#267 Ask Scott and Jenny: Chapter Three
Scott Benner
Answers to Your Diabetes Questions…
Ask Scott and Jenny, Answers to Your Diabetes Questions
Let’s talk about standard deviation and target range.
Let’s talk about Loop and absorption time to better understand food impact, glycemic index and extended bolus.
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Scott Benner 0:00
This episode of The Juicebox Podcast is sponsored by in pen from companion medical. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And to Always consult a physician before making any changes to your healthcare plan, or becoming bold with insulin. MDI users, this one's for you. How would you like to live your life less complicated? You can do that within pen in pen is a reusable injector pen that has its own smartphone app. They talk to each other through the Bluetooth. that Bluetooth is magic, isn't it? You know what the app does? I'm going to tell you a lot of battle over the next few weeks on these Friday shows. But for right now, dose calculator dose reminders reporting actually tells you if the temperature of your insulin has gone out of range. Not only that, it connects to your CGM. Ooh, I got you there tonight, an app on your phone that connects to your continuous glucose monitor that connects to your insulin pen. Now you want to know more about indepen don't you? Check out companion medical.com. Welcome to ask Scott and Jenny. In today's episode, I Scott and Jenny Jenny Smith from the diabetes Pro Tip series in defining diabetes. You know Jenny, Jenny works at Integrated diabetes. She's a CDE, a registered pump trainer CGM trainer dietician, she has type one. Her favorite candy is dark chocolate peanut butter cups. And if Jenny was a professional baseball player, she'd be Hank Aaron.
In today's episode of the show, Jenny and I are going to be taking questions from you the listeners. In this episode, we're going to talk even more about understanding standard deviation and absorption times for loopers. Now that absorption time for lupus thing, don't get confused and think if I'm not looping, this doesn't work for me. It's also going to be able to inform you about how to understand your extended boluses. Trust me, it's all about timing and amount.
mirdif asks one interesting journey after we did standard deviation in a defining diabetes. I get this question a lot now. So obviously we there's something we didn't say there. We caused more questions than then
Jennifer Smith, CDE 2:42
then I think I read this one, what three day
Scott Benner 2:45
target for standard deviation? And if you set your targets tightly for alert purposes, will it look like your standard deviation is greater? Will that not affect the value of murder? We did talk about this in the office? Because I've had the same thought. But I won't. Yeah, I'll let me go over it one more time in case we missed something in that episode.
Jennifer Smith, CDE 3:03
Yeah, so standard deviation really speaks to the variance up down. So even if you had your target set, let's say, in your CGM, you have your target set from 80 to 120, let's say a very tight target, okay. But you have this roller coaster that's happening this up, down, up, down, up, down, up down, you know, from, you know, on the low end, maybe in the 50s. And on the high end, maybe up to like the 120s, you're still you're going to have a higher standard deviation, because the variance even within that target that you're still meeting, you're still having a roller coaster. Now the standard deviation is going to get higher. If you have more variance, let's say even if you're your target is that 80 to 120. And you're going from 50 all the way up to 300. And way back down and way back up to 250 and back down, then the standard deviation is even going to be larger than it was with a roller coaster within a target. The aim for standard deviation. I'm always kind of cautious to say we're aiming for a standard deviation of this solid rock, you know, this one number. The lower the standard deviation, the better. That's that's the easiest way to say I mean, if you're looking at a standard deviation of 70, you've got a heck of a lot of variance you do. Your CGM graph probably looks like a roller coaster at an amusement park, right? That's not what we want to aim for. Even within a tight target. You still don't want all of this happening. You want more gentle rolling hills from you know within less or within a tighter range, right? That's going to bring the standard deviation down. So if you have you know, a target range set from 150 to 180. And you're meeting it and your standard deviation is 21. That's a beautiful standard deviation, but your target is leaving you high. Right? So you're doing a good job of keeping things to a minimum as far as excursions, but you just need to ratchet your target down to keep that same low standard deviation. So I hope that makes sense. I'm going
Scott Benner 5:29
to share what we do because it's by no means the rule but it's a place where I've become comfortable with living life and finding a balance. Right. So Arden's target is set at 70. And 120. I'd love to be between 7120 as much as possible, it's not as much a target as it is. alarms for me, like when do we have 120? So I know what to do, right. I love for Arden standard deviation to be lower than it is. But in honesty, I tried just not to go over 40 Like that's like, and that's not great. Yeah, but it's, it's I shoot for more like 35 I try not to go over 40 If you look at Arden's graphs, they're interesting in that 18 hours of the day, her blood sugar is like 80. You know, most of the time, there's two meals that are varying cause a variance Right. And, and she'll jump up usually, it's like 181 60, conventional pumping, I was able to get down a little more quickly. But we're doing now not as fast. But conventional pumping, I didn't have 18 hours of ad that was solid. So in my mind, it's a bit of a trade off, and I'm learning how to do the meals better. I think that you should think about standard deviation more in the context that Jenny put it in. You don't want it to be 70. Not good. Right. But if you're shooting for 20%, or something like that, probably not that realistic. So I've heard under 40. I don't know where I've heard that from is that a reasonable like Mendoza line for
Jennifer Smith, CDE 7:13
under 40? Absolutely. I mean, if you're really it, I usually with the with the people that we work with trying to aim for, you know, the 30s or without consistently running just way too low with little deviation, the 20s can be great, as long as like Arden is kind of hovering at that at with little deviation. Great. That would be awesome. You might be in the 20s. But you know, 30s is kind of where we aim. Overall, with a little bit lower or whatnot. Depending on what situation in life you might be at two, with the women that I work with through pregnancy, we aim lower, tighter overall everything.
Scott Benner 7:55
Let me give you an example because I'm looking at a live grant for art and for 24 hours, right? So in the last in the last one day Ardens a one C has been 5.8 with an average blood sugar of 119 that put our standard deviation at 42. Now if you go out over 90 days, Arden's averaged a one C is 5.6. Over 90 days, her average blood sugar's still 115. But her deviation will probably go up. It does. So it goes it says 45 Over the last 90 days now we are still learning some things and so we have some more prolonged blood sugar's but for instance, in the last seven days, her standard deviations 38. Right. So as I get better at it, you know, over the last 90 days, because you know of this loop thing, you know, you see it come down, I will get the deviation consistently under 40. I think it's going to be more consistently like 35 Once I figured out the meals, but then, you know, I think Jenny's Right. Like once you have the tools in place and things are working. I see standard deviation not as a target. I see it more as See, I don't want to call it a report card, because I don't mean it like that. But I think of that more something you look at later to say, oh, things are getting better, not something right day to day. It's like a comparison
Jennifer Smith, CDE 9:19
almost to say this is where I was this is where I am now. Oh, it looks like it has improved.
Scott Benner 9:26
I would look at if you're looking day to day, I just look at average blood sugar, and I try to keep it lower. And then I look at at deviations like high high deviations. Obviously I don't want a low blood sugar. So I don't have a lot of problems with lows. But I don't want to see big spikes that lasts too long or big spikes. Right. So Meredith, I hope that answers some question and then I'm about to tell you something about in pen. And I think I should first warn you it's possible the information could blow your mind. So I don't know what you want to do put a hat on or hold your hands in the side of your head or something like that, but When you Bolus within Penn say you're having some food, right? And you look at your plate and you're going 10 times, you decide that's 35 carbs, you go into the in pen app, tell it 35 carbs, and it tells you how much insulin to inject, right? Hold yourself tight now because the here's the rest of it. Now pen users, no, you have to prime your pen a little bit. So you prime the Impend, and then dial up the insulin that the app tells you, let's say it tells you a 3.5 units, you inject those 3.5 units, the in pen actually can see the difference between the prime and the 3.5. And it doesn't. So you know, I'm saying like, when it's calculating how much insulin you have, it's not saying like 3.5 plus the priming amount of insulin it know, how does it know? The fascinating, right, like just boom, I don't understand. I mean, for a pen user, or somebody who's doing injections, this is an incredible leap. Your insulin on board is being kept by an app on your phone. And it can see the difference between the priming of your pen and the Bolus. Get out of here. You obviously need to know more companion medical.com. There's links in your show notes at Juicebox Podcast comm. And one more thing, starting I think next week, maybe the week after these ads are actually going to be a conversation within pen user and world champion, paddle boarder, Fiona wild. Fiona is going to tell us what she loves about it. And it's enough of me telling you what I can, you know, read in a PR kit. Let's hear from a real user. I'm wondering about carb types, oh, entering into a loop. I get confused about what to put when I'm eating a combo meal. For example, what if I'm having pizza and fruit or a burger and veggies or, you know, like yogurt fast carbs plus protein? She said I thought maybe since Jimmy was a dietitian too. This might be something she can help decipher how to Bolus for different combinations. So what Matty's bigger question is and how this will work out for the rest of you is she's really asking about absorption time, I think in loop right, to
Jennifer Smith, CDE 12:15
an glycemic index to a conventional pump system. Yeah, in game
Scott Benner 12:19
conventional pump system, it's going to be glycemic index. And the idea of extending boluses or temporary or something like that. So it's, it's crap, slightly different tools, same reason. But to give people context, you don't listen, who don't use the looping system, you will tell the loop Hey, I'm eating 35 carbs now. And then you have to tell it how long you expect it to be in your system, how long you expect it to take to absorb is that one hour, 30 minutes, two hours, three hours, like that kind of thing. If you get that absorption time wrong, when you put the setting when you put the carbs in the loop, it really big causes a lot of high blood sugars when you get it wrong the wrong way. So do you have any thoughts on this? Because I'd actually love to hear them. I'm gonna sit back and listen like a listener for a second.
Jennifer Smith, CDE 13:03
It's a very good question. I think that the icons that are within the fast moderate and slow groupings, if you are a looper and using them are defined by like a glycemic index nature, right there fast ones are going to get absorbed pretty quickly loop says they're two hour moderate or like a three hour really slow, which would be like high fat, really high protein kind of meal would be a slow absorption, right? icons like a lollipop, a taco or pizza. Okay. Now, most mixed meal, she brings up a good question. Most mixed meals that are a content of carbohydrates, and protein and fat and healthy fiber. Good example being something like grilled chicken, steamed veggies, and maybe like quinoa or brown rice or something like that, right? That's a good mixed meal, a three hour absorption would be a good place to start. It's mixed. You've got a little bit of everything. Now, on the flip side of that, let's say you have like a thumb size of grilled chicken, one broccoli spear and a plate full of brown rice. Hmm. Question time there is based on the content, right the content but the portion that's the glycemic load. It's not only glycemic index, but it's the amount if you've got a plate full of high index carb that you're eating, very minimal little other things that's no longer a combination meal. That's more like a two hour that's like it's fast now rice is as an example in this can be a can be a bad example because some people's experience with rice can be longer impacting same thing with pasta. Some people get really quick impact from pasta some people get really like long drawn out. And I mean if I went into it further, some of It has to do with cooking method and again what you eat with it and whatever. But in a simple answer, most combination meals that are not heavy simple carb should be about a three hour absorption for our absorption would definitely be those Merle meals like she's saying, let's say I'm eating a big old cheeseburger and french fries but I'm also having an apple on the side, that's still a fairly long digesting meal. A trick or a tip that might work it let's say you're eating the apple First eat the apple, put it in as a 15 gram you know kar Bolus absorption two hours. And then when you go ahead and Bolus for the rest of the combo meal, or go ahead and rest as the rest as a four hour absorption. That way, you're kind of addressing both types of food and the way that they may be being digested because of how you've kind of eaten them. Whereas the apple at the end of the meal sitting on top of the burger and the French fries and whatnot. Group it in and to for our absorption.
Scott Benner 16:10
I was gonna I was gonna say to rice so at home. I only use a basmati rice. It's okay, and that does not impact Arden nearly like if we were to go to a Chinese restaurant, she was just going to grab like white rice, right? It's just it's easier. You know, bread with no high fructose corn syrup. Great way to cut yourself a break. And pasta, I use dreamfields It does not hit Arden nearly like other pasta does. Both in intensity and time. So there are sort of ways to like cheat around it with certain foods and what you said about about cooking methods I just made I just made another another note for myself about something we could talk about in the future. Because that's really interesting.
Ask Scott and Jenny was brought to you today buy in pen from companion medical, please go to companion medical comm or click on the links in your show notes of your podcast player, or the ones you can find at juicebox podcast.com. For more information. Just think about what it would mean if your insulin pen could keep track of your insulin on board and so many other things. Just like a pump. The impact is fantastic. It's like that little train that just keeps going get any mean climb and Chugga chugga chugga that thing you don't I mean, it's like no stopping us. Now that's not the train. But if the train could sing, you know if the little engine that could could sing I imagine it would sing ain't no stopping us now. What would that even sound like? I'll leave you with that thought. As it fills your head all day long and torments you. You know what? That's not fair. You need to get that out of your head. Do this instead, think about this companion medical.com with links in your show notes for juicebox podcast.com
About Jenny Smith
Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com
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