#1010 Setting Basal Insulin (REMASTERED Diabetes Pro Tip)

September 23, 2023Scott Benner

Scott and Jenny emphasize that having correct basal insulin is essential for understanding and managing blood sugar levels. Whether using a pump or injections, many people have incorrect basal insulin levels, leading to unexplained blood sugar fluctuations. The episode provides insights into what basal insulin is, how to make adjustments, and why it is crucial for effective diabetes management.

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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 0:04
Hello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right, you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CD and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisit double. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. 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 or becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have an amazing offer for you right now at my link only contour next one.com forward slash juicebox free meter you can get an absolutely free contour next gen starter kit that's contour next.com forward slash juice box free meter while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. 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 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 Basal rate 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 Basal 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 basil. 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. 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 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 is what we talked it up. But okay, if you want it like so let's add one that's about setting up your Basal testing and getting it right. And I was like alright, well we'll we'll definitely do that if the people are asking for a journey than we have to deliver. That's right. That's what I'm

Jennifer Smith, CDE 4:33
that's what we're thinking so alveolus so,

Scott Benner 4:35
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 the opposite. I'm assuming there's a super like specific way because I remember being taught at like, you know, in the doctor's office, like very specific don't eat food for this much time like makes you feel like this whole thing and this is what your Basal rate is going to 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 basil 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 four 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 Basal insulin should go crazy, Jenny, because I feel like you're gonna get to talk a lot.

Jennifer Smith, CDE 5:50
Well, I mean, the accepted medical way to do it can also vary. You know, I've heard, I've heard a lot of different but I've also heard heard enough similarities that you, I guess, our medical way to do it within integrated when we start working with somebody brand new. That's a first and foremost question, Have you verified that your Basal is are working well, and Basal evaluation can also be done using injected Basal insulin as well, not in the same way or as extensively as a pumped Basal rate, right. But you can evaluate to see 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 Basal test in. Okay. The biggest thing heading into any basil test is that there isn't any food that's going to be impacting in that basil time period. And there's no lingering impact of your Bolus. So for an overnight test, we aim to say, have your dinner in 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 Basil doing to hold things steady. Now the other variables since we had an episode about variables to write I did 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 a Basal Taff on an overnight when any of those pieces are. Right, you

Scott Benner 8:24
know what I wonder, too, is I'm starting to believe that there's a different Basal rate that my daughter needs depending on our site. So I think there's a leg Basal rate for her and I think there's a belly Basal rate for

Jennifer Smith, CDE 8:36
that's actually funny I used when I use my upper bought for my knee pads. Prior to looping with a Medtronic pump. I noticed that on my butt, I need about 10% More Basal insulin. And so I set up a Basal profile that I call but

Scott Benner 9:02
I could definitely say but yeah,

Jennifer Smith, CDE 9:04
I called it but and I had it 10% higher than my standard tested Basal rate, right that ran on my other normal sites, which seemed to work the same. So you're not crazy in 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 Basal testing then is to have fair stability, and not like this entirely flatline. But the goal is to not have more variance than about 20 to 30 points up or down from where your fingerstick value at 10pm is. And the goal at 10pm. Once that 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 here. thinking, oh gosh, if it was like 150, I'd totally correct that at bedtime, 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, you just let it sit. So if you go to bed at 188, you leave it alone. Because the basals job is to not correct that the Basal job is to hold you pretty steady. If you're not going to have more than a 20 to 30 point variance up or down from that. That means all night long, you 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 10:38
And if you wish that then you imagine that the Basal is pretty steady, correct. Okay, correct.

Jennifer Smith, CDE 10:43
If you accomplish that with little variance, but not a lot, and you wake up, let's say at 169, awesome, your Basal, 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 basil does show that it's not right. Let's say that 10pm 188 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 basil at two o'clock, so that it wouldn't be high anymore. That's actually it's kind of missing the boat, right? Because where you really want to adjust the Basal is about one to two hours prior to the drift to being too high or too low starts. 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 11:57
And that's and for people listening that get confused by that. If you think about Pre-Bolus, and you put insulin in, 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 to build up its efficacy, I guess, right? And then be able to hold you stable.

Jennifer Smith, CDE 12:17
Okay, correct. Yep. So that's circulating insulin level, that's a great description, it needs some time to bump up or bumped down to the rate that's going to be then effective an hour to two hours from now at that rate.

Scott Benner 12:30
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 a temp down, you can but if your blood sugar's falling at 70 Shutting off, your Basal is not going to do anything to affect what's happening right now. Now, you'll make your blood sugar high, two hours later, right after your seizure.

Jennifer Smith, CDE 12:54
Right. Exactly. Right. Yeah. Or after you had, you know, 30 grams of a juice box or whatever. Yes, exactly. Yeah. So it seems same thing, you know, if you're drifting down, you adjust the Basal down a little bit, still 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. And by 2am, you're at 280. That's, that's a pretty big change. And again, we would probably adjust the Basal at least by point one, maybe even point one, five. Depending,

Scott Benner 14:01
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 it 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 if I don't know if that ends up working, is it for adults or not? But the more people I talked 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 child just did not use the insulin the same way. Right

Think of basil 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 basil is not working, turn it up. And if it's too loud, turn it down. And because Arden's using, you know, a Dexcom, G six, I, I just turn it up until she gets where I wanted 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 of a sudden, it's been come acceptable, and 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 16:17
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 yeah. Anyway, I don't think I don't think that that's irresponsible. I mean, you're doing again, and again, in the topic of basil specific adjustment. If you're talking about temporary basil adjustment, you 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 we're talking about setting true basil though, we really want to make sure that we set the the basil 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 Basal test. And then if it doesn't work quite well, because now you're ending up lower than you wanted. Great. Just dial it back a little bit in the adjustment that you made. But at least it'll be a better picture. You know, overall, and you can always test over and over again. Most people hate basil testing, myself included. Well, listen,

Scott Benner 17:46
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 Basil tests. And I looked at the sheet, I'm 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 act of 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. 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. It just changes. I will say this, because you you alluded to it earlier, and you were just talking about the idea of Basal 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 there 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 art and 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 At 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 watched 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 a little wrong, everything went today, or didn't say once he's 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 of the attached to your mortality somehow. You know, if your blood sugar's always 200 Yes, but you know if it jumps once or twice, come on, like ease up a little bit. Okay, right. So how reasonable is it that once I basil test, I'm actually going to know what my Basal rates are. That remastered diabetes Pro Tip series is sponsored by assenza diabetes makers of the contour next gen blood glucose meter, and they have a unique offer just for listeners of the Juicebox Podcast. If you're new to contour, you can get a free contour next gen starter kit by visiting this special link contour next one.com forward slash juice box free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juice box free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen, it fits well on your hand, and features Second Chance sampling, which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next.com forward slash juicebox free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips, you can use my link and save time and money buying your contour next products from the convenience of your home, it's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now, through your insurance. Contour next one.com forward slash juice box for a meter go get yourself a free starter kit. while supplies last US residents only touched by type one has a wide array of resources and programs for people living with type one diabetes. When you visit touched by type one.org. Go up to the top of the page where it says programs there you're going to see all of the terrific things that touched by type one is doing and I mean, it's a lot type one, it's school, the D box program golfing for diabetes dancing for diabetes, which is a terrific program. You just click on that to check that out. Both for cause their awareness campaigns and the annual conference that I've spoken at a number of years in a row. It's just amazing, just like touch by type one touched by type one.org or find them on Facebook and Instagram. links in the show notes links at juicebox podcast.com. To touch by type one and the other great sponsors that are supporting the remastering of the diabetes Pro Tip series touched by type one.org. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. G voc hypo pen is a ready to use glucagon option that can treat very low blood sugar in adults and kids with diabetes ages two and above. Find out more go to G vo glucagon.com forward slash juicebox G voc shouldn't be used in patients with pheochromocytoma or insulinoma visit G voc glucagon.com/risk. The other times I basil fast and then I don't have any better of an answer.

Jennifer Smith, CDE 24:35
There might be especially if like I said before, if you're doing some basil 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 basil test could be not very purposeful it could be kind of null and void. And this is something I encounter a lot with women and something I bring up when I work with them to begin with in a in a first visit. is one, you said you've done basil testing, but two, or you know your cycle impact if you have one, and two did basil 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 play of management without significant hormone impact. And that's where Basal testing needs to happen. It needs to happen without the impact of the pre cycle, or ovulation hormones kind of coming into play. So if you haven't basil tested in those sweet spots up completely wrong, what's happening and what your basil needs are. Once you do have that sweet spot, put into play, then auger. And this is an important piece that a lot of people ask about too, is great. So then I need to test and 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 a Temp Basal, see how well this is 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. Okay, so you can plug that into a Basal 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 8am. They're pretty stable until four or 5pm, they might go up or down again. Another piece for Basal testing is that most most people, again, your diabetes may vary. But most people will have about four will most people have one valley and one peak to their Basal 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 stays kind of lower, and then it may shift back up into the evening time. Okay, so you kind of had one dip in 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 basil 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 27:54
you have to stay flexible too. You can't just say to yourself, look, I've set this Basal rate, it starts at 3pm and 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 basil always works. It's not working now. And the reasons you know, we talked 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, it's telling you something your blood sugar going up is your body's saying, Hey, I don't have enough insulin. Don't like wanna hear why just believe it. You know what I mean? 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 and 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 move away. 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, people 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 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 one. Absolutely. Jenny 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 30:29
Yeah, I think that's also a really good point, Scott, because if this is where you could also say, is it a trend now? 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, it 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 is 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? Great. If a couple of days, you're ending up low, then you shifted back down again. Yeah. See,

Scott Benner 31:20
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, good, 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, your blood sugar at that level, get just learn. Don't ask your wife, are you really going to 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 let 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 going to 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, right? But it's so much easier to ramp up your insulin and bring it back than it is to

Jennifer Smith, CDE 32:14
sooner than later. Where 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 32:48
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, is very excited for themselves. And then she said, you don't have a doctor's appointment July, is it? 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 on the 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 gonna bring my new stuff with me, you can show me how to do all of it. And I said, and if you never make it there to show or maybe you figure it out on YouTube or somewhere, whatever. And you know, 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 but but I was like don't wait till July. So because a July is six weeks from now, six weeks from now you're going to tell the doctor what you want. They're gonna wait a week because people don't do things right away for you. They're gonna send in their prescriptions for you, then you're not gonna get this pump for six months. If you do that, like start today. Go right now. Be proactive.

Jennifer Smith, CDE 34:08
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 reason 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 the office and you ask to talk to their nurse, then you say this needs to get to the doctor needs to be signed, it needs to be taken care of.

Scott Benner 34:31
Arden's endocrinologist and I have been adjusting her Synthroid Arden is taking Synthroid and site ml now and we've been making we've been making adjustments by email. But But what's taking and it's still taking a long time to get it straight. I imagine if I only made the adjustment every three months when I saw Arden 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 slumps over and she's like her her blood pressure Blood pressure gets incredibly low. And she looks like she's dying the whole time. And so once she has more Synthroid, she sits right back up again. It's, it's literally like grabbing a marionette bytestrings When When she has not centered, 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 35:23
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 the 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. Yes, 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 see as such. Hi. 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 to that. Yeah.

Scott Benner 36:01
All right. standing out 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 saying, Oh, the fire company will 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 it. Just hold the hose. I get started with my hose. Right? Yeah, why don't I just see what I can get accomplished here. All right. So bringing this all back to your Basal insulin, 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 explained to a person what it was. And after I explained it, I had to explain it again. And so and you can still hear people go so that's the level mere like people on MDR they're like so and I get it like they're newly diagnosed maybe sometimes or they never got a firm explanation. But we treat Basal 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 Basil. Basil is not right. Nothing else works coming off of it.

Jennifer Smith, CDE 37:05
Well, and so many people think that Basal job is to bring blood sugar down. Right? So 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're 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 No I wanted my basil should is here, here and here. And it should be bringing me down. No, that's not basil job. Basil job is to hold just steady. If you didn't eat all day long, you shouldn't have much variance.

Scott Benner 37:54
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 an act 325 years later that thing is how come you blah, blah, blah, blah, blah. There are things in the past. There's decisions you're making right now with your diabetes that are going to affect you in three hours, or six hours. And it's not now so much like it's interesting to how people overreact to the idea of Pre-Bolus Sing 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 stably 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 39:08
The only reason it would start working right away is if you physically had that cannula in a vessel, right? It was literally going right into the vein popping into her bloodstream.

Scott Benner 39:18
Right? So in normal situations, which Jenny's bringing up probably because she knows we actually had a pump probably Nick a vein in art and one and for two days I could we couldn't get her blood sugar to go above like 50 Most of the time until we finally just changed your 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 the texted Jenny I sounded like you guys sound when you email me. I was like, I don't know what's happening.

Jennifer Smith, CDE 39:45
Better so much.

Scott Benner 39:48
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 the genuine gotta figure it out, you know, but, but anyway, yes, the point is, is that timing of your basil, just as important as the amount of your basil. And to Jenny's point, for those of you who are thinking that basil is in charge of 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 session, right? Imagine your body function and, you know, sugar on one side, and your and your and your basil 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 Basal enough strength to fight off the background things that are happening in your body. If I right, right, and when you eat, you know, a reasonably normal meal, that basil 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 Basal rate is going to be okay. Because it's not. And then so that's, that's another thing. So once you get done Basal testing and figuring out your Basal 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 or after that, or right, right, maybe it's pizza 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 and must have made her high like four hours after she you know. So

Jennifer Smith, CDE 41:59
it's that's just 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? Yeah. So we talked about things like adding fat in Yes, your background basil, if you know it's solid and set to begin with, then you know how to play with that temporary basil feature to accommodate for long term impacts like fat fat 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. Yeah, so most people need a Basal 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 at 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, it's that usually fat starts to impact by about three hours, you get this leg drift, and then you get stuck high. 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 basil to begin with is that well, you can increase using temporary basil and offset the impact of that fat.

Scott Benner 43:43
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 basil. So the unit really just keeps replacing the basil you don't have. So you put the unit in, replaces the basil keeps you stable at 250. But you still haven't addressed the number. And so then you wait an hour and 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 basil. You need a yak up your Basal rate and Bolus for the number. And remember that turning up the basil 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 just you need that T shirt. I'm telling you right now, I can't do this podcast forever. People are 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 Let this podcast episodes 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 who are speaking privately and they're like, how do I figure out you know, how much more basil 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. And I was like, no, they started getting low, put it the point three, five, 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 often 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 the diabetes tool, like give it a shot and see what happens? You know, point four, okay, now, let's see what happens. Not enough stuff,

Jennifer Smith, CDE 46:16
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 and the Medtronic pumps. 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 basil is doing its job, the meal can't be there, right. So if you wanted to look at morning time, you'd 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 happens for little 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 gonna get an idea behind what their normal breakfast time is in that morning time to see did the basil 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. He played with his Legos for a long period didn't even care about eating breakfast. I'm like, awesome. Yeah, that was a basil test. I was like, there was nothing. There was no food, no Bolus, he was sitting and playing with Legos. Fabulous. We've got information.

Scott Benner 47:58
That's cool. That's x. 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 basil is right, your blood sugar is going to be 90, it's going to 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 basil up and get a low blood sugar and think oh my gosh, that's because I turned my basil up. But again, it might have 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, it doesn'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 not with insulin to do it, it's fine, but get stable somewhere and start over even when things go crazy here. I'll say that to Kelly, I'll be like listen, I said we're out like everything's out of whack. Like we got to find a stable point so 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 a. It's like trying to catch a ball. You mean like you gotta wait till it lands. Anyway. All right. Um, do you feel like we've covered it? I think for the most part yeah, I think we have to. I appreciate everyone who reached out and asked about a more specific episode about basil testing. This was it. I hope you liked it. Goodbye, Jenny. Hi. I want to thank assenza diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free contour next gen starter kit at contour next one.com forward slash juice box for E meter while supplies last US residents only. If you're enjoying the remastered episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org. A huge thank you to one of today's sponsors G voc glucagon, find out more about Chivo Capo pen at GE Vogue glucagon.com forward slash juicebox you spell that GVOKEGLUC AG o n.com. Forward slash juicebox. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed you're starting over episode 1001 all about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low Beegees in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two in Episode 1008 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and an episode 1025 We talked about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with this and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active took me already from a decent 6.5 A one C down to a 5.6. In the past eight months. I've never met Scott. But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. If you're living with diabetes, or the caregiver of someone who is and you're looking for an online community of supportive people who understand, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, there are over 41,000 active members and we add 300 new members every week. There is a conversation happening right now that would interest you, inform you or give you the opportunity to share something that you've learned Juicebox Podcast, type one diabetes on Facebook, and it's not just for type ones, any kind of diabetes, any way you're connected to it. You are invited to join this absolutely free and welcoming community. Jenny Smith 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 and most makes and models of insulin pumps and continuous glucose monitoring systems. She has also had type one diabetes for over 35 years and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link.