#915 Best of Juicebox: Diabetes Pro Tip: Pre Bolus

May 20, 2023Scott Benner

Originally posted on Mar 25, 2019.

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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 915 of the Juicebox Podcast.

Today, we're gonna be revisiting episode 217 From March 25 2019. This is the Pre-Bolus episode of the diabetes Pro Tip series. Today, Jenny Smith and I talked about Pre-Bolus thing. I mean not today, but I don't know, like four years ago, but for years has not made this one any less of a fan favorite. 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 healthcare plan or becoming bold with insulin. If you head to cozy earth.com You will save 35% off your entire order with the offer code juice box at checkout one word juice box at checkout at cozy earth.com to get 35% off everything they have joggers, sheets, towels, pajamas, I mean they've got so much great stuff, check them out cozy earth.com Use juicebox at checkout to save 35%.

The podcast is sponsored today by better help better help is the world's largest therapy service and is 100% online. With better help, you can tap into a network of over 25,000 licensed and experienced therapists who can help you with a wide range of issues better help.com forward slash juicebox. To get started, you just answer a few questions about your needs and preferences in therapy. That way BetterHelp can match you with the right therapist from their network. And when you use my link, you'll save 10% On your first month of therapy. You can message your therapist at any time and schedule live sessions when it's convenient for you. Talk to them however you feel comfortable text chat phone or video call. If your therapist isn't the right fit, for any reason at all, you can switch to a new therapist at no additional charge. And the best part for me is that with better help you get the same professionalism and quality you expect from in office therapy. But with a therapist who is custom picked for you, and you're gonna get more scheduling flexibility, and a more affordable price betterhelp.com forward slash juicebox that's better help h e l p.com. Forward slash juicebox save 10% On your first month of therapy. In the episode about insulin, I told you that, that my nurse practitioner CDE told us that fear of insulin was the biggest sticking point for people making good decisions with their diabetes, right. And after I got past my fear of insulin, the next hurdle I had to get past was Pre-Bolus. And I am now years and years later at a time where I will tell you that if you do not Pre-Bolus a meal, the likelihood of success is near zero. And if you have success without Pre-Bolus saying.

All that means is that you gave yourself too much insulin prior to that. And it's just catching up now. And so this is it. We're going to talk about Pre-Bolus And then we're going to talk about how about insulin action, right the action of the insulin and how to balance it against the impact of the carbs or your body function. So tell me, let's go over the part that people aren't gonna find comforting at first, right which is the amount of time it takes insulin to begin working in a person varies person to person and insulin to insulin. Is that pretty fair to say?

Jennifer Smith, CDE 4:07
It's pretty fair to say yes. And insulin to insulin. I would definitely say most of the the rapids on the market should be fairly similar. The rapid acting influence on the market and their time of action should be fairly similar now. Person to person. Yes, that may vary

Scott Benner 4:30
situation to situation as well

Jennifer Smith, CDE 4:32
as situation it may vary. But again, that's the learning part of it. Okay,

Scott Benner 4:37
so person, the person could end up meaning just your body chemistry could mean where your infusion set is right, you know, or your injection site. Absolutely. Say you're a person who gets stuck on I always injected my belly in the same place that spot might not be as reactive to the insulin as if you would just try a new spot. If you went to a new spot it might work quicker than it has been in your old spot. Right? If you're wearing infusion set it could we alluded to it before you could get better action from your insulin on day one than you do on day three or better on day two, then you know, two hours after you've put it on, there's a lot of different variables. But we're speaking generally here to you'll apply them to your variables later. Now, if you've heard this podcast before, you'll know that I have alluded to how insulin works in a number of different ways. So I'm gonna give my kind of cartoony description of it, and then we're gonna let Jenny talk about it for real.

Jennifer Smith, CDE 5:32
Her acuity might be better, as we'll see.

Scott Benner 5:34
So here's how I pictured in my head a couple of different ways. The first way is I think of a tug of war. And I imagine a rope with a with a flag hanging in the middle of it. And on one side of this tug of war rope is insulin. And on the other side is your carbs and your body function. It could be adrenaline, it could be fear, could be anxiety, whatever it helps to drive your blood sugar up. That stuff's on one side of the rope. The insolence on the other side, unlike a tug of war in a schoolyard, our goal is not for one side to win, our goal is for them both to pull and pull and pull until they get exhausted, and they both go, I can't do this anymore, and they dropped the rope and our flags still in the center. That flag represents the blood sugar. You start at when the impact of the carbs begins in my mind. So I'll explain a little more. If you let them both start pulling at the same time, the carbs are generally speaking, going to gain power and momentum before the insulin begins to work. So now your rope is going towards a high blood sugar and you're you're starting to head up. Now suddenly, you're 50 points higher. And what if you started with 150 blood sugar, now you're 200. And now these carbs have momentum. They have speed, they're pulling your blood sugar up. Now all the sudden, 1520 30 minutes later, the insulin is like, oh, no, no, wait, I have a job to do. I remember and it kind of comes online. But now it's pulling, it can overpower the the momentum that the carbs have created. Plus, you now have another 100 points of blood sugar to contend with. And all you have is the insulin that you counted your carbs for. So even if you counted your carbs perfectly, and realize that this meal is five units, once the momentum of the carbs is rocketing your blood sugar up, once you have a number that is higher than you started with those five units are not even going to begin to cover what's happening, let alone the food that you've put in. But if you put the insulin in first, and let the insulin come online slowly and begin to pull down and create the momentum in the other way, then you flip the script. And now the carbs are fighting. So instead of having a fight at 180, blood sugar, you're having a fight at an 80 blood sugar. And instead of your blood sugar falling at 80 It's being the attempt is that it's now trying to be pulled up by the carbs. And that's how when you see people with a stable graph, that's how they're doing it. And so for me, in a perfect situation for me, my daughter's blood sugar is diagonal down when I give her most foods. There's differences you know, food to food, situation to situation, but in a perfect world. To me, that's it, you want your insulin working, your blood sugar trending down, creating some momentum down, when you allow the carbs to begin to pull up. Right now, you'd explain that in a technical way that sounds

Jennifer Smith, CDE 8:37
and most in most settings, yes, that's 100% I mean, insulin, our rapid I've always thought that rapid is such a misnomer. Honestly, rapid indicates like now rapid is like sweating out, click, click, click lights with design, it's working. And it's, you know, still education is take your insulin and start to eat. I mean, even from most endo offices, it's take your insulin and start to eat, it's going to be working very, very quickly. That's not the case. And anybody who has been taking insulin long enough, and you've seen the spikes, and you've seen the issues, despite counting your carbs as precisely and weighing them and everything and you're still seeing these issues. It's the mismatch of insulin timing, it is so rapid take anywhere between about 15 to 30 minutes to really get that active peak, not peak, but that active phase where then when you start putting your carbs in. They will match as you said that carb digestion will start to match with the insulin you'll get a nice gentle curve up and it should then start to curve back down. And there is a lot of there's a lot of education that also focuses On, as you mentioned, watching for that curve down, watching for the curve down to start so that you know the insulin is already moving things.

Scott Benner 10:12
Yeah. And to give you some context that a person I spoke about in a previous episode, who was having trouble, told me, but what am I gonna do, I'm gonna be scared. I said, well try it a little bit this time and then a little more next time and a little more next time and go for it. And, and so I always tell this story somewhere. And I think here's the right place to tell it. Prior to glucose sensing technology being a thing that anyone knew about prior to Dexcom, I was again in the office and the CD says to me, Hey, you're gonna get one of those Dexcom things. And I thought, I don't know what that is, you know, and she starts telling me it's, it's, it's a continuous glucose monitor. And I'm like, Yeah, I again, don't know. And then she tells me this simple story. There's a 17 year old boy in her practice, who loves candy, certain kinds of candy, and he can't figure out how to Bolus it. So he gets a Dexcom, whatever the first one was, I don't even remember anymore. His whole goal was to eat this candy without a spike. So he goes out to the store. And he buys like little grab bags of these candies, and a number of them enough for a week and every day starts on this experiment first day, just like you said, eats, gives himself as his insulin, just like he had been told his whole life, blood sugar goes up to 20, something like that sits there forever. Eventually, he has to give himself more insulin to bring it back down again. Next day, he tries a little sooner, give himself a few minutes, 510 minutes gets a little less of a rise. So the next day, he goes even sooner. And then before you know it, it's a little sooner, a little more, and he starts adjusting it back and forth a little more a little sooner, a little later, until one day, he eats the candy. And his blood sugar never moves. And she tells me that story. And I thought immediately Wow, that means it's possible. Yeah, that was the first time I thought I was like, if that kid can do it with candy. I can do it with anything. Like anything, right? And so yes, give me that CGM place. And I got it. And I and I started dispense with my fear. And I started learning about it. There were hiccups along the way, right? I've given her insulin, and she's gotten lower than I meant to for two when she's eating. But you know, once twice, I'll go back to this over and over again, when something goes wrong. It's not a mistake. It's a learning experience. It's data for next time, right? Right. So I put the insulin in, and she goes down to 70 and sits at 70. While she's eating. It's beautiful. You know, like, there she goes. And then and then then a spike. Even if I really messed up on the amount of insulin, I used a spike takes you to 120. Right, right. Right. Right. It's just, it's all about that timing and amount. And I repeat it over and over again, that you all the things you and I are going to speak about all the things that people hear about on this podcast, if you want to know how to use your insulin, at its core, the very first step is timing and amount. If you get you can use the right amount at the wrong time, you can use the wrong amount at the right time, that it's too much, you have to have the right amount of insulin at the right time, you have to balance the action of the insulin against the impact of the carbs. If I do that, I don't want to say it's easy, because that's insulting to people. But let me just say I don't think about diabetes that much anymore.

Jennifer Smith, CDE 13:27
It's easier, it's much easier if you do that. It is easier. Absolutely. And it's a lot more. It gives you a lot more visual than to understand. Because it's not so much of an unknown Well, gosh, I counted the carbs, I took the right amount of insulin and this is always happening to me. Why. And if you can start to put those pieces together, it's not a wi anymore. It's like turning the light bulb on.

Scott Benner 13:58
Here's how I explain what Jenny just said. The Dexcom G six continuous glucose monitor gives you a complete picture of your glucose showing you where it's going and how fast it's getting there. There can be nothing more important. The Dexcom GS six also eliminates finger sticks for calibration, diabetes treatment decisions, and diabetes management. It also has an automatic inserter. Like it just you know, you stick it on and you push the button and the next thing you know you're wearing it. Now you can use the Dexcom receiver to get the information from your transmitter. But for those of you who enjoy using your cell phone, it works great with iPhone and Android as well. The last little thing about Dexcom isn't so little. How about the share and follow features also for Android and iPhone. Your loved ones can follow your blood sugar anywhere in the world. And if you're the parent or caregiver of someone with type one diabetes, you can be watching their blood sugar as well. You want to know what Arden's blood sugar is right now. It's 82 just glanced up and saw Just like that. Now my results are mine and yours may vary, but my daughter's a one C has been between 5.2 and 6.2. For over five solid years, the decisions we make about how to give my daughter insulin and when to give it to her, come directly from the data that comes from the Dexcom G six. And I don't know if you know this or not, but my daughter does not have one dietary restriction. Those numbers are accomplished through waffles, just as well as through salads, through burgers, just as well as through zucchini, it doesn't matter anything that impacts my daughter's blood sugar, that impact is shown to me by the Dexcom JSX. And then I make good decisions. You want to make some good decisions, go to dexcom.com forward slash juice box and get started today. That's the best decision you're ever going to make. This is a short episode, and I don't want you to have to have to add breaks. So hang on for me for one more second, let's talk about Omni pod. This past week, I visited the Omni pod headquarters in Massachusetts, where they've just moved their production facility. It's about to go live. And I got the tour of the floor where you're on the pods are going to be made from now on right here in America, right in Massachusetts, I want you to know that what I witnessed in Massachusetts on that assembly line, it didn't just renew my excitement about Omni pod, it shot me over the moon, the accomplishment of bringing a production like that into one facility, putting it under your roof that showed me a real commitment to the people living with type one diabetes. Right? This isn't being made overseas somewhere, you know, a bunch of different factories. It's all right there at the Omnipod headquarters, and its state of the art an absolutely stunning. This is a company who is behind you for the long haul. I believe that before but I believe it even more. Now, here's what you want to do go to my Omni pod.com Ford slash juice box or click on the links in your show notes or juicebox podcast.com. When you get there request a free experience kit. That's right, a pack a pod experience kit on the pod is gonna send you a pod that is an exact replica of the one you'll get when you start using the product for real, but this one's non functioning. And so it's safe to wear for you to try out, you'll be able to find out if you like it, where you want to wear it. And you'll notice how after you've had it on for a little while you don't even remember that it's there. Miami pod.com forward slash juicebox. The links in your show notes or juicebox podcast.com.

Last thing, don't forget dancing for diabetes that's dancing the number four diabetes.com. It's the little organization that does a ton of good for a lot of people living with type one, they're on Facebook and Instagram. And at dancing the number four diabetes.com Check them out. Here's how I explain what Jenny just said. I think of it as this equation that it's a mathematical equation that doesn't have any math in it. I did this that happen. So next time I'll do more or less sooner, you know, little less little more, that kind of thing. And I always just I always just keep looking at it like that. I did this and that happen. It's the idea of being in a fistfight and you want to hit first because now you have caused an effect. Right? And if you and so now, you know I've done something. And that's what happened next. Now I can make a good decision about what what I do next, instead of waiting for diabetes to do something to you. And then you're just covering up your face hoping not to get knocked out. Right? Like because you don't know what's happening. You don't know why it's happening. I have no context for what's going on. But when you make the first move, you can be sure that what happens next was impacted by what you did. I put insulin in 10 minutes before you ate 10 minutes before I ate. And my blood sugar went to 150. So the next time I'm going to try 15 minutes. And if it goes to 130 I might try 20 minutes. And you know if I get low then later I might say okay, I might need a little more a little less. Now here's where people always say well, how much Scott How long? You know, give me the time give me the amount? That answer for me. It's always going to be I don't know figure it out for yourself. Okay, you have to

Jennifer Smith, CDE 19:22
this is the starting place. Yes. This is where to start. This is how to start. You have to do your own. I mean, diabetes is a science experiment. It's a daily I feel like every day you're almost given like this new petri dish and you're told, keep the dots growing purple today. Okay, let's work on keeping the dots growing problem is that something green pops in and then these like little horny pink things pop on. You're like, oh, no, but it is it's like it's a science experiment that for the most part when you figure out what does work the timing around the most typical foods that you Eat and whatnot, it takes a lot less thinking out of the equation.

Scott Benner 20:04
Yeah. And while this isn't about Pre-Bolus, and it will come up later, but it's important for me to say, because I think this is impactful when you really stop and think about your, your habits around food. They're pretty similar. Right? So, you know, you're not I always say like this, like, if you're a person who gets a pizza on a Friday night and has two slices, you don't suddenly next Friday have seven slices, you don't go from being a two slice person to a seven slice person, right? Like, and so, so you can start making these decisions about how much insulin and when, and you can make them based on historical knowledge about what's going

Jennifer Smith, CDE 20:41
on? Yeah, I usually tell people as the Pre-Bolus piece, you've got, most people have about 20 to 25 foods that are the most common for you to eat regularly. Yeah, that's at least 80% of your control there, at least. So if you can nail the Bolus timing around those and figure it out, for the most part, you know, variations in setting will happen, whatever, yeah, but for the most part, if you've figured that out, you're also much more likely to be able to figure out food that isn't your norm, because of the similarities to what you've chosen. And what you're usually eating,

Scott Benner 21:27
because you can stay flexible. I call it saying stay fluid, right? So here's, here's where I'll tell people this, don't get mad. I don't count carbs. I actually think about it a little backwards from the VB how most of you think about it, I don't look at the food and say eat away at or measured and say okay, well, that's 25 carbs. And my pump says that, I get one unit for every 10. So that's two and a half units. In honesty, there is no accurate insulin to carb ratio set up in Ardens pump. We don't even I don't even pay attention to that. I look at a plate and I say to myself, that's seven units. I think that if she's going to sit down and gorge herself on nachos and cheese, the last time that happened, it took 10 units. But I think of it as insulin, not as carbs. And of course that takes a little practice, right? It does, it does. And it is a little contingent on you having a CGM. I'm not going to lie about that, right, because I start with a healthy Pre-Bolus. And healthy would mean in amount and time. And then I watch her CGM, and I don't really watch it, I have her tolerances set tightly enough that if she leaves that range, I find out about it. So as an example, if I were to give art in something incredibly carb heavy, I might use a Temp Basal increase, and a Pre-Bolus to try to spread out the action of the insulin across this timeline where there's going to be these carbs, right? If I make a Bolus, and 30 minutes after I do it, she's 121 30 Diagonal up. I look at that line. And it tells me something based on my previous knowledge, it's that I say to myself, ooh, this I missed, like, this isn't enough insulin. And I will give her more I will bump it and nudge it back. It's not a ton more, it's enough to stop the arrows,

Jennifer Smith, CDE 23:25
right. And the arrows are very important to bring up in this in this as well. Because if you are using a CGM, those arrows do indicate a rate of change. And again, that's not something that most people realize. They don't understand that and not understand that it's that they've not been told they've not been told, Hey, these arrows tell you that you're increasing by 30 to 60 points in the next 30 minutes. Okay, if that's the case, and I know what my plan of correction factor is, or whatever, I can say, Okay, I'm going to need this much more insulin because if I don't correct my rising 130 blood sugar in the next 30 minutes, I could be 30 to 60 points higher. I could be as high as 190. I don't want to be 190 I've obviously miscalculated someplace, I can throw in a bit more insulin to counter that expected and stabilize it. Yes.

Scott Benner 24:20
Yeah. It very much. It very much is remembering to like I guess the way I usually say it is that you have to trust that what you know is going to happen is going to happen, right? Yeah, you see, and I think that the least important aspect of what the Dexcom does is the number. It's the direction and the speed, direction and

Jennifer Smith, CDE 24:48
100% I wish more please say that again, is the direction it's the trend. It is not just the number

Scott Benner 24:56
the numbers nice like don't get me wrong. It's a starting point, but You know, if you're 60 and stable, and you haven't had insulin for three hours and you haven't had food for three hours, well, maybe you could get away with like a Temp Basal decrease of 100% for half an hour, maybe you'll rise to 90, right. But if you're 60, and you're falling, well, then you don't have enough time, because as we've now discussed over and over again, insulin doesn't begin working right away. Also, Temp Basal is our insulin. It's funny how people think of bolusing and basil is different. But once you're on a pump, it's the same thing. You can't just turn your basil off, and it starts happening right away,

Jennifer Smith, CDE 25:34
takes about 60 minutes for circulating insulin level to be different.

Scott Benner 25:38
I always write and I always try to think of it a little bit as like Ardens Pre-Bolus time like if Ardens Pre-Bolus time is 20 minutes, well then setting a Temp Basal is not really going to start working for at least 20 minutes. Plus, it's a fraction of the Basal rate if, if you're getting a unit an hour, and I say to her, okay, let's double it, let's double it to two units an hour, that impact of that doesn't begin for 20 minutes or so plus, it's not the whole unit. Actually, it's the it's the fraction of it. So when we talk about basil, we'll get to that. But so Pre-Bolus Singh is really just the idea of balancing, again, the action of the insulin against the impact of the carbs, giving yourself a chance not letting the carbs wash you away. Because here's what happens when the carbs wash you like, count your carbs exactly right. You put your insulin in, you spike up the 200. When that happens, that insulin was only for the food. It wasn't for the 200 blood sugar, and it wasn't for the momentum of the rise. And so when I see that, like, I guess an easier way to say this when when I don't have time for a Pre-Bolus and Pre-Bolus thing to me is never about the number, you can Pre-Bolus a 65 blood sugar, you know, you can Pre-Bolus a 90 blood sugar because still no matter what, if you're stable at 65, the insulin you put in is not going to start working until it starts working. So you have and so don't get me wrong if I see a 65 blood sugar and an artist needs 10 units for what she's eating. I don't put all 10 units in at a 65. I might do an extended Bolus which we'll talk about and extended Bolus but I get some insulin moving, I make sure the insulin is on the winning side of this tug of war to start. But in a situation where I can't Pre-Bolus Let's say I know the meal is five units. 100% certain it's five units. But for whatever reason life, let's call it I can't Pre-Bolus and Ardens. You know, I'm going to start eating right now. I'll give her seven units. Because I Bolus for the food, the five units for the food I knew. And I probe and I'm Pre-Bolus Singh. The rise I know is coming and the end the number I know is coming. So I'm already treating a high blood sugar that hasn't happened yet. Because I know what's going to happen because I didn't Pre-Bolus

Jennifer Smith, CDE 28:03
Right. John Walsh goes into detail about what you're doing in a little bit of a different way. He calls it super Bolus, I call it an over Bolus thing. Yeah. And he calls it super Bolus in the way that you take that five units, let's say in your example. And let's say your basil behind that meal for the next two hours is one unit an hour, you actually take your basil running for the next two hours, and you add it into the Bolus for the meal and you take it all upfront. And then to decrease the chance of being too low later. Because of so much upfront action and the blood sugar staying normal, you actually set a temporary Basal decrease, he recommends starting with 100% Because you've loaded that onto the front to avoid a low but on the back end. Some people find though that a Temp Basal 100% off is too much. They only need a 50% they still call the spike and prevent it. But in the back end, they're not having a low then. So similar kind of concept. Yeah,

Scott Benner 29:07
I consider that trading Bolus for Basal. So So you know, say 120 Diagonal up 3040 minutes after a meal and I go, Oh, geez, I got to stop that arrow. How much do I Bolus to stop the arrow? I usually Bolus an hour's worth of a base of Basal insulin. That way if the arrow stops and I stay steady, and she doesn't go down, I say okay, well obviously I was just wrong on the initial amount. But in those situations where you push the button, you know the unit and a half goes in, and five seconds later the error goes from one to 22 Diagonal out the flat you go oh, I didn't need that. Right Temp Basal off. Half hour. All I've done is trade the Basal for the Bolus. Absolutely. Here's a good place to say this and we'll say this in each of these little vignettes. Never suspend your Basal. It's always temporary basals when you suspend you're shutting your pump off when you shut your Jump off. It does not. You have to remember to turn it back on. Yes. Yep. It's always temporary because you can set a Temp Basal for a half an hour, an hour, two hours, but at the end of that time, it was bad. And I'll go back on and start delivering your Basal. It's always temporary Basil is not not don't suspend your pump. Okay, so I think Do you think we covered Pre-Bolus? There?

Jennifer Smith, CDE 30:20
I think that's pretty good. Good. Yeah, that's awesome.

Scott Benner 30:25
Don't forget that you can work with Jenny yourself. If you want just go to integrated diabetes.com To find out how. Let's also take a moment to thank our sponsors Dexcom on the pod and dancing for diabetes. There are links in the show notes of your podcast player app, or at juicebox podcast.com. But you can always go to dexcom.com forward slash juicebox. My omnipod.com forward slash choose bucks or dancing the number four diabetes.com. I hope you're enjoying the Pro Tip series. This was episode four, where we talked about Pre-Bolus. And don't forget that episode one is for those starting over, or just being diagnosed. Episode Two was all about multiple daily injections. Episode Three, we talked all about insulin. Today, of course Pre-Bolus Singh in the next episode, Temp Basal rates huge and important. And then after that insulin pumping, they're designed to be listened to in order to trust me listen to them in order. I have just a little bit of music left here. So let me thank everyone for the great reviews and ratings on iTunes. Very much appreciated. A huge thank you to one of today's sponsors better help, you can get 10% off your first month of therapy with my link better help.com forward slash juice box that's better. H e l p.com. Forward slash juice box. If you've been thinking about speaking with someone, this is a great way to do it on your terms. betterhelp.com forward slash juicebox. All right, I want to thank you for listening to this episode of the Best of the Juicebox Podcast. And I'd also like to thank people who made better microphones since this was made. Those people should be lauded. And I think we're all very, very grateful. Thanks again for listening. I'll be back very soon with another episode of The Juicebox Podcast made on this microphone. The one that sounds amazing