to set foot on the football field.

Scott Benner 17:15
Right? Yeah, well, and the other ways to think about it, because really, this is just about striking someone in their mind in a way to think about it. You, you can create stability over 24 hours, by having all of these decisions, right? And people are like, Oh, that's too much to do. But it's not really you're talking about having your basil set well, understanding, you know, if there are certain times of day where your basil needs to be stronger or weaker, knowing when that is starting that Basal program prior to when that happens. But I'll try to make sense of it a different way. If you're on a football team. And you're on the offensive line, you have five guys on your offensive line, but I rush six, someone's not getting blocked, right, and you're getting sacked. So the way to think about that is if you have, I don't know 20 carbs of insulin in your meal. But you somehow Bolus for 30, you've sent more rushers than you have blockers, correct, right. The other way to think of it is if you bring in a tight end block, and that guy's only rushing for, there's no way he's probably getting to you because now you're you got six guys blocking four guys, it's all about putting the right amount of resistance on the other side of the attack. And in truth, both sides are attacking, right, the insulin is trying to pull that, that sugar out of your blood. And the carbs or your body function is trying really hard to push your blood sugar up. So this is usually the time excuse me, when I'm on stage and talking about this, I tell people just to take their hands, put them out flat, put your palms together and push together. And you just need to push so that your left hand can overpower your right hand and your right hand can overpower your left hand. And when you do that, you have stability. You take those palms that are probably in the prayer position right now and you turn them sideways. And that's a flatline. So the thing pushing from the top can't overwhelm the thing pushing from the bottom to thing pushing from the bottom can't overwhelm the thing pushing from the top and your insulin. And your insulin need is now in this just fight that neither of them can win. And that's what that's what a flatline on a graph is it's just, it's the need of insulin, those carbs, and the resistance of that insulin, that insulin, both dialed in, in a way where neither of them can win the fight. And if you have too much insulin, you're going to get low. And if you have too many carbs, you're gonna get high and honestly I don't think there's too many carbs I think of it is not nothing solid. Right? And

Jennifer Smith, CDE 19:51
that's a good point to make because quite honestly, we were too carb centric. And if you really understand food in general Yes, we're taking insulin to work with carbohydrate. Otherwise it wouldn't be called an insulin to carb ratio, right? But anytime there is more food there, and more food usually means more of those other macronutrients to things like proteins and fats. And so learning, learning by watching your trends around things can teach you how to create enough for later, when those other things may be impacting. And you want to keep control.

Scott Benner 20:32
Yeah, you have to meet the need, like I've, I think, throughout the years of making the podcast, I'm most happy with that statement meet the need. Because the need may be lower, at times, it may be higher at times. But if you don't meet it with the right amount of insulin, you're gonna lose one way or the other higher? Well, it's just but somehow in my mind tying together, the idea of the timing of the insulin, and how to how you can make it not exist in the future, gives you the power to make it exist, excuse me, gives you the power to make it exist even more in the future, if you want it to correct. But what ends up happening to most people, is they don't get themselves into this mindset, that everything I'm doing now with insulin is actually happening later. And then they're always I don't know, it's like, you're, it's like you're chasing the flash through time. And you're always ending here always ending up where he was 15 minutes ago trying to fix the problem. Right? Right, you need to be ahead of it. And, and I think that, to be honest, that's gonna transition really well into the next defining episode. So I want to make sure that you don't have anything else you'd like to add to this. I know, this is not like a standard diabetes term, or idea. It's just an idea that makes my mind right about using insulin?

Jennifer Smith, CDE 21:52
Well, I think it's a good point to bring up especially considering the way that people have started to learn more about manipulating their use of insulin. And in terms of what we now have access to technology wise, many of you know the algorithm driven systems utilize this, this watch, right, this predictive nature. And so that also works with how insulin is going to be put into the picture now based on what it's predicting to happen. Coming into the next hour, two hours into the future. Yeah. So it's, it's definitely something to, to know. And understand.

Scott Benner 22:38
See, I love you, because I didn't know what you were about to say. And then what I had planned to say was, I've learned so much about this watching, Arden's algorithm work. Yes. Right. And so yes, you and I are just people and the people listening are just people, our computing powers, not quite as high as a, as an algorithm and algorithm, right. So I'm not, I'm not asking you in your mind to track you know, 20 different timelines of point oh, five boluses, just to understand that, that's how it happens that they kind of feather and layer on top of each other. And then in a regular situation, without algorithm, you could use that information to make some good decisions. But where I really learned to believe in it, is watching the algorithm watching it, you know, I tell the algorithm, hey, her blood sugar requires 1.1 unit events on our for for basil. And it goes, Okay, that's my starting point. But there are times when it decides what you know, it looks and it says, Well, what I think is going to happen in the future, an hour from now indicates to me that if we change her Basil 2.7, right now, we'll be able to keep stability off in the future. And you watch that algorithm, give insulin, take it away in the form of a basil over and over and over again. And even really good settings. Like even if you have rock solid settings, and your day hasn't been full of too many variables, you know, exercise or tough foods, the balls for whatever, you still see a rise and fall of basil throughout the day, because this thing's making these automated changes. And in some algorithms, also bolusing it'll make its decisions. And then it looks up and goes, Oh, this didn't work. You know, like we need we need more and it'll Bolus or Ooh, Jesus didn't work, you're going to get low, and it'll rip away your basil for long periods of time to try to stop below in the future. And it's not always successful. But it's successful so frequently. It just really made me believe that I know it's the best we can do when we're injecting to inject once your Basal insulin during the day and you get what you get you manage around it or even with a pump or you set your your Basal rate at something certain or try to make some adjustments to get ahead of problems that you see happen every day at a certain time. But it's just not it's not enough. Right? Yeah. No, it's a great start. It's an amazing tool, but it is not everything that you're going to require. And so the rest of that has to be you. And, you know, seeing these trends and being able to make adjustments to it to hopefully stay ahead of problems, so that you're not always chasing a problem. Like, if you keep showing up 15 minutes after the bank robber leaves, you're never gonna catch them, you know, you got to you got to be inside waiting for him. And anyway, in my mind, understanding how to create a black hole in the future with insulin is, is the first big step and understanding how to manipulate it in a number of different ways. So guys, this is where the episode ended. But then Jenny, and I kept talking about it, it was gonna be a private conversation, but I thought you might want to hear it. So I'm going to include it right after this word from us, but

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Wow, that's so heavy. And then Arden texted twice in between it was like it really is like a time travel movie. It's it's like, you know, you're trying to understand you're like Wait was that in the future? The past you get kind of like twisted up. It's not easy, but the people who end up understanding it really understand it.

Jennifer Smith, CDE 28:34
Right. You know, and that's the that's the that's the Kenny facts maybe not necessarily exactly that level. But that's the person who is really looking and understanding especially the algorithm driven pumps. I don't know how many people I look at their data initially on talking to them. And they're like, I don't know, I thought it was gonna be all so much better. But I still have this big standard deviation. It's all roller coaster. And I was like, Yeah, because your pump is taking away this much insulin. And then it's like jamming you full of extra insulin because it took it away. And now you're sky high riding right? And then it's got to take it away again, because now you're drifting. I'm like, we got to stop, stop the deficit.

Scott Benner 29:16
Everybody. Listen, we're still recording, I think maybe this gets to stay in. You still have to Pre-Bolus it's, you know, and I know that already. But it's interesting that people are seeing it right away and thinking, oh, gosh, the thing, the machine will just do it. Like, in your point earlier, the insulin doesn't work rapidly enough for you not to Pre-Bolus your meals, you're always going to get behind and then the thing is going to come along and try its hardest to stop it. Eventually it's going to stop because the food's gonna digest and then you're gonna get low afterwards. And you know, and then it's not much different. It's everything is I don't know it's real. vibey you just have to, you gotta find it. You know, it's like dancing. It's like Dancing with a woman. Like you just got to close your eyes and just, you know, you gotta go with it. Yeah, you sit there and try to figure it out all the time, because you just look like that weird guy in the middle of the floor trying to do the right thing. Her hips, move your hips move. Yeah, that's it, you know. So together, yeah.

Jennifer Smith, CDE 30:17
And, you know, when you said, you know, watching an algorithm work, I think that's a really good way, if you have the chance to kind of pay attention and watch, it's a really good way to see a lot of people are also, you know, I don't love my active insulin time that my algorithm is set for, I think it's way too long. We had it set for like, two or two and a half hours in our conventional pump. Well, your explanation, or you know what, we talked about all those little pulses. In algorithm driven systems, those little pulses are now seen by the algorithm as new starting places. Yeah, it's kind of a long term finish line, right? Yeah. So it needs the length, the time period to be able to predict into. So

Scott Benner 31:03
I think that's why the first day of on the pod five, they say that very first pot the first time you put it on, it's collecting data at that point. Now, it doesn't happen at the beginning of every new pod, like every time you switch it. It's the very first time you put that algorithm on it needs that first pod to figure things out. Yeah, it's all fascinating. Okay. All right, hold on. I'm all worried No, I'm warm.

Jennifer Smith, CDE 31:30
I'm glad you're warm.

Scott Benner 31:31
Cool, you're in. You're up there in Wisconsin. You're lucky you're alive. You're gonna be living inside of Han Solo is TomTom to stay alive at some point up there.

First, a huge thanks to Jenny Smith. As always, for being on the show and sharing her knowledge with us. Jenny works at Integrated diabetes comm if you want to hire her, you can also want to thank us med the newest sponsor of the Juicebox Podcast and remind you to go to us med.com Ford slash juicebox. To get your free benefits check find out if US med is right for you. Or you can call them at 888721151 for better service, better care. Get your diabetes supplies from us med

All right, I thought that was a fun episode. Let me just remind you that anything you need about the podcast can be found at Juicebox Podcast COMM The diabetes pro tips and these defining diabetes, as well as other series of the podcasts are also there. You can actually find defining diabetes, and diabetes pro tip at diabetes pro tip comm as well. Or you could just look in your podcast player and search for them. Just if you're in this podcast player, please follow or subscribe to the show. It's really good for the show and and that way you'll get the newest episodes as they come out. Plus, it makes me feel nice and I mean if you're trying to do something simple and nice for me, subscribing in a podcast player would be pretty cool. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.

#656 Defining Diabetes: Barriers

April 04, 2022Scott Benner

Scott and Jenny Smith define diabetes terms

In this Defining Diabetes episode, Scott and Jenny explain barriers.

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Scott Benner 0:00
Hello friends, and welcome to episode Wow 656 of the Juicebox Podcast. That number took me by surprise

today, today's episode defining diabetes with Jenny Smith is going to be just a little different than usual. First, Jenny and I are going to define a term, we're going to talk about barriers. Jenny and I are going to talk about some situations where you might need barriers between your medical devices and your skin. And then I'm going to read to you a ton of suggestions from the private Facebook group about the barriers and creams and wipes and all the stuff that they find helpful. little bonus content on the end of a defining diabetes episode. While you're listening, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan. We're becoming bold with insulin. Don't forget that Jenny Smith does this for a living you can find her an integrated diabetes.com. And if you're a US resident who has type one, or is the caregiver of someone with type one, I would personally appreciate it if you took the survey AT T one D exchange.org. Forward slash juicebox.

This show is sponsored today by the glucagon that my daughter carries G voc hypo Penn Find out more at G voc glucagon.com. Forward slash juicebox. Alright, Jay, so my only my only only experienced with this came when Arden was about eight years old. I haven't thought about this in a while I wrote a blog post about a really long time ago. But she was starting to get irritation under her insulin pump. Okay, and I was at my wit's end, I really didn't understand that I wasn't as entrenched in all this back then as I am now. The Internet wasn't as helpful as it is now. And I I didn't know what was going on, right. So I stand there one day like thinking I swear to you like just standing thinking. And I was, I don't know what happened was rubbing my fingers together while I was thinking. And I was like, wow, my fingers are so dry, like dry and cracked. And like, why are my hands dry and cracked. And I thought about I thought about it, I was like, I am touching alcohol constantly. Right? I'm cleaning Arden sites, I'm cleaning her pod sites, I'm always my hands always behind them. And that sent me to the internet, where I did some Googling and learned that in Europe, I believe this a long time ago. So you know, don't hold me to exactly where but the standard of care is that you don't prep sites with alcohol, right? You prep them with I forget what they do a mild soap and warm water or something like that. And then just dry the site, dry the site. And I switched to that and art and stopped having irritation. And my fingers aren't crusty and hard anymore. So that's how I fix that. Now Arden obviously didn't have a real significant reaction because the alcohol I think was just drying her skin and then making her more susceptible to whatever was in the adhesive, which I imagine the adhesives probably made out of something completely different now than what it was made up back then. But that was the first time I thought about it. And then in the first like 20 episodes of this podcast, a woman came on. I can't even remember the kid's name still Mason. Because this kid had, like he put on any kind of medical graded he's of and his entire body broke out. It was horrifying, right? And but she wanted to use these things. And this woman just man, she just figured it out. Like she built a concoction of barriers and wipes and everything and made it to this kid could wear it. But it's a world I don't know much about so I'm going to ask you like how many people do you think out of 10 or 100 have to put some sort of adhesive barrier on is it many?

Jennifer Smith, CDE 4:25
I think that a an easier estimate is probably out of 10 I'd say that there's probably one person out of 10 Give or take that probably has experienced some type of adhesive irritation at some point. So like you found you removed something that was essentially just it was literally taking all of the natural oils out of the body. That's what alcohol wiper Alcohol does, right? It just it's a degreaser it takes everything off. So does it clean your skin? Sure, but it cleans it almost to the point that then when you're putting something else on top of it, that kind of like locks in that dryness and is sticky, you're irritating skin that's now dry, and you're doing it over and over. It's not just like one time, right. So sometimes it's cleaning up enough of what you're doing that can take care of it. Other people though, definitely have to use a barrier of some type. I mean, I've seen rashes that are very just specific, right around the edge like the the underneath the adhesive doesn't seem so bad. But it's like right around the edge of the adhesive. That gets irritated enough that it almost looks like the pump site is still there. Or the CGM site is still there, even though it's not. Some people have it bad enough that it it blisters, like horribly like blisters, like almost like you'd see in Oh, what is it leaves of three, let it be, you know,

Scott Benner 6:13
poison ivy or poison ivy,

Jennifer Smith, CDE 6:14
poison ivy, I couldn't like I knew the little rhyme but I couldn't think of the plant like poison ivy, poison oak, which I actually had, I had one of them, they didn't know which one it was, but I had one of them in the blisters. And it's so itchy like unbelievably right. So some people get that degree, and it takes forever to heal. And when you have I mean any kind of body, but little tiny bodies have such little real estate to begin with. That if you've got this big inflamed site on one area that takes an entire month or six weeks to heal up. That's now you're sticking it someplace consistent enough that you can start to cause problems in another place just because you're not rotating well. Right, right. So I mean the kinds of barriers there are some, like hypoallergenic types of barriers like tegaderm, there's another one called IV 3000. It's like a really, really clear thin that you kind of cut a little hole in where the infusion set or the sensor is going to go into the skin. Clean the skin, put that on top of it, put the pump site or the in the in the sensor on top of that. So really, it's adhesive is sitting on top of this barrier not on your skin. That works for some people. Other people as a barrier can get away with just using like a topical kind of like a spray Benadryl let it dry, put the side on top of it or a spray floaties can spray it right over their skin same thing and that can be enough. So I've seen I've seen everything that we

Scott Benner 7:54
have to be a little bit so I went to this so after this this lady came on and and she actually the kid's name was Henry. That makes me feel bad. Why did I say Mason? I don't know. Damn, I was so confident when I said Mason. But the woman's name was Rachel and after she was on the podcast I actually asked her to write a blog post which I still have on the on the face of my of my my website because people use it so much. But here here's this is from 2015 But she washed the area with warm water and antibacterial soap Do not use alcohol. Completely dry the area. She applies one puff of Flonase she says you can sweet talk or demand this prescription from your endo if it's necessary. Then she applied a thin layer of have Alon barrier cream that she got from Amazon it's made by three MC a V i l o n again this is like eight years ago. Then she says she applied a layer of tegaderm HP 9534 HP not just tegaderm and I'm like boy this lady dug deep you know

Jennifer Smith, CDE 9:00
and the ticketor comes in multiple sizes too. So if you're looking for it know the size of your site that you want to cover because it comes small to big she listed

Scott Benner 9:09
six by seven centimeters. Place the inset through the tegaderm HP. Then she said they placed another layer of tegaderm on top of the pump to provide an extra layer or barrier for the adhesive of the detached inset. Not sure what she means there when wet blow dry sight with a hairdryer on a cool setting. Apply prescription hydrocortisone after removing the tegaderm hp on at on an old site and she only removes extra adhesive with something called Callan doula oil. Yeah, so she this is I mean, if anybody wants to see it's this this little kid. His face is red. He's got splotches all over him nowhere near where his medical adhesive is either. He was just allergic to this.

Jennifer Smith, CDE 9:56
I had a gentleman who emailed me an adult diagnosed as an adult, who all of a sudden for some reason, started having irritation around his sensors, like had been using them forever. And on a business trip was itchy itchy around the site and he removed it. And it was like that blistered that blistered level of skin. And then he was like, Well, maybe it's just the site, you know, maybe it got like, maybe I didn't clean it well enough. So he put a new one on, and by the next morning, he had irritation, same thing around the skin. And the funny thing is, it went on and into that week, places up the same side of his body where he had no sights at all sounds like the same little boy. He had, like, Welty blistery places on his body that had not even been touched by a site yet something

Scott Benner 10:51
else. It's terrible. If anybody's interested, I can't believe I'm saying this, as we're in the six hundreds now, but it's episode 14 of the podcast. Wow, that was a long time ago, Scott 2015. And

Jennifer Smith, CDE 11:05
she's got a lot of really awesome. I mean, all it sounds like she's gone through like, all of the products, the only thing that that we would usually caution is what we call green housing, a pump site, or even to CGM

Scott Benner 11:21
because of humidity. Right? Right. You

Jennifer Smith, CDE 11:23
would, in fact, if I'm glad it worked for her again and have one great, we don't recommend it, though, because the humidity or any moisture underneath that could actually create more irritation underneath yet. But again, her story, it works for her and her son, so that's great. Yeah,

Scott Benner 11:42
I mean, it's a it's a real indication, at least to me that if you I mean, try hard enough, get the right information, get a little lucky, you might be okay with it. But I see people who just persevere and there's no need for that, like, there's some of these barriers are just too available and work too. Yeah, you know,

Jennifer Smith, CDE 12:00
well, and the one thing I was gonna bring up to about this is that in terms of when you might see a seasonal need to use barriers versus other times of the year that it's not necessary at all. So you know, if that's something that you're noticing, don't think that you're crazy, you know, once you get into like, fall and winter, your issues go away, or once you get out of the dry season and you get more into summer, it goes away. It could certainly just be seasonal, based on kind of the humidity and nature of the air.

Scott Benner 12:31
Yeah, well, okay. Well, I'm, I'm glad we talked about this, I'm going to put you know what I'm gonna do with this one, I'm going to, I'm going to do some work, Jenny, I am going to go back to the Facebook group. And I'm going to ask people for what they're using modern day here. And I'm going to put the list at the end of the podcast. Awesome. All right. I mean, I'm busy, but I'll do it. Thank you very, very, so helpful for everybody. Well, I'm looking for a pat on the back here because this is extra effort. But I think it's not just kidding. I know I think I think it'd be interesting because because this article that she wrote is so old to hear if people are found updated stuff and maybe get a good list. So I think it's a great idea. All right, awesome. Thank you. Yeah.

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Don't forget there are a ton more defining diabetes episodes right there in your podcast player. And at juicebox podcast.com. You can also find the diabetes Pro Tip series and many of the other series. All right, wherever you listen, you might want to check out the private Facebook group for the Juicebox Podcast. It's called Juicebox Podcast type one diabetes. And please consider taking the T one D exchange survey AT T one D exchange.org. Forward slash juicebox right back to the episode now. Maybe I'm going to read people's suggestions in different voices. Each suggestion gets a different voice. I'm a man of 1000 voices are you ready

so I put a post on the private Facebook group after Jenny and I recorded this. The post was simple it said barrier wipes creams and patches. If you have a recommendation, please leave it here. Your product or methods may be used in an upcoming episode. Now I'm going to get through this as well as I can, there were 187 responses, I'm quite certain I won't be reading all of them to you. Alright, I'm sorry, there's not going to be any attribution to the people who left these because it'll make it'll just make me crazy to try to add the names. So you're ready. Smith and Nephew skin prep, which is a protective barrier wipe available on Amazon. In the past, we've used that company's version of adhesive to put overtop of Ardens CGM. Currently we're just using the overlay that Dexcom provides. Somebody here says they use expression med patches. This person says what works best for them before a pod they put on kavalan spray as a barrier. And for removing the pod Lift Spray and then lift wipes. They say they work amazingly well. They use dream cream from Lush on the site where the pod was afterwards and then somebody came in and said I love dream cream. I don't know what dream cream is. But two people here think is pretty cool. Someone here says they're using baby oil to help the devices come off to loosen up the adhesive and they're using a adhesive called HyperFlex which they say is available on Amazon. This person says they use two layers of Flo neighs base and then skin tack that works well for them. Here is a person that says wipe site with alcohol wipe. Spray Flo neighs. Dab one skin tag placed x comma on the pod. Then they put on Alexa cam patch for Dexcom or a pod pal for Omni pod. When they have a skin reaction, they use hydrocortisone to clear it up. Brandy Johnson here to make a good point. I'm going to read it for you. She said the one thing I'm seeing here is that there are two different issues some people in the thread have a typical mild allergic reaction and they can get away with less prep, but others have major reactions that are almost like chemical burns. She said hers was the ladder and the only thing that worked for her was to completely cover the device adhesive. Bandaid brand extra large size, Hydra colorectal bandage on the skin and then the device on top of that this next person says that when you're dealing with type one and eczema, a cloth feel adhesive patch works better than a latex feel adhesive patch. There go to is something called simp patch or sim patch Excuse me. And they also use the Smith and Nephew remover wipes which is a good company and I've used some of their products in the past as well. Becky says that she cleans sites after the device comes off with something called my cellular my seller water M IC e ll AR to remove the residue. This person is suggesting something called LaRoche Posey Lipikar balm. Wow for the rashes says that their child gets horrendous dry cracked skin in the winter. LaRoche Posey Lipikar balm AP plus intense repair body lotion sounds like I'm doing an ad for it. I don't even know if it works. Here's a vote for skin tack for a barrier and then they use a stay put adhesive for Dexcom they've bought peels for fun but they don't last as long they say not as long as the stay put brand

here's another person says floaties is a barrier for preventing a rash but you really have to let it dry out where the adhesive won't work well. They also like skin tack wipes and tech away wipes as a person here talking about how hype effects comes in a two inch roll. That looks like another Amazon thing. Here's someone talking about a wipe they use to prep the skin. They say it's like alcohol more portable than soap and water dries quicker they don't need Flonase brava skin barrier spray is what they're talking about brava skin barrier spray they're also talking about something called BZ K antiseptic, antiseptic tablets but you guys use a whole bunch of stuff. I have to be honest I just wipe it off with some warm water boom we slap that thing right on there I'm starting to feel lucky that we can do that. Um Let's see what we got here. Smith and Nephew tincture of benzos pump spread A liquid bandaid spray and it worked really well they said and they've added the Smith and Nephew but haven't tried it yet. Some people said they use googan for removal. I didn't know that was for people. Is it here's one for next care mmm 11803 spray liquid bandage. This person says they remove the adhesive afterwards with an alcohol wipe hmm I personally don't like using alcohol but to each his own. This next person says kavalan spray is the best. There are T one is elite allergic excuse me to all adhesives. Even breaks out from skin tack Flonase helps them but they prefer the calculon spray. This person says for for a barrier they use try my Jesus Lord Tria, MCI n o l o n e spray. Creams these baby oil Aqua four and Vanicream patches they love expression med patches and for removing adhesive they like baby oil. Sometimes yunusov But they don't like the chemical smell. I'll tell you what that yunusov works really well but it does stink. Stinky stinky stinky. Like after you use it you almost have to wash and wash the area so you don't smell it. But it is what we use here yunusov When we use it I don't really don't really use that often. Someone here is talking about a liquid adhesive called Marisol three M kavalan wipes for tea slim antibiotic cream for after the change. This person says they've tried several different brands of over patches. By far the most sticky and long lasting has been Lex cam adhesive waterproof looks like they make a Dexcom G six adhesive this Lex cam company another Amazon item wow there's so much here you guys are pretty cool to answer these questions like this person says they're allergic to expression med patches. And they go through a whole thing here skin tack is a possibility currently they're doing a clean slate with hypoallergenic soap dry Flonase times to dry Smith and Nephew dry hype effects sugar under patch then the Dexcom and hype effects on top and acute sugar patch for design so Alright, well that's nice. Wow, this she put a picture of her kid's arm here. It's really terrible. It he said he's uh, allergies are just nasty sometimes for people. Okay, Cavalia and cream tegaderm. Alright, I'm getting pretty far down the list here starting to see a lot of duplicates. Although here's a new one. All care protective barrier wipes. That's a ll kare. That one's from Isabel Isabel. Look at you helping out. What's next? This person says the sugar patch best patches the sugar patch.

Let's see. Let's do another sugar patch skin prep. Alright, we're getting down to it here. I think it's a great thread by the way. I'm going to leave it up for a little while in the private group. If you go to the top and go to featured I'm going to leave this thread in there so you can really go pick through it. Yeah, I think I'm down to I think I'm down to some repetition here. I'm just I'm scrolling real quick to be sure. Oh Goo Gone does make a bandage remover so they make one for your skin as well. Here's a vote for not just a patch calm tegaderm Fixi see adhesive patches for G sixes fixie see if i x i see on Amazon expression met against they put medical again. Sensi care barrier wipes and Cincy care adhesive remover spray have been awesome, says Julie. Sugar patch they put medical Flonase What's this one? This one's different. colo past barrier wipes to protect the skin COLOPL A S T. This one first person says I have to be honest what we use. It's hard to beat the free Dexcom over patches. They'll send you 10 of them every month if he asked for them. I agree we use them. They're terrific. Arden of course isn't allergic to anything so we don't have to worry about a lot of this but they are great if you don't have any allergies to adhesive. Here's one from Josh he says freedom band for Dexcom G six Benadryl, Some people use Benadryl spray underneath a barrier to prevent adhesive reactions. This person says not to use alcohol I have to agree. Alright guys, I think that's it. We've, we've, as they say, done it. I'm still scrolling. By the way, there's so many lovely people. Here's one safe and simple skin barrier on Amazon. I haven't seen that one yet. So another vote for fix IQ. Let's see. And we've done all right. Wow, I'm looking at some people's pictures of the reactions to adhesives and they're just terrible. Okay, guys, that's it. 187 replies, I've done a good job of picking through them and getting you everyone that was in there. None of these people are sponsors. I did not take any money to say anybody's the product I just thought this would be something for you. That might be helpful just to hear what everybody else is doing. Again, if you go to Juicebox Podcast, type one diabetes on facebook and join the private Facebook group. Right there in the featured tab at the top. You'll find this post which I will leave up there for absolutely as long as it is popular and people are commenting on it. Last thing I want to say is that for a great many of you, if not for most of you, and he's problems like this will never be an issue. But for the people for whom it is an issue. It is a serious one. And I hope something here today helped you.

A huge thank you to one of today's sponsors, G voc glucagon find out more about Chivo Kibo pen at G Vogue glucagon.com Ford slash juicebox you spell that? G v o OKEGL. You see ag o n.com forward slash juicebox. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. If you're enjoying the show, please share it with someone who you think might also enjoy it.

#652 Defining Diabetes: Pump Break

March 29, 2022Scott Benner

Scott and Jenny Smith define diabetes terms

In this Defining Diabetes episode, Scott and Jenny explain Pump Break

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:00
Hello friends, and welcome to episode 652 of the Juicebox Podcast.

Today on the podcast, Jenny Smith and I are going to find a term from your life with diabetes. In today's defining diabetes, we'll be discussing pump break. While you're listening, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan. We're becoming bold with insulin

Are you looking for a way to help people with type one? Are you looking for a way to support the Juicebox Podcast, I have a little something you can do that will do both of those things. And it will take you fewer than 10 minutes. Head to T one D exchange.org. Forward slash juicebox. Take the survey. And that's it. You need to be a US resident who has type one or a US resident who is the caregiver of someone with type one. Other than that, there are no rules T one D exchange.org For slash juicebox.

This episode of The Juicebox Podcast is sponsored by two of my longest advertisers, Omni pod makers of the Omni pod dash, head to Omni pod.com forward slash juicebox to get started today and see if you're eligible for a free 30 day trial of the Omni pod dash. The podcast is also sponsored by Dexcom, makers of the Dexcom G six continuous glucose monitor, say hello to dexcom@dexcom.com Ford slash juicebox. You may be eligible for a free 10 day trial of the Dexcom G six, you'll find out the link links to these and all the sponsors are available at juicebox podcast.com. And right there in the show notes of the audio app that you're listening in. Jenny, I'd like to define pump brake. And I have to admit that I don't know enough. I think because I don't have diabetes. This one's lost on me. Right? Okay. From my perspective, I believe that Ardens insulin pump has made Arden's diabetes easier. Sure, because I'm not wearing it. I don't have any reason to want her to stop it. But

Jennifer Smith, CDE 2:50
she's then obviously never voiced a desire to stop it either. Because I think that's a big piece, especially with kids and teens that were parents are really trying to listen to their kid, it's not so much that the parent would for the most part, I don't think 99.9% of parents would ever want to remove the pump, right? I think it comes more from the desire of the child expressing a frustration that they say okay, well, let's try this.

Scott Benner 3:19
So Arden has when she was younger in the past said, you know, I'm going to stop wearing a pump, and I go, okay, that's fine. Here's how this is going to work. From now on, we're going to take a shot of long acid long acting insulin, probably in the morning. Maybe at night, we'll work that out. You're gonna have to do an injection every time you eat. And then she was like, oh, nevermind. It was it was like that. And I wasn't trying to scare. I was just like, that's fine, if that's what you want to do. And she was much younger. She has not mentioned it in many years. I would admit that. But, but I take your point, you know, if the kid wants to take a break from it, I get that I think that's fine. From your perspective, though, as an adult, you've had diabetes forever. Like, have you ever stopped using your pump to take a break?

Jennifer Smith, CDE 4:10
Yes. Um, but not. God, it's been a really, really, really long time since I did that. I mean, it's probably been six to eight years. Okay. And I know that at one point I had done it in the past only because I really just well one in particular was going diving. So I can tell you that I did it for and it was only like a two day because that was just going to be the time period in which we were actually diving where you can't physically like where the pump down. You know it was going to be like a whole pain in the butt to just do it. And since they were on the pad and couldn't just easily disconnect and leave my site connected, I was just, I'm just going to go to injections. So there are some maybe life types of things, too, that people would decide to do that for as well. But another I think, reason in the past that I had done it was just to give it a try and remember what my strategy was like, with MDI. It was more of a learning, not a, I'm really tired of my pump, I just want to be completely disconnected and have nothing on my body. Now, I didn't disconnect completely. Obviously, I kept by my continuous monitor on. So I still had all of that information to use in order to dose with injections and smooth things a lot better. I mean, I, I don't think I've been off of a CGM for maybe more than like, three days because I didn't have enough supplies left maybe. Or I mean, I've been on a CGM consistently for like 16 years. So MDI without a CGM, I don't know that world anymore other than just, I'll just do a heck of a lot of finger sticks. Because I did do that when I was pumping before I had a CGM, right. And I just did. I mean, I think my order for for testers was like, my doctor had written for like 14 test strips a day or something was what back then and I used.

Scott Benner 6:29
We did that with rd. So I would say 10 was like a slow day for us. Yeah. Because you were like, in the morning, before meals after meals, were we at like, basically trying to be a CGM. Before I even knew what one was

Jennifer Smith, CDE 6:45
that time. I mean, I before I had a CGM, I always had a two o'clock in the morning alarm that went off. In fact, many times I was awake just before my alarm went off, because my body was so used to getting up at that time, it was just the norm. Yeah.

Scott Benner 7:00
Do you know back then? Back then, when I was young, if you would have said to me without a clock or a watch, or any way to follow time, if you would have said to me, Scott, right now start and tell me tell me when an hour is, I could almost do 60 minutes to the second because I would think like, alright, Arden just ate in an hour, I'll test her. And yeah, I would set alarms and set alarms to the point where my body knew when an hour and passed, it was right. It was ridiculous. I do not have that skill anymore. And I'm glad glad of it. Well, and

Jennifer Smith, CDE 7:33
I think it's, it's good to bring this all in in terms of going back to just injections coming off of a pump taking a pump vacation, because like I did in the past, it was sort of a trial of do I remember how to do this. So I don't necessarily think it's actually a bad thing to maybe do. If your child is willing, or if that's an adult, you're like, Yeah, I don't I don't know, if all my technology failed, and it was over like a holiday weekend, or I was on some remote island somewhere. And they couldn't overnight me a new pump, you know, what would I do? So it is a good idea to have an idea, you know, to have that back knowledge of where would you go and what would you do? But it also then starts with? How would I go to injections? How would I take what I'm doing on my pump? And transition that into dosing strategy and calculations and everything? To make it work? Well, there's

Scott Benner 8:30
no way with a with an algorithm like there's no way to mimic an algorithm with I guess you could inject yourself 1000 times but even then you couldn't take basil away. You couldn't take yeah, there's no way to do it. I could probably go back to the way before,

Jennifer Smith, CDE 8:45
but just conventional pumping. Yeah,

Scott Benner 8:48
I could get I could probably mimic that with MDI pretty well, but it's a lot of injections. I mean, you're going to be shooting a couple of times in two hours after a meal maybe if something happens, or you're trying to eat something with fat in it, but when you talk to adults who who say I want to take a pump break isn't is that usually a what do you think? Literally? What do you think? What do you see from people? What precipitates the the idea that they want to take a break when it comes from an adult?

Jennifer Smith, CDE 9:21
I think it's a couple of things like I said the one diving that I did it's so it's sometimes it's more like a life thing where they just don't the perceived hassle of pumping part like all of the pieces and whatnot that may be in disruptive to what they're going to be doing or may not just work well with what they're doing. That may be a reason. Another reason that I've had is some people for some reason start to get irritation with the adhesive enough to the point that they just need a break. They just can't imagine putting Another piece of something on their body with, you know, like an outbreak rash that just takes forever to heal as well. So that might be another reason. Usually, for something like that, I say, well, you're using this type of a pump or this type of infusions that let's just without putting it on, let's do the pump vacation. And I'll give you you know, the rules to do that. But let's also at the same time, get a couple extra different kinds of infusion sets, and just kind of pop it on your body. Without it being used. Let's see if it's truly this product, the adhesive? How can we kind of get around it, especially if we work through all of the other under adhesives? With the other product? And nothing seems to be helping enough?

Scott Benner 10:46
It's It's so unfair people who already have an autoimmune issue. You know, it's, it's reasonable that they might have more allergies than other people too. And then you have to stick this stuff on. I probably probably should do an episode at some point about barriers to and how people probably agree. Yeah, cuz I, I'm gonna put that on the list added to the list. Yeah. I'll do it now. Because I think we all know, yes, I'll forget if I don't write it down right now. Okay, so

Jennifer Smith, CDE 11:13
So those are some of the reasons Yes, I

Scott Benner 11:16
would say yeah. Because I think that's, I mean, it's funny because my brain jumps to like, like people being annoyed wearing something. And so they want to take a break. But the medical reasons are, I mean, for the adhesive itself is that that's probably that's probably the biggest one because it's not like you can power through that, like I've seen terrible, like, some people's rashes are terrible yet

Jennifer Smith, CDE 11:40
Correct. I mean, I've got one team that I've worked with for a while now who loved using the pump. But the problems that we saw with use of the pump, he is doing so much better on multiple daily injections than ever was consistent with the pump. And so, you know, in a decision like that, then it's okay, this is how we would take a pump vacation. Will we ever get back to the pump? I don't know, the big thing there was to look at, what kind of management could we get with multiple daily injections versus the issues that the pump was bringing in to the management? And for him, it was a cut and dry. I mean, there was definitely adjustment and stuff once you go back to just injection management. But it's it's better for him,

Scott Benner 12:30
was it sites was he gonna get an absorption,

Jennifer Smith, CDE 12:35
totally inconsistent absorption sites could be fine for three days. And then they could be really bad within 12 hours. Sometimes there was irritation from the adhesive. Sometimes. I mean, it was a host of things that were just, and because of it, like there was no consistency in blood sugar, because we never really could tell how well insulin was really working some days, he'd have these beautiful lines and like the next day be completely sitting at like 300 Like it was it was not doing anything different food wise and this. This guy eats like the same thing. So

Scott Benner 13:12
that's a perfect example of it. Okay, so yeah. Alright, so let's just like high level, you're gonna stop using your pump. Let's see if you made me do this. You stopped me when I'm wrong. Okay, if you said to me, Scott, Arden can't use a pump anymore. I would say I would add up her Basal rates, right and find out what her Basal insulin is over 24 hours. Right? I would probably Hmm. Because she has an algorithm that takes her Phaselis away sometimes. Would I lessen it a little bit? Ooh, interesting question. No, I would probably be aggressive, I would probably add up her Basal insulin and then shoot that much. I would fight with a doctor if they didn't want to give me a more modern Basal insulin. I don't think I'd want to use level mirror or Lantis if I didn't have to like it just because that's anecdotal from what I'm seeing from other people. Correct. You know, like,

Jennifer Smith, CDE 14:06
Yeah, I think you bring up just the point that there are better newer Basal insulins that are definitely much more consistent 24 hour action like a true 100% 24 hours you will get out of this Basal injection,

Scott Benner 14:20
right and I have I have anxiety thinking back on. We didn't use Lantus big. Oh my god, we didn't use Lantus because it burned Arden. Oh, it's not uncommon to hear I did not remember that though. Because she tried to gasp and loom JEV and it burned her to I wonder, Oh, that's interesting. They might not have anything to do with each other. They just never thought of that. It's been so many years. So Arden used Levin

Jennifer Smith, CDE 14:43
and they're made by different companies but who knows what the chemicals in them that might have caused that interesting to be similar.

Scott Benner 14:50
So Arden use levemir we split it and I would hopefully not want to do that. Like this splitting. It's like it's just it's I mean it works but it's a pain. And then from there, I guess I would just, I'd look at her meal ratio, and we'd shoot and Pre-Bolus and see what happens.

short episode short ads Dexcom G six continuous glucose monitor, here's why you want it, you can see the speed and direction of your blood sugar, including the number right there on your Apple, iPhone or Android device. And you could even use the Dexcom receiver, if you like, up to 10 people can follow your Dexcom if you like, they don't have to. That's up to you. dexcom.com forward slash juice box, see the speed direction and number. Right now. Arden is eating Chinese food right now, right now. And her blood sugar is 123. And it's just starting to make that little like me, like maybe we didn't Bolus enough, I'm not quite sure yet. But we're gonna know soon. And with Dexcom, I'm going to use the data to stop it from ever being an issue. We missed on this Bolus a little bit, we'll be able to come right back at it using the data that comes from Dexcom. So aside of all those safety features, like alarms that you set, high alarms, low alarms rise and fall alerts, things that you can use during the day. And while you're sleeping for comfort. I mean, those are all great reasons to have Dexcom. You know, I'm talking about management. But safety and security is another great reason dexcom.com forward slash juicebox there may be no more important thing, if you are using insulin than being able to see where your blood sugar is going, and how fast it's going there. Now, in a moment, when we figure out that maybe we didn't Bolus enough for this meal, we're going to use Ardens Omnipod. To set on I think I'm going to set like a Temp Basal increase here. On top of this, this this takeout or maybe we'll just Bolus again, I'm not sure. But with the Omni pod, we have nothing but possibilities. Temp Basal increases, extended boluses bolusing, without injections, to Bliss insulin pumping. And you may wonder why am I bringing that up here? Because I'm basically talking about some takeout food. Well, what about this in about an hour, Arden is going to need to take a shower, and she won't have to disconnect from her pump to do that. Can you imagine if you had to disconnect from your tube pump while you had Chinese food rolling around in your belly digesting, right your body's pulling out those those little molecules of sugar and sticking them into your blood you need that insulin right then you don't want to have times when you have to disconnect from your insulin pump. That could be bathing, swimming, activities, weightlifting, running, all the places where some people take their pumps off, you were an omni pod, you get your insulin just the way you're supposed to Omni pod.com forward slash juice box. Alright, I'm going to go over everything here real quick. At Omni pod.com forward slash juice box you can find out if you're eligible for a free 30 day trial of the Omni pod dash, you may be@dexcom.com forward slash juice box, you can find out if you're eligible for a free 10 day trial of the Dexcom G six. They're standing here what I'm saying you want to hit these links Get started today with the technology that my daughter and so many other people are using to keep their blood sugar's stable, to keep their lives healthy. And to keep their days safe. dexcom.com forward slash juicebox omnipod.com forward slash juice box. These are our results. And yours may vary. For full safety risk and information free trial terms and conditions you can visit omnipod.com forward slash juice box

there's lots more to this episode. So let's get right back to J. Me but you know, mostly J

Jennifer Smith, CDE 19:20
I think the biggest thing there is calculation. Yeah, cuz then it's all right. It's all self calculation at that point. So you know, then it becomes a lot of daily equations and a lot of daily calculation or tracking of insulin on board, right. So with the way that you manage in a very, like tight micromanaging way. If you have just a breakfast lunch and dinner Bolus going in, you see a definite finish of the Bolus by the next time you're going to eat. But if you are really heavy handed in managing and keeping and that I'm not saying that badly, it's just that If you're heavy handed and managing and it's working really well, then your your little lingering trickles of the end of active insulin from one Bolus into maybe a correction or a snack came into the picture or something like that, which can be very common with little kids with their snaps next snack kind of breezing through the day, then your timer is almost consistently being restarted and your analysis of insulin on board becomes deeper, because there's more there to consider.

Scott Benner 20:30
Yeah, I You just made me feel like like I was imagining in my head like bands of like bands or rubber bands. No, no, no, like, like, how am I gonna explain this? Timelines? So yes, so there's insulin that's running on a timeline from the Bolus for breakfast. And if you're MDI, you put it in at 9am. And that one timeline ends usually before you'd put in more, so you'd be only working in this one linear line. But but with the algorithm or even pumping, you might Bolus 30 minutes later Bolus, again, that's a new Bolus on a different timeline, the first 9am, the second one's at 9:45am. And then before you know it, you grab a snack at 1015. And that's a third run there are all these overlapping, yes, timelines of insulin running concurrently. And they're all starting peaking and stopping at different times. It's almost like a symphony. Really, when you're doing all that, and you don't, you don't so much control it as you just sort of, I don't know

Jennifer Smith, CDE 21:38
with it. Yeah, right. I mean, it becomes, you know, the old term of stalking, that really is why on MDI, it becomes more beneficial to just have a pretty rigid schedule, like you get up in the morning in a fasting state, I think that's the, if your Basal is really well dialed in, and you're waking in a really healthy range, and you've done enough testing that you can fast into like the mid morning, and you know that your Basal isn't allowing you to drop at least not too much or rise at least too much, then could you test out and say, well, morning isn't really my weird place, I can vary when I wake up in the morning, it might be the next boluses down the line, though, that you really have to keep in a I know my active insulin time is three and a half hours. So I'm going to eat breakfast at eight o'clock today. So maybe by noon, I'll definitely be out of that active insulin window enough that lunch will be its true own effect coming into the afternoon. But like I said, if you're stacking, kind of, because you're eating and snacking, and eating and snacking and grabbing and whatever happens through a day. It's a it's a tracking that you end up having to do.

Scott Benner 22:54
Yeah, it's it's so interesting. Like, I wish I wish I could put it together visually the way I see it in my head, just, you know, layers on top of layers floating in their own timelines. And though yes, all right, yeah. If this is a plan thing, contact the doctor. Make sure you have a pen or needles and you know the insulin that you need. And

Jennifer Smith, CDE 23:17
yep, and that, you know, like you were saying before with basil, everybody on a pump should have a basil sitting in the refrigerator anyway, in case of pump failure. That's a good rule of thumb. That if you are a pumper, even if you have a backup pump, again, all things beautiful. Not all of your systems as backups will fail. But in the time or the day that that does happen, you may have to go back to a Basal injected insulin. And sure if you at least have one on order, could you quickly swing by your pharmacy and grab it and come home? Absolutely. But you know what, if it happens at two o'clock in the morning, it's easier to have a basil sitting in your fridge that you can just take and not have to worry

Scott Benner 24:04
like Jenny's trying to make me feel bad. I don't. About once a year Kelly's like do we have Basal insulin in case Ardens pump has a problem. Am I gonna know what I don't know? But every time there's been a problem, it has been at two o'clock in the morning. I'll tell you that.

Jennifer Smith, CDE 24:20
So the example here is don't be like Scott

Scott Benner 24:23
episode with the word Adele in it somewhere. We went to an Adele concert. Arden's PDM died at the Adele concert. She was still getting basil. And so I remember just it happened. And it was Kelly's birthday present. And so nobody wanted to bake Kelly upset. So I just reached over Arden had popcorn. I took it from her and I was like stop eating. And and because we couldn't Bolus and then we got home. And then I got you know, I got told about not having Basal insulin. It was a lovely woman that every married man understands what I'm saying. And I got I got to explain to me that I was wrong. And then I remembered there was a kid in town that used Omni pods. And we literally woke them up and stole their their

Jennifer Smith, CDE 25:10
extra PBM for PDM. Yeah, yeah. I mean, the good thing in the story is, of course, that the pod didn't fail. It was just the PDM that wasn't working. So it was good to know that your pumps still giving you basil.

Scott Benner 25:21
Yeah, it was the old PDM it just died. And she stuck. She kept getting basil. I was positive. That was right. But in fairness, to my anxiety, there were people I was able to text right from the Adele concert and go, Hey, I'm right about this on a she's still getting basil. And they were like, yes, it was like, yes.

Jennifer Smith, CDE 25:39
Yeah, yeah. So yeah, I mean, it boils down to a Basal insulin in the fridge, as you were kind of doing some figuring or calculations. It's what is your current pump delivering in terms of what is your base basil? Even if you have an algorithm driven pump? What is the bass profile supposed to be delivering for you in a day? Now if you're going to get a little bit more nitpicky about it on average? Could you go and see, well, what is your algorithm algorithm on average kind of taking away? What does it averaging out? Mean? In the moment, you're probably not going to do that, go to your base Basal profile, look at what it would give you over a 24 hour time period. And then because pump sites are supposed to be a little bit better at consistency in absorption. That's the reason that if you're coming from MDI, going to a pump, we usually take the Basal down by about 10 to 20% of what your injected dose would be. So if you're doing the opposite, you'd actually take your base diesel in the pump, and you may dial it up by 10 to 20% as the injected Basal dose, okay.

Scott Benner 26:42
Yeah, I think rd would probably it's interesting article, I would probably start Arden around 26, maybe units. And because she but she's so heavy the other way, like like Arden's meal ratios, and meals really heavy. So we're lighter on basil, but that's just because it works on the algorithm, I guess I would learn

Jennifer Smith, CDE 27:08
conversation makes me want to, I mean, not really want to but makes me kind of want to like, get some of my basil out of the fridge and just play around for a couple of days.

Scott Benner 27:19
I mean, Arden's meal ratio is one to four and a half. So I mean, she gets I'm gonna pull up a caucus, she

Jennifer Smith, CDE 27:25
gets big. I mean, and depending on how much she's eating in a meal, I would expect that her basil versus Bolus is probably well off of the your basil Bolus should be 5050. That's

Scott Benner 27:38
probably I mean, if she ate 50 carbs, divided by 4.5.

Jennifer Smith, CDE 27:45
It's getting about Yeah, I was gonna say 10 to 11 units. Yeah.

Scott Benner 27:50
You some people, I tell you what, like some of her like high fat meals. Y'all have a stroke. If you saw that Bolus going. There's plenty of people would be like, how much are you using? And I'm like 19 units

Jennifer Smith, CDE 28:03
of insulin well, and that I mean, that brings up another point. It's like then on MDI, how do you mirror what you were doing? Even not on a even not an algorithm driven pump, but just an unconventional pump, at least you have things like extended Bolus and temporary basil that you have to your advantage on injections, the best thing that you can do is use your hindsight. Where would you have added more insulin for a meal like this previously, and even if it was an extended Bolus, if you're waiting for a rise to Bolus extra for fat or wherever you figured that you usually would have needed more, you're still gonna need another injection. Now, the question is, how much more now? And are you just gonna have to break that? What would have normally been entered into the pump? Do you have to break it up yourself in multiple injection,

Scott Benner 28:54
you're making me wonder if I increased Arden's basil and decreased her meal ratio made it weaker. If we would call it things we maybe couldn't even find stability by making changes like that. I wonder if we could you know, it's a crapshoot because the algorithm will save you try to save you if if the basil is too heavy to begin with.

Jennifer Smith, CDE 29:15
Correct. And you're you're saving on injections is just food, right? Or extra insulin? I guess it's either or right.

Scott Benner 29:25
The one the one high side I could see is that, you know, big boluses don't tend to absorb as well, like through sites. So maybe that is interesting.

Jennifer Smith, CDE 29:33
Yeah. And for boluses, then I mean, the simple math is really just it's two calculations. You have to have a blood sugar calculation and you have a food calculation, right? So you take a current blood sugar, take away the target that you're aiming for, let's say 100. And then you divide it but what by whatever is your correction factor, your ISF, your insulin sensitivity factor? Let's say it's 50. Right. That gives you how much corrective insulin if any, you might need At this mealtime, the second calculation is just carbs divided by your insulin to carb ratio. And that's just the part for food. And then you add them together.

Scott Benner 30:08
So if Arden's blood sugar was 150, and I wanted it to be 100. Yeah, I would take 50 divided by her correction factor extra factor, which is like 45. Maybe. And I would come up with like, one point something, whatever that would end up being I click Yes. 1.1 1.1. And that would be my injection.

Jennifer Smith, CDE 30:27
That would be your injection just to correct, then she's going to eat 60 grams of carb divided by what 4.5 You said is her ratio. I mean, that's 13 units. So now she's getting 14.1 units or 14 because you can't really do microscopic Bolus via injection.

Scott Benner 30:44
I'll tell you, you just took me right back to the anxiety of when Arden was diagnosed doing that math. Yeah, that feeling is the exact reason this podcast exists because I was like, Well, I can't do that.

Jennifer Smith, CDE 30:56
Too much math, all the law that is too much.

Scott Benner 30:59
All right. Well, Jenny, thank you very much for doing this.

Jennifer Smith, CDE 31:01
Yes, of course.

Scott Benner 31:11
Did you know that Jenny Smith works at a little place called integrated diabetes.com and that you could hire her to help you with your type one. It's true. Alright, guys, another great episode, I want to thank Omni pod and Dexcom for sponsoring this episode of The Juicebox Podcast, please don't forget, you may be eligible for a free 10 day trial of the Dexcom je six, you'll know that if you go to dexcom.com forward slash juicebox, you may be eligible for a free 30 day trial of the Alibhai dash. That little bit of information can be found out about that's not English. But let's keep going@omnipod.com forward slash juicebox.

There are so many more defining diabetes episodes, you can find them in your podcast player by searching defining diabetes juice box, or you can find them at Juicebox Podcast calm and at diabetes protip.com. At those same links, you can also find the diabetes pro tip episodes, there are actually a ton of series within the podcast that you may find interesting. The easiest way to learn about them is to join the private Facebook group Juicebox Podcast type one diabetes, go right up to the top of the page after you get in. It's a private group. So you'll have to answer a couple of questions to prove you're a person. But after you do that, you go up to the featured tab. And there's these great lists of all the series that exists inside of the Juicebox Podcast. That little group has over 22,000 members in it. Absolutely a wonderful place to watch people talk about diabetes, to ask your questions. Or if you think you have a little bit of information you'd like to share with others, it might be a great place for you to answer one of those questions Juicebox Podcast, type one diabetes, there's also a link to that at Juicebox Podcast comm if you don't feel me, you get confused between now when you get to the Facebook machine, I don't know. I mean, I've given you a lot to do join the Facebook group. Check on that Dexcom stuff, check on that Omni pod stuff. Don't forget to take the survey AT T one D exchange.org. Forward slash juice box. I mean, it's a solid 20 minutes of stuff you got to do today, but I gave you a shorter episode, so there's plenty of time. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.

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