#226 Diabetes Pro Tip: The Perfect Bolus

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

I am thrilled to welcome Jenny Smith, CDE back to the show. Jenny will be joining us for an extended series of conversations that focus solely on the management ideas that we discuss on the podcast.

Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com.

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Alexa - Google Play/Android - iHeart Radio -  Radio Public or their favorite podcast app.

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

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

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

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

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

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

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

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

Unknown Speaker 2:39
Pog, Oh,

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

Jennifer Smith, CDE 3:47
a triangle.

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

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

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

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

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

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

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

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

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

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

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

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

Scott Benner 9:56
Okay to also try to spike

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

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

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

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

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

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

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

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

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

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

Scott Benner 14:29
Interesting.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Jennifer Smith, CDE 28:31
so be stable,

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

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#225 Diabetes Pro Tip: Bump and Nudge

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

I am thrilled to welcome Jenny Smith, CDE back to the show. Jenny will be joining us for an extended series of conversations that focus solely on the management ideas that we discuss on the podcast.

Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com.

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Alexa - Google Play/Android - iHeart Radio -  Radio Public or their favorite podcast app.

+ Click for EPISODE TRANSCRIPT

---

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

Scott Benner 0:00
Hello everyone and welcome to Episode 225 of the Juicebox Podcast. Today's show is a continuation of the diabetes pro tip series with Jenny Smith. This installment is the eighth in the series and it's called bumping nudge. You'll find out why in just a second. I briefly want to thank our sponsors on the pod dex calm and dancing for diabetes for always being there, you can go to dexcom.com slash juicebox dancing for diabetes.com that dancing the number four diabetes.com or my omnipod.com slash juice box to find out more. There are also links in the show notes of your podcast player and that Juicebox Podcast comm

pumping nudge is the eighth in my diabetes pro tip series with CDE Jenny Smith, don't forget that you can hire Jenny. She works for integrated diabetes calm and she would love to help you do better with your type one. There are links in the show notes to Jenny's email address where you can go to integrated diabetes comm let's please remember that nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise and to always consult a physician before becoming bold with insulin or making any changes to your health care plan. This is a short but really powerful and important episode. Please remember that the diabetes pro tip series is designed to be listened to an order don't just jump in here. Go back to the beginning. This is installment eight of the series. The first one was called newly diagnosed. We're starting over

Jenny Hello How are you?

Jennifer Smith, CDE 1:47
I'm good. How are you got so good. Yay.

Scott Benner 2:08
short episode going over the idea of bumping and nudging blood sugars, which is something we talked about on the podcast all the time. I'm a huge believer in the in the infuriating statement that you won't get high if you never get high. Sure, that's not as easy as it sounds, but that's how I think about it in my head. Right? So I want to fight with the high blood sugar if I don't experience high blood sugar. Of course, that's not always gonna work. I'm not saying that. But I am saying that it's avoidable a lot of the time. I think of it as bumping and nudging just bumping and nudging it could be bumping. I love that

Jennifer Smith, CDE 2:48
term. I love that. I love it.

Scott Benner 2:50
Right? Yeah, you can do it with insulin can also do it with food. You can also do it with a deficit of insulin, which you can create with Temp Basal. We're going to talk about it all right now.

Jennifer Smith, CDE 3:02
We also do it with exercise.

Scott Benner 3:04
Do you know i just i just interviewed somebody who you won't hear for six months. But a girl who has had Type One Diabetes since she was a little kid and she's like she was so compliant like with whatever her mom asked. So she'd eat like celery all there for blood sugar was high. But if she but if she wanted a cookie, she would go exercise and then come back and say to her mother, I just ran around the house this many times and went up and down the steps this many times I would like my cookie now. And this is this was back when she was doing Oh gosh, the words just slipped out of my head. What what's the old timey insulin regular insulin regular an MPH that's what she was mph. Back then she would do a little exercise to get her cookie. But I you know this by the way, this girl is delightful. You have to find the episode with her.

Jennifer Smith, CDE 3:54
My, my mom would do the same thing with me. We're at my grandparents house, usually in the summertime for a couple of weeks. Usually at that time of the year, it was rainy, at least several days out of that time and I couldn't do anything outside. She would have me run around my grandmother's kitchen table and they had a pretty big dining room because it was a farmhouse. And I would literally my mom would be you need to run around. You need to move you need to move. And I was like, Okay, I mean at that point.

Unknown Speaker 4:23
That's all movie. You know, there'd be a snack

Scott Benner 4:25
after this. I guess it's all right. So yeah, yes. Okay, so. So basically, we'll start with this if you have a glucose monitor. You can't think about the alarms. The way you're thinking about them right now you have to your low alarm, you should put wherever you think you need to know like whatever gives you enough time to react. I don't care what that is. That's up to you completely. Ours is at 70 Some people put theirs at 60. You know, 80 whatever, I don't care. It's the high alarm that I care about. Because you need to be able to react to a rising blood sugar quickly. If you react to it quickly, you're able often to react to it with less insulin, you're present, right? It takes less insulin to stop a 120 diagonal up than it does to stop a 150 or a 180. Straight up or 202 arrows up, you could have avoided the problem that you're having now 45 minutes ago, if you knew it was coming, right, right, right now people will say, but Scott, I don't want this thing to alarm all the time. And it's gonna bother me and my kids at school, and I hear all your complaints, put them away. And here's why. Eventually, if you listen to these podcasts long enough, these concepts will lead to a world where you don't really ever leave your 120 blood sugar. So you won't get a ton of alarms. And on the days when that happens, I don't know mute your phone, but don't make a bad decision to avoid a problem that I think is avoidable. And so I know I've said this a billion times, but it belongs in this episode. And I know I talked about driving a lot. But when you're driving, and you find yourself just kind of drifting off of the road, you don't turn the wheel 90 degrees to the left to avoid the curb. It's this almost imperceivable turn of the wheel, you're just nudging it back the tiniest bit. Yeah, that's how you avoid swerving into the oncoming traffic, because you've only turned it a little bit. This is how you stay off the diabetes roller coaster, it is that simple, right? So you stop arise before it can happen. And you use such a small amount of insulin that the likelihood of being low after you've done that is mostly imperceivable. Right? How much does that make sense? Jenny? Where should this be on the Mount Rushmore of diabetes thoughts?

Jennifer Smith, CDE 6:48
I think it should be right, they're taught along with the early the early information of insulin use, it really should be, it should be it should be right there with when you're prescribed insulin. This is our target for high blood sugar should really in my professional opinion, it should be ratcheted down, we should not be being told that post meal blood sugars of 200 or 224 kids

is appropriate only because it's safe.

Scott Benner 7:25
Right and safe in as much as you're not going to have a seizure. correct? That's

Jennifer Smith, CDE 7:30
correct. I mean, am I saying that you're aiming for, you know, a no rise at all? No, am I saying that you're aiming to stay, you know, if you've been consistently rising to 250, and your alarm isn't set to 250, or 300, maybe you bring it down to 200 for a little bit, and then maybe you bring your high alarm down to 180, or you bring it down to 160. But as you do that, like you said, you're gonna see, it takes a lot less to address a rise than it does to correct a blood sugar that's already too high.

Scott Benner 8:02
And in the beginning, this will take more of your effort. But as time goes on, it takes nothing. It really does. I know sometimes I'll explode a bolus out on screen when I'm doing a talk, right? And when you blow it up like that, and show all the decisions that were made you think, Wow, this does look like a ton of effort. Right? I always have to start by telling people what you're viewing up here, encompass about three seconds of my thoughts spread out over five minutes. Right, right. You'll spend more time in initially then, than you will one day. And so it's the same with this idea. I know it feels like if you set it at 120. It's always going to be beeping, but one day it won't be and And wouldn't you rather be bothered even on a on a bad day and a quote unquote bad day? Wouldn't you be bothered? Wouldn't you like to be bothered five times to bump a 120 back down? That might take up 20 minutes of your overall day, then to be stuck in a 300 blood sugar and comes with it all day long, right? All right, little bits of effort. little bits of insulin, way better way, way, way, way better to avoid the highest because you can't get high if you never get high. You can stop it from happening. Does it always work? It doesn't always work. But mainly, I will say this, Arden spikes about twice a day. And it's timing stuff where we don't have the ability to do what we're doing. But when I tell you Arden spikes, I'm talking about 151 70 you know and we get it right back again. So imagine if you had to 180s or to 160s in a day and the rest was between 120 and 70. That's where you get an A one see it's in the fives.

Jennifer Smith, CDE 9:52
Right. for clarification to even about Arden spikes. It's not that you've waited until she's 172 Dress it, you've gotten the alert, the rise is happening, you've addressed it, you've probably taken a correction at like 120 or 130. Because you see the trend happening, she may still get to 151 70 before that insulin starts to working, but the curve down is probably more like an up down almost like a roller coaster. Right? But you're addressing it so that that ride down then is nice and smooth into the end versus being way too high. And crashing from Bolus, Bolus, Bolus, Bolus, oh, now I'm like 50. And because

Scott Benner 10:33
I reacted sooner, I still am keeping mainly the balance of the insulin action carbon pack. I'm still keeping them pretty well balanced. I obviously missed a little bit in the carbs. Got ahead. But I got back in the game soon enough that I'm not going to create a crazy low later, right, you come in for like a nice landing afterwards, which somebody just texted me the other day and says, Can you please tell me what that means. And I always like I think just put your hand up high, and then dip it down and then bring it flat again. And like that's sort of like this. That's what you're trying to make happen. Right? You're trying to come to

Jennifer Smith, CDE 11:04
the end of a roller coasters, what I explained is kind of where you're the rush of that ride down and then you like roll into the station. That's it. It's a flat and smooth, perfectly

Scott Benner 11:15
bringing in for a nice landing. Right? Okay, so, so sure you can bump and nudge that way, right. But what if I'm at the tail end, for example of a meal bolus, and I'm noticing I'm 110 151 hundred, I'm starting to drift down. But I'm so far past this Bolus that I'm now in that space where people do the thing, they can just go, I hope this stops. Right, right? Like, wouldn't it be nice if this stuff, what I like in that situation is a Temp Basal decrease, right, take away some of the basal rate. So now Jenny can see me which is a little unfair, but I'm holding both of my hands together palm, the palm, and I'm pushing a thumb bazel is so important to think about like this on one side is the impact of your body and carbs. And on the other side is the impact of the insulin. And when you push at the same rate, no side wins, like I'm not going wildly one way or the other. Right. But all of a sudden, we get to a situation like I just described where Okay, the insulins winning a little bit, right, the carbs that were there can't hold up the insulin that's left behind. So we start drifting towards a lower blood sugar, we'll just use your pump to tell it to use less insulin, take away a little bit of the force that that insulin has now maybe you'll catch it with Temp Basal, maybe you won't. But in certain situations, it's the best way to start. You know, he I forever see people were like, Oh, I'm heartbroken. I had to give my kid juice overnight. And you look and you see this 90 blood sugar that was just drifting down, that later, by the way, turned into a 180 because they put all this juice in. So you could have in that situation, if you really felt like you needed the juice bump with the juice, you don't have to drink the whole thing, drink enough to bring it back in for a nice landing. Or if you're far enough ahead of insulin impact, try dialing back your your bazel and see if that doesn't catch it and your natural body functions don't come back up again.

Jennifer Smith, CDE 13:16
And if you're an evaluation time period as just a kind of an aside in the overnight, if you give that little nudge with juice comes up a little bit and address down and you give a nudge again and it comes up and it drifts back down. That's bazel you're in bazel only unless you have a correction from earlier that brought you down so much. That's still working. Visa only that's a good you've got too much bazel there's too much they're up down up, down, up down and it never stays stable. You got too much.

Scott Benner 13:49
Alright guys, you know how I do it short episodes, short ads. Ready rapid fire succession. Check out the new Dexcom g six continuous glucose monitors today go to dexcom.com slash juice box to find out more. You're going to be able to see what direction your blood sugar is moving and how fast it's moving in that direction. And with their share and follow feature, you'll be able to find out what the blood sugar is of a loved one who is away from you that's compatible with Android and iPhone. Like I can see Arden's blood sugar right now, but she's not in the house 109 and that cool. You want that to dexcom.com slash juice box with links in your show notes or Juicebox Podcast comm now on the Omni pod on the pod is the only tubeless insulin pump in the world. It's the insulin pump that art has been using for over a decade. And trust me, you want to check it out. But you don't have to trust me too much. Because Omnipod will offer you for free a pod experience kit. That's right, they'll send that demo right to your house. Just go to Miami pod.com forward slash juice box, put in your name and your address. Click in enter there, whatever. It's called the button I don't know, click like like, and they'll send it right to your house. You can hold it, feel it, try it on wear it, see what you think and decide for yourself, you don't need to trust me, you can trust your eyes. Last thing I need you to support dancing for diabetes, I want you to go to dancing number four diabetes.com. And check them out on Facebook and Instagram, great organization doing wonderful things for children with diabetes, through dance. I say a lot that if you find yourself when you find yourself bolusing too often, your bazel is probably too low. If you find yourself out and doing to address in that situation too often with food, your base is likely to high. Right?

Jennifer Smith, CDE 15:38
Right. And you want to stop nudging as much as you can.

Scott Benner 15:42
We all want to go to sleep and nobody wants to eat juice in the middle of the night. That's all the things we're trying to avoid right here. And I know a lot of it still sounds like oh, yeah, buddy, that. That sounds nice. But how do I accomplish this? I think that by now you're getting towards the end of this series. I think Jenny and I have laid it out pretty well, a couple of different ways here. So and important to remember. Because if you've ever spoken to me privately, if you listen long enough, I will beat into your head over and over again. It's about timing and amount. It's about timing about even with Basal, even though you don't think of it the same way. Because Basal doesn't all go in at the same time. If your basal rate is too high, you have too much insulin and at the wrong time. So with I've simplified diabetes down to like a handful of ideas that are sometimes so distilled, that even when I say them out loud, I go, does it just sound ridiculous to people when they hear it. But please trust me. At the end of this series, I'm going to go over all these ideas in simple sentences. It'll be a very short episode, you remember those sentences, apply what you've heard here. You're going to be on your way I you know, I can't promise but I swear I've seen it happen.

Jennifer Smith, CDE 16:54
And I believe a little print off sheets got,

Scott Benner 16:57
oh, I don't want to get away.

Jennifer Smith, CDE 17:00
I know. I know. Well, the full full ideas are really behind all of those little simple statements. So if you had just a little simple fit, and you're like, I don't even know what that means. And those reminders,

Scott Benner 17:11
I actually, I use them too. Yeah, I've had times where I'm like, What is happening? Because it's life, right? Like stuffs going on. You don't know like, why am I bolusing all the time. And I actually stopped myself one time. And I remember standing in my kitchen thinking, what would I tell someone? If they asked me this? And oh, that's ridiculous. But I was like, Oh, my God, or bazel needs to be increased. Boom. And there I was, I was like, Oh, that was I should have listened to me. But like for days, I was like, what's the problem here? So you're gonna get those like simple ideas broken down into sentences that you can kind of repeat and keep in your head, you know, that that'll should reignite the ideas that you heard in the podcast. Okay. So, to go over this again, because it's in a different episode. You need to think about how food affects your blood sugar. Sure, you need to think about how in some affects your blood sugar, sure, but always to remember that you need to understand how the food affects the insulin so you can reverse engineer ideas. You're so used to thinking, I have this high blood sugar and I'm trying to force it down with insulin. Well, what if you have a low blood sugar you're trying to force it up with food and I don't want to use too much. That starts us off on that rollercoaster, right we forget to believe that what we know is going to happen is going to happen we put in this food for low blood sugar, we shoot up now our insolence Miss time, we eventually put in enough insulin it gets Miss time with the food, the food now digest to your system. All the insolence left, you fly back down again, oh my god, what do I do, I throw in more food than I wait and I get high and you start looking at the garage and thinking I just gonna pull the door down Start the car put on my favorite. But we don't need to do that. What we need to do is to bump in nudge with the food as well. And so this is crafting

Jennifer Smith, CDE 19:00
and nudging with the food might actually be a little different. If you know and pay attention to in those, let's say the drops where you're going to nudge with some food. Why is it declining? Is it truly bazel? like we talked about overnight, right? Where you meet need a lot less nudge, little incremental nudge versus you've got three units of iob. And you're dropping, and the drop is actually happening a lot more precipitously, right? You're really like coming down? Well, that little nudge of three sips of juice. If that's not the time to like nudge us, you need a little bit more aggressive nudge than that.

Scott Benner 19:42
Yeah, I tell people all the time if you see a 65 and it's really stable and you want to try to shut your Bayes law for half an hour to see if it comes back up right on but if it's a 65 and dropping like a stone for the love of god drink a juice eat a banana shut off like like, you know, you've really messed up somewhere so

Jennifer Smith, CDE 19:58
right but Right, but

Scott Benner 20:00
the opposite idea of that is not I'm gonna quote a mom that I spoke to. She said, Why did I always give the whole package of gummy bears? Why did I just automatically think because I opened the package he had eat all of the gummy bears. Why not? You know why are three because 15 carbs, 15 minutes 15 carbs 15 minutes. Right bad advice you got from a doctor one time.

Jennifer Smith, CDE 20:25
And it was again it comes to the safety. Right? It comes to the safety piece of this is an easy rip off. None in the moment. This is just please do this because it will at least

alleviate the wall, right? You'll be safe.

Scott Benner 20:40
It's jamming on the brakes 100 yards before you have to stop because you can't be 100% certain you're gonna be able to stop but before you get the hundred yards away because a doctor is not with you because they don't know the situation. Because they don't want you calling them on the phone every five minutes. Now I bolused because I'm going to tell you when some people start explaining to me their bosses. I'm like, Look, I'm good at this. But that is hard to get straight in your head when somebody and you know they're keeping something. They're forgetting something. And so you're like, I can't make sense of this. Like show me a graph. Like when did you eat and sometimes they don't even though, right?

Jennifer Smith, CDE 21:15
I like that's the reason I like little tiny like the Jelly Belly jelly beans. They're a gram of carb apiece. doodles are a gram of carb apiece. They're an easy way to nudge with food in a counted way. Rather than like sips of juice really guy I don't know, I might have had a bigger sip or a little or sip, right? Whatever my sip might be the whole container. I don't know.

Scott Benner 21:39
I'm telling you again, Ninja like level of understanding, I can sometimes stick a straw in Arden's mouth from a juice box as she's drinking it, I just go and that's enough. That's just something that comes with time, right? Like, you're not gonna figure that on day one. But the idea that it might not be all of it. And this and I alluded to earlier, it's gonna sound a little crass. But there are times when you just have to have the balls to wait. Like, you can't just, you can't just over treat an 85 you know what I mean? Like I said it before, I've saw a woman online who told who once said that, that's a mom, and I'm sure she was scared out of her mind. I don't mean to make light of her. But she's like, I saved my kid's life last night. With a juice box. A kid was like 110 diagonal down. I was like, wait a minute, you may very well have been on your way to the greatest night's sleep ever. You're never gonna know. Right? And because this wasn't like what you were talking about. It wasn't like a big bolus that was gone wrong. This was just like a drifting blood sugar. And I was like, Oh, you gotta wait, the you know, you have to. And so let's talk about here, like, because we're gonna try to bump a nudge and in and out of an area. What is that area? And so I mean, you have to define your target. Yes. What is it you're going for? Right? I don't need Arden's bunch are gonna be at five constantly. I don't feel that way. But I and I don't like her blood sugar to be under 70. But I got to tell you that if she drifts under 70 for a couple of minutes, I'm not running around looking for the glucagon. You know, like, let me see how I can just get this to kind of gradually come back up again. Same thing if she gets the 140. And it sits in a guy. I really missed this. But you know what, now I'm only an hour and a half past this Bolus, I really do have to wait a second to see what's going on here. Or I have to decide I'm not gonna look at this 140. And I may need to redress with food later. Right. Right,

Jennifer Smith, CDE 23:33
right. Absolutely. And, you know, that also speaks then to the benefit of now we've got the CGM, right, because with the CGM, you can see more often what's happening that 140 hour and a half after eating, it might be a stable 140 you don't know whether the next three blips are going to start a downtrend or they're going to start an uptrend or they're just going to kind of stay stable. So you have to really have that same thing with your 70 before if she's laying on the couch watching a TV program at 70. Okay, yes, she's not out running a marathon. She's not going to go to the amusement park and walk around for four hours. sitting on the couch.

Scott Benner 24:11
Yeah. Yeah. Even when Arden is like incredibly active on a hot day playing softball, I still like a blood sugar right around 90 and so if I see 90 trying to get away from me it's it could be just you know, you have a Gatorade with you take two splashes of Gatorade, then go back to the water, or, you know, have half of this juice box or are you hungry? You know, sometimes people are hungry. You'll think about it like that. Because you have diabetes. You always think about food as being this like surgical strike. But if you're playing you know a sport, maybe it would be nice to take a bite of a banana every time you sat on the bench or something like that, right? performance energy is different than blood sugar strategy energy. for athletes, there's about 1000 different ways to think about bumping and nudging your blood sugar around so I want you to open your mind to it think differently. Try to really make sense of it. Jenny's Gotta go she's got a life. Okay? work. So I'm gonna let her go and say thank you.

Jennifer Smith, CDE 25:07
Absolutely always, always nice Jenny,

Scott Benner 25:09
I'll talk to you soon. Everything I'm about to say can be found in the show notes of your podcast player at Juicebox Podcast calm but if you'd like to hire Jenny, go to integrated diabetes.com or email her right through your podcast player. Thank you Dexcom Omni pod and dancing for diabetes for supporting the show. You can go to dancing for diabetes.com my omnipod.com slash juice box or dexcom.com slash juice box to find out more. Don't forget on the pod we'll send you a free no obligation demonstration of the pod just for filling out a little bit information and saying you want it even though they're not on this episode. Don't forget real good foods calm you'll save 20% of your order by using the offer code juice box. That's a lot of money you can save. This was installment number eight of my diabetes pro tip series. installment nine is available now and it is called the perfect Bolus. I hope you're enjoying the podcast. I hope you're enjoying the series. If you are please go to iTunes and leave a wonderful rating and review for the show. It helps it to be found by more people

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Please support the sponsors

The Juicebox Podcast is a free show, but if you'd like to support the podcast directly, you can make a gift here. Recent donations were used to pay for podcast hosting fees. Thank you to all who have sent 5, 10 and 20 dollars!

Donate

#224 Diabetes Pro Tip: Mastering a CGM

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

I am thrilled to welcome Jenny Smith, CDE back to the show. Jenny will be joining us for an extended series of conversations that focus solely on the management ideas that we discuss on the podcast.

Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com.

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Alexa - Google Play/Android - iHeart Radio -  Radio Public or their favorite podcast app.

+ Click for EPISODE TRANSCRIPT

---

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

Scott Benner 0:00
Hello everyone and welcome to Episode 224 of the Juicebox Podcast. Today's episode is the seventh installment of my diabetes pro tip series with the CDE Jenny Smith. Jenny has been living with Type One Diabetes since she was a child. So she has first hand knowledge of the day to day events that affect life with type one. Jennifer holds a bachelor's degree in human nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. Besides helping me here on the podcast, sometimes Jenny works for integrated diabetes services. And if you like the way Jenny thinks about diabetes, and you'd like to hire her yourself, you can do that. Go to integrated diabetes comm there's also a link in the show notes where you can email Jenny directly. As always, this episode of The Juicebox Podcast is sponsored by Omni pod Dexcom and dancing for diabetes. There are links in your show notes and at Juicebox podcast.com for all the sponsors. But if you'd like to go directly to them, you can go to my omnipod.com forward slash juicebox dexcom.com forward slash juicebox or dancing the number for diabetes.com.

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 medical plan or becoming bold with insulin.

This is the seventh installment in my series called diabetes pro tips. And if you have not heard episodes, one through six, please stop this one. Now go back and start at the beginning. These pro tip episodes are designed to work in Congress with each other, you should listen to them in order. However, if you're all caught up, sit back and relax and get ready to listen to Jenny Smith and I talk all about continuous glucose monitors. And as you've become accustomed the pro tip series come out in blocks of three. Right now there are two other installments available. eight and nine. They're called bumping nudge and the perfect bolus.

Jennifer Smith, CDE 2:24
What's on our agenda today

Scott Benner 2:26
we are going to talk about continuous glucose monitors.

Jennifer Smith, CDE 2:30
It's a big topic

Scott Benner 2:31
it is right.

So I tell a story that I think is going to fit here in this episode. We were in my daughter's endocrinologist visit a long, long time ago, probably a decade ago. And the nurse practitioner asked me Are you going to get one of these CGM Xers. And that's how new the whole idea was. And I said, I don't know what you're talking about, you know. And so she begins to tell me a story about this 17 year old kid in the practice, who loves m&ms but can't seem to eat them without a spike. So he gets the dexcom, which I think back then would have been the seven plus maybe 10 years ago is that the first one with a

Jennifer Smith, CDE 3:14
seven seven. I know that in 2006 is when I got my first CGM and the seven was on the market, along with whatever came with Medtronic and then Abbott's navigator had come out. And that's actually the first PBM that I had, and I loved it. It was unbelievably accurate.

Scott Benner 3:33
Yeah, I remember that one too.

Jennifer Smith, CDE 3:34
Yeah. So it probably was a seven when you are.

Scott Benner 3:37
There it is. So she's telling us about this thing called Dexcom. I don't know what it is. I don't know what she's talking about the the letter CGM mean nothing to me. Right? Chinese, right. I just I was like, it could have been any language except English. I didn't know what she was talking about. But then she tells me this story. And she says that the boy gets the glucose monitor. And he goes home to the grocery store and buys this little single serving packs of m&ms. But he grabs seven of them. And the first day he goes home and he eats the m&ms as he always would. He puts in his insulin as he always would. And he watches his blood sugar go up. And it kind of stays up after that. So the next day, he thought, oh, okay, I must need more insulin. So it gives himself more insulin in his blood sugar goes up less. So the third day he thought he had it fixed. He's like, this is it. I just need more but give himself more. He barely goes up at all, but then he crashes low later. So the kids like Okay, so the next day a little sooner, a little less, a little more. he messes around back and forth, back and forth with us. And then she looks at me, I'll never forget the look on her face. Because she was astonished, right? And she goes, I saw his graph. He put his insulin in, ate the candy and his blood sugar never moved. And she's telling me a story about that. And all I can think in my mind was well if that's possible with that, then that's possible with anything. Like that's what I left with that feeling of like there's information coming back to me They can do that. That's amazing. Because I used to be one of those people. We'd go into the, I don't really show them the pump anymore. But we used to go in and they download your data. They look at, you know, your boluses and all this stuff and where your blood sugar's were and she'd say to me, Hey, you tested she, you know, RNA at lunch at noon, you test at 1230. She's like, why would you do that? And I said, Well, don't you want to know what's happening? Like, I want to know what's happening. So it was a number of years later that she she said back to me, she was I realized, now prior to you having a glucose monitor, she's like you were doing it yourself. Like you were trying to act as a glucose monitor. You were figuring out what was happening, which made sense to me back then,

Jennifer Smith, CDE 5:39
my finger sticks prior to CGM, and on average, were about 14 a day,

Scott Benner 5:45
I'd have to say that's where we were to,

Jennifer Smith, CDE 5:46
because I literally similar as you, I wanted to know where things were not only before, but especially after because it's a learning piece. Yeah, just like the m&m, it's how did this work or not work? And what do I need to do to make sure that it works the next time because I like this right? Or like to do this kind of exercise or whatever it is.

Scott Benner 6:07
I was so amazed. Just doing that just you know, it Fried my mind back then like to test and go, but but she went to 300. And then 45 minutes later, she was 340. But then she fell and like all that stuff. It was it was interesting information. It was valuable, but it wasn't enough. Right. Right. Like it was it wasn't enough to make sense, at least for me, I couldn't make sense of it still. Could

Jennifer Smith, CDE 6:28
you literally when you do finger six, then you have to do the connection of the dots yourself. Yeah. And I couldn't do nothing in between.

Scott Benner 6:35
I couldn't make that leap. I just couldn't figure out what like, like, what you're like those gaps. Like I couldn't figure out what it was. And it's not Jurassic Park, I couldn't just use frog DNA to fill in the gaps. Right? Because you see the gap. You see what happens? And they're they're, you know, they're making babies by themselves. And it's just it's not good. But you don't want to fill the data in with something unknown is what I'm getting at. So I did as best I could. I heard her story. Oh, my goodness, I ran to get a CGM. You know, we got the Dexcom right away. I can still remember sitting in that we have the endos office, right. And the nurse practitioner put it on for the first time and Arden didn't like it. And I remember breaking my heart. Like I remember thinking like, oh, god Did that hurt. You know, and and now, you know, with the G six Arden Arden honestly says like, I can't even I don't feel it at all right? Yeah, it just it's but back then, you know, there she was, gosh, I don't know, four or five years old, right? So I tell you every week go to dancing for diabetes calm and you really should support them and check them out on Facebook and Instagram and everything. And a lot of you do, which I appreciate. But I just wanted to do more for them. So in May, I'm actually going down to speak at one of their events, but we were trying to figure out a way that I could help them, you know, fundraise. Here's what we decided dancy for diabetes and I have teamed up to give away to not only the people attending the conference, but to you the listeners to the Juicebox Podcast, an opportunity to speak with me. So if you would like a chance to chat with me one on one I'll be conducting 245 minute phone calls or Skype, you know FaceTime, whatever you got, as well as one big one hour call. That includes a 30 minute follow up. So there's three calls in there to 45 minute calls. One one hour call that includes a 30 minute follow up. That's three opportunities to ask me anything you want. Talk about whatever's on your mind. So while I'm at the dancing for diabetes event on May 18, I'm actually going to choose the winners at random before I leave the conference. To have your name included in this opportunity go to dancing for diabetes.com and click on the donate today button between now and may 17. There's a suggested donation of $10. But I don't think dancing for diabetes is going to get upset if you donate more. And all you have to do is be sure to mention juicebox in the notes of your donation. Those of you who do not have internet access, although I don't know how you would get this podcast without it. Or if you have an inability to make a donation you can mail your name to dancing for diabetes go to their website for their contact information. I hope to see everyone at the conference in Orlando but if you can't make it this really is a wonderful way to pick my brain. We can talk about the Avengers movie or Brexit, whatever you want. Even you know diabetes. There she was four or five years old, this little dress and she's so like sitting up on the table and trying to be tough and everything and oh, and it wasn't good. But we stuck with it because of what I was getting back from it. I just found it to be amazing. And now today, today I think that if you're listening to this podcast and is of any value to you, I have to give half the credit to the Dexcom and the other half of it on the pod like I I took those two tools and figured out how to use them on with them

Jennifer Smith, CDE 9:59
but you also I'd have to give myself a big part of that credit because you took tools. It's like any kind of tool, you could have a hammer as one of the simplest tools that there is. And if you don't put it to use, it's a great tool, but it doesn't do anything else for you. Except that they're,

Scott Benner 10:17
you're very kind. I was avoiding saying something nice about myself. But let's do that for a second. But let's, let's translate it out to the people listening. My goal with this podcast is just to be your MLM story, right? Like, I want you, I want to hand you off tools that you then take home and learn how to be professional with right, I'm not, I'm not gonna stand with you forever, Jenny can't come to your house, right? But we're gonna, we're gonna throw this.

Jennifer Smith, CDE 10:41
Anytime

Scott Benner 10:42
that somebody said to me once, can you come live with me? I started thinking there might be a number or I'd say yes to that. But I don't know what it is exactly. How much would it cost for me to abandon my family? Guys, I'm leaving. But but but seriously, I genuinely mean that, like you, you're going to get these tools. You learn how to use them in situations. And before you know it, they work in more and more, what you would have called complex or difficult situations is exactly the same thing. When people come to me and say, Sure, this is great. But how does this work during hormonal time, or during a growth period during illness or during You know, when your daughter's playing softball, I always say the same thing exactly the same way.

Jennifer Smith, CDE 11:21
This tool makes me more comfortable, of course, right? Especially when I mean, we talked already about insulin. And it's actually I mean, this tool shows you not only effective food, but more. So how to be more comfortable with insulin use.

Scott Benner 11:38
Yeah. So not unlike the first time I thought about an insulin pump. And while everyone else was yelling, oh, you won't have to inject so much. I was thinking, Oh, I could manipulate the basal insulin. Like that seemed like the exciting part to me. And we've CGM and you probably have heard people say this before if you have considered a glucose monitor. But the most exciting thing about a CGM isn't the number that it shows you. I'm sitting here now Arden's blood sugar 75. She got insulin for lunch, I'm going to find out when 47 minutes ago, she was 9547 minutes ago when we put the insulin in. She's 75 now. So that's comforting to see that she 75. But what you don't hear me talking about when I tell you that is that there was a moment when she was 89 diagonal down and she was drifting down. But she wasn't falling that fast. I could see how quickly she was falling. That's the information from the CGM. That's just mind blowing. Sure, she's going down. But she's going down at a speed I'm comfortable with based on the food that I know is going in, because that battle is about to start really happening that's really going to kick in and the second. I love that she's drifting down at that moment, because you know, when lunch hits her, I like like, you know, we've talked about before, like the insulin to have momentum. Right? If you think it's about the number you're misunderstanding the CGM. If you think about the m&m story, you have to know it's about timing and amount. It's about speed and direction. Right? Like, which way is my blood sugar moving? And how fast is it going? When you know that it's everything? It's the difference between treating a 75 blood sugar and leaving it alone. So I can see right now Arden's blood sugar is steady, which means I want you because the trendline is horizontal, and her arrow is probably horizontal. And that arrow is still telling you something, right? Like even being horizontal, it's telling you we're steady and Dexcom gives you the breakdown. What that means steady could still mean plus or minus a point every five minutes. But great. You don't I mean,

Jennifer Smith, CDE 13:56
but it's happening so. So slowly at that horizontal arrow, they usually say that it's less than a point a minute. Right? And so and that's where to bring in that that angle there. Oh, that you saw with the 80 something blood sugar. I mean, had it been angled up or angled down. It's still the same rate of change, right? It's about one to two points per minute. Yeah,

Scott Benner 14:17
yeah, it's it right. And so when people talk about, Scott, I don't know I don't understand how you don't count carbs. So here's a here's a way I don't count carbs. Sure. I go historical. I look at a plate and I say I think this is 10 units, right? But Arden had pancakes this weekend. Big homemade not measured pancakes. And I have a feeling that pancakes are going to be 12 units. ish. So I double her bazel rate for an hour and a half. 15 minutes before she gets the pancakes. Her blood sugar is already 78 then she's coming out of bed 10 minutes ish before the food starts. I do the 12 unit Bolus but I take one unit that I've added from the bazel. Right, so now it's an 11 unit bolus, I extended out 80% right away 20% over an hour. Now I'm creating kind of like that blanket of insulin like we talked about. Now, if I get it wrong, I adjust. The most times I expect by getting it wrong means I won't even be aggressive enough. And I'll have to come back and bump it down again. When I see a diagonal up arrow, 30 minutes after pancakes, I say to myself, ooh, I messed this up. Maybe I shouldn't have extended the bolus, or maybe I should have put more up front. But anyway, I'm going to bump that arrow back down again, in this situation last weekend. I was so aggressive that I had to bail on the Temp Basal rate. And so about 45 minutes after Arden ate, she was 70, which was fantastic. But I was like, I still have insulin going. I don't need any more clearly. So we cancelled the Temp Basal. Right. And she rode low for ever. I mean, it was great. 85 like right in there.

Jennifer Smith, CDE 16:01
Right. healthy. That's not low. That's right. healthy. She wrote health lower

Scott Benner 16:06
than you. Yeah, of course. I definitely misspoke. They're lower than you would expect after pancakes. Yep. But but at a great blood sugar. Because I was able to use what the CGM was telling me and what the CGM was telling me Was she was starting to drift lower from like 90 and I and I read that drift as these pancakes are through her now to enough of a degree that we shouldn't be going down anymore. Right. All right. So I bail on the Temp Basal. I don't shut her Basal off, I just go back to the regular base. All right. So we're going along like that for hours. I mean, hours and hours. Now there's nothing. There's nothing now I know the insulins gone from the pancakes. Now I know the pancakes are definitely out of our body. And at some point, that arrow kind of diagonals down a little bit. And we were getting ready to go out to the mall, her and her friend. So I said to her, Hey, take your vitamins, the little gummy vitamins, they must have like six carbs and she pops her vitamins in, we get in the car, the arrow kind of bangs back up a little bit again, right in that 75 area. So we get to the mall. And I'm like, Okay, I'm gonna ride this out to see what happens. Like, I'm not panicking here. But we were there for about 20 minutes or so. And I wasn't sure if like the excitement of the shopping was gonna make her go up or not. And it didn't she was walking around. And my wife and I left her alone. Went did something else and I text her at some point. Hey, I think you should shut your Basal off for a half an hour. And she did. And we stayed right at like, at the whole time she was shopping without the CGM. There's just in my opinion, I don't know how to make any of that happen. Like maybe there's a way. But if there is a way you're listening to the wrong podcast, because I can't quite figure it out. Right, right. So right. I think those CGM are absolutely stunning. I want to know how you talk about using a glucose monitor with with your patients.

I want to know how you talk about using a glucose monitor with with your patients.

Jennifer Smith, CDE 18:08
One of the big things I usually say when people are really either considering one or they've been using one for a long time, but they've may not really be using it to their benefit. Let's say they're looking like you kind of alluded to just the number, right? What's the number? What's the number? They're not learning from it, because there certainly is some optimization when you start using a continuous monitor. But of any form of technology. I might have said this before. I mean, if I were to have to choose between a pump or a CGM, I would say please let me keep my CGM. Right, right. Because even then, if I had to go back to multiple daily injections, I can micromanage that as long as I know the direction of where things are headed. I can you know, and with a pump, then it just brings in more precision. So using a CGM, along with a pump is a another huge beneficial tool, you know, to management. So I guess as far as that it's really helping people to learn what is what's the benefit of that trend that they're seeing? And I think, in the end, many people I find, tend to overreact to the trend too. And you know, oh, my goodness, I you know, things are going up or going down. Well, you do have to make you have to make some considerations within that trend then too, because Have you just eaten? Is there a load of insulin here? Have you just exercised all of those variables that could be there? there a reason for some of that Trent? that trend just like the guy with the m&ms, right. He knew something was going on with his m&ms. He didn't want to be high, but he's like, awesome. I'm going to use this and fiddle with it and figure it out. So you know, CGM can give you that figuring piece that you don't have with finger sticks alone. I mean, you know, again, doing a million finger sticks before I actually had a seat. GM per day, I was still missing all of the pieces in between I missed I was missing. When did it start to rise? Or when did it start to fall? Yeah, I know that I'm like 40 points higher now than I was after I ate my meal. But why and where did the rise actually start? Right. So those are some of the biggest pieces. And I think getting people over the over the overreaction to the trending is something, it's hard for many people to be able to try to say, okay, things are rising. You ate Now, let's do some self experimentation. Let's see. You know, is this happening today, around 80% of your most common foods, which most people have about 20 to 25 foods that are pretty common for them to eat over and over. Use your CGM to your advantage that's 85% of your management then is figuring out and that's the reason that you have outside of not, let's say carb counting in the real sense of doing it. You have a sense just based on the meal because you've done it so much. You can see. This should probably be about 12 units, or that's more about five units. I mean, Ginger actually does the same thing. She doesn't really carb count. Truly she's like this green apple that I eat every morning with peanut butter takes two units. Yeah, you know. And using a CGM, then I think that's the biggest thing for management is the figuring that it allows

Scott Benner 21:38
Yeah, so I think that you hear a lot of people in the beginning talk about like that anxiety right? There was a huge concern in the beginning of CGM, a lot of old school people in the in the diabetes space for like, this is gonna make people crazy. They're just going to stare at that thing all the time. And that probably did happen to some people. But again, it's it's like I say all the time, like if you're looking at what's happening to your blood sugar and think of it as a mistake. That's your mistake, right? It should be like let me experience this. Let me see what this is. Let me see what happens when I put the phone in here versus in there. And that quickly died down I you quickly heard even some of the more ardent I don't know what to call them. But naysayers calm down after a while, you know, saw the value in it. I thought the most important thing was to explain to people that it's not just an alarm for when you're allowed. And I use that phrase in anytime I speak somewhere on this podcast. I say, look, if you're looking at your CGM as a don't die alarm, you're making a huge mistake. It is it is the it is the very least of what it does. And so I mean, it's cool that it tells you Oh my god, oh my god, your blood sugar is getting really low really fast. That's amazing. Don't get me wrong. It's gonna it's gonna

Jennifer Smith, CDE 22:48
turn one of those alarms off that it's always there, no matter how much you hate that, that noise. It's,

Scott Benner 22:53
it's there. The FDA tells them look under 55 we're gonna bang and we're gonna bang an alarm in people's ears. There's nothing they can do about it. And fair, fair, right? But if that's what you're looking at it as it's incredibly short sighted when people say to me all the time like Arden's tolerances are. Her low alarm is set at 70. And on my phone, her high alarm is 120 on her phone, it's 130. So I like to have a if she's raising up, I like to be able to think about it for a couple of minutes before I involve her in the conversation. I don't want her beeping at 120, right. But people say oh, it must be all the time. It must be beeping constantly. And I'm like, no, it never beeps. And that's actually how I don't worry, I'll get back to my thought about moving down the high Dexcom alarm after these messages from the pod and Dexcom. Let's start first with on the pod. The tubeless insulin pump that Arden has been using since she was four years old over a decade now. Choosing Omni pod all of those years ago was and remains to this day one of the best diabetes decisions that my family has ever made. And I'd like to tell you why. With Omni pod, you do not have to disconnect for activity. With a tube pump, you'll have to take your pump off to play soccer or to go swimming to take a shower, you know, and if you're an adult, you're having adult time. You might want to take it off for that too, but not on the pot on the pot is always with you. And why is that important? Because you're always getting your basal insulin. It's a completely under appreciated idea. But when you take your pump off for a half an hour, an hour, two hours to go play a sport, you're not getting insulin. And sure while you're running around, it might seem like oh, this is fine. But eventually you're going to experience a high blood sugar from that. Getting a constant flow of background insulin is incredibly important. And only on the pod allows you to wear their device throughout your life without having to take it off for any of the you know, activities that you enjoy so much. Want you to go to Miami pod.com Ford slash juicebox. Or to the links in your show notes or at Juicebox podcast.com. You can do that today. And absolutely for free. And with zero obligation on the pod, we'll send you out a pod experience, get a free demo of the pod that you can actually hold field touch, keep it in your hand, see what it is, and then wear it, you get the test drive it before you buy, it's a non working pot, don't worry, it doesn't have insulin in it or you know, a candle or anything like that. But it's an exact replica of what you'll be wearing. So you can feel the weight and the size and decide for yourself, if you'd like to try it, my omnipod.com forward slash juicebox. Now on to Dexcom. The Dexcom g six continuous glucose monitor is without a doubt, the Cadillac of continuous glucose monitors. Everything you hear me talk about on this podcast is predicated on the data and information that comes back from ardens Dexcom g sex, we don't need a big long ad for this dexcom.com forward slash juice box get started right now. You need to see what direction your blood sugar is going and how fast it's getting there. And you want to be able to see your loved ones remotely with an Android or iPhone. Come on dexcom.com forward slash juicebox get going today. If you've been hesitant, please trust me when I tell you there's absolutely no reason to not move forward with Dexcom. There are links for all of the advertisers at Juicebox Podcast comm or in the show notes of the podcast app that you're listening to right now. I implore you don't wait another second. Go to Bolus with Omni pod. Get the information you need from Dexcom and support dancing for diabetes.

It must be beeping constantly. And I'm like no, it never beeps. And that's actually how the kind of this way that we talked about doing this here. This being fluid. It makes diabetes a very much a very much a smaller part of your day because you're not thinking about it. Because when it does be, you know, oh, it's trying to leave this tight range. I'll just bump it back down again. Right when you put that threshold up at 400, because you're like, I don't want to hear this thing beep. Well, that means that by the time you think to look at it two hours later in your blood sugar's 280 right now. Yeah, and now you've all this mistimed insulin. Now you're putting in a bunch of insulin to bring it down your insulin resistance so it doesn't work as well. Suddenly, you're going to be a little later. Later, you'll feed the low, you won't have the bolus you get on the roller coaster. I'd rather know now I talked about it in a million different ways I open bills. I don't think I can pay you on day one, because I want to know what they are right? I want to know when her blood sugar's trying to go over 120. And if you do that, there's a great episode way back in the podcast with a scientist from Dexcom. There was a study done, the lower you lower your high alarm on your CGM, the lower your agency goes because you react sooner with less insulin stopping arise and staving off a future low because you're only using a tiny bit events and we've talked about it before you're going to listen through these things. Again, they're going to make total sense to you. I want to address when people say well, I don't want to wear a bunch of stuff. You know some it's some adults just don't want to wear things. That's fine, but I hear a lot of parents. I don't want to look at her. I don't want to look at him and see him attached to something I don't he's not a robot. He's not like that kind of stuff. Arden hated that CGM. The first day she put it on right. And I wouldn't think she thinks twice about it anymore. Not even a little bit. She rolled out that she rolled out the door this morning for school in a pair of leggings. You can see her CGM on her hip and she doesn't care she's wearing a top that doesn't go all the way down to her to her belt or her on the potty sticking out like in that gap of space on her belly. She doesn't think twice about it. You can make those things normal and and they will be you know at some point so I don't know for me CGM is about reacting. And and instead of,

Jennifer Smith, CDE 29:23
you know, appropriately reacting rather than, rather than being you're being proactive really. If you have a CGM, you can be proactive, rather than having to always be reactive at the like you said, Have you CGM set at 400. And you're finally seeing it at 280. Because you're not feeling the greatest. You could have been proactive well above or well ahead of that right.

Scott Benner 29:46
And that proactiveness By the way, takes less time and less involvement than it does to be to 80 and fighting with it for hours. That it seems. It seems counterintuitive because people say to me all the time, you must be so intense. volved all the time and I'm like, man, I don't think about diabetes for more than about 10 minutes a day. You know, like on the really bad days, 20 minutes, but but I'm not mired down in it. Like, there's no hand wringing in my house all day long, like staring at big numbers wondering when they're gonna come down? Are they gonna make lows? We just don't have that. I mean, don't get everyone should. I'm generalizing to make my point. It happens sometimes, right? But, but as a day to day idea, it is not something that occurs here. And I if you've heard me speak somewhere, in my slide presentation, there's a picture of Muhammad Ali standing over top of someone he's just knocked out. And I always start that part by going Has anyone ever been in a fistfight? And inevitably, it's always a little kid who's like, I have, like a golf. And I was like, well, you shouldn't hit people. But but but you know, I tell people all the time, like you, you want to act, like, like we talked about, you want to react, but really, you want to be able to act B first, right? You want to make a decision first, because besides stopping an arrow, there's the concept of cause and effect. Correct, right. And there's this idea that, you know, people always run around yelling, well, that's just diabetes every time something happens, they don't understand that was just diabetes. And I always say that when you're saying, well, that's just diabetes, what you really mean is, I don't know how to use insulin correctly. Right? Right. Right. And so your blood sugar doesn't go up to 400. Because the diabetes very tapped you on the head? Like, there's a reason I don't know what it is. Maybe you might not know what it is. But there's a reason. So at the very least, if you act first, then with some some confidence, you can say that what happened next was a result of your action. Right? least you're not always covering your face in defense, like, like a boxer who just can't, can't get upon it anymore, right? diabetes is not pummeling you in the face. You you maybe you hit it too hard. Maybe you end up with a 65. You didn't mean to, but at least you know, wow, I put that insulin in here and I got the 65. Next time, I'll use less. Next time, I'll do my Pre-Bolus, five minutes shorter, whatever it ends up being I don't know. Right? Right. But I'm a big fan of acting first, and then taking that feedback and making a better decision next time with it.

Jennifer Smith, CDE 32:13
Absolutely. And that's why I think it's it's, it's when you're especially if you're new to CGM, or starting out, sort of over with the CGM, or you haven't used it consistently on a day to day basis, because you have felt more frustrated about it, I think, if you get it down to some basics of use to begin with, and like you said, kind of tighten up those targets. Even if it's just a short time period, you can designate and say, okay, for the next seven days, I'm going to have my targets that the high alert for 130 in the low alert set for maybe 70, or even 80. If you're hypo, you know, hyper unaware, or you just really worried or whatever about the lower end, because tightening it up helps but also then fitting in more of your more more of your regular habits. In that testing time period, your typical foods, the things that you like to eat for breakfast, or lunch or for dinner, or for snacks. Because if you're committing to using something by applying it to your body, and you know being a robot

Scott Benner 33:21
in for a pound.

Jennifer Smith, CDE 33:22
That's right, exactly. If you're committing to using it, then get everything that you should be getting out of using it.

Scott Benner 33:28
And there's a there's a way to start, in my opinion, I'm interested in what you think. But I think that when you first have a CGM on it, you're accustomed to wearing it. Finally, you know what this information means. The first thing you do is you get your bazel, right. Like, like, to me it's bazel. First, make sure your bazel is right. And I tell people all the time, if you haven't had insulin or food for three or so hours, and your blood sugar is not 85, your bazel is not right. And so and so if you're 180 or 200, shoot lower, I don't like don't shoot for 85 right away, shoot for lower and keep kind of just cranking it down and cranking it down. After you've got your bazel. In a situation where you're staying pretty stable most of the time without getting low. That's then you can start thinking about Pre-Bolus. And then and then the CGM can really help you with that too. If I'm 120 and I haven't had food or insulin for hours, when I put in some insulin here, how soon before I start seeing a diagonal arrow is it 10 minutes 1520. Some people say a half an hour, everybody's numbers different. So once your bazel is right, and you can trust the cause and effect that I've Bolus now and it took 15 minutes, let's say for my blood sugar to start going down. Within reason trust that that's probably your Pre-Bolus 15 minutes right when your blood sugar is in range. Now keep in mind if your blood sugar's higher, you'll be more insulin resistant that Pre-Bolus time won't be the same but but for the for the sake of the conversation. Now you have your bazel right now you know your Pre-Bolus time. Now you can start using insulin and being a little more aggressive with it. I've put about Pre-Bolus in I'm 90 diagonal down, I've started to eat my blood sugar shot up. Now here's where the CGM becomes incredibly helpful. So you've you've got your insulin and you've eaten but you're going up. Are you going up? Like a short sharp incline right or is it what I call the prices? right you know the prices might the the what which which is it the minor the the climber the gates like Yoda, he really getting it right. And he's got the pic in his hand he's going back. And it's it's this very gentle gray that goes on forever and you watch it the whole time. God he's gonna stop he's gonna stop he's gonna stop Oh, he'll definitely stop is nobody's gonna fall off the edge. It's not gonna happen through the whole thing and it just keeps going. That's that CGM line that it tricks you. Because you keep thinking it's not on a crazy incline. I'm not shooting up. I'm just climbing. It's going to stop in a minute. But no, it's not. So not most of the time. Most of the time I find a gentle grade up means not You almost got the amount, right. And you're pretty happy with it. Right? Right. And your Pre-Bolus might have been not quite long enough, right? The sharp up is a complete. I just thought the curse but it's a complete cluster, you're like you have not you didn't have nearly enough Pre-Bolus and you did not use nearly enough food. So there is nothing about your Bolus that even gave resistance to that carb impact at all.

Jennifer Smith, CDE 36:30
Right, you can even more often with that arrow up more often at the Pre-Bolus. Especially if you are using a ratio for your carbs and counting your carbs and whatnot. Most often, if you have a pretty significant quick, straight up or double up arrow, within 30 minutes, 45 minutes of a meal, there's a deficit there and or the deficit is more because you did not Pre-Bolus there wasn't times like that tug of war between the insulin that you said, you know, in a podcast before, there was not enough time to let insulin get the upper hand,

Scott Benner 37:06
right. And I'll tell you that that exact situation, that scenario you're describing, that taught me how to overhaul us. So what the first time I put in insulin and her blood sugar started to shoot up, I just made the leap, I was like I missed big time. And I didn't just put in like another half unit, like I crush it, I was like I'm gonna stop these hours. If I have to feed them later, I will. But I'm not going to let this blood sugar go up like this. And so I realized a meal that I thought was going to take five units with no Pre-Bolus needed eight units. And so that taught me in the future, when I don't have time to Pre-Bolus I'll just give eight units for the five unit meal because I can create that action of insulin and overpower this even without a Pre-Bolus. If I use too much, it's a little more. I call it like that's definitely more of a pro level tip kind of a situation. I'm like you're you're more of a diabetes ninja. Once you're doing stuff like that i i hold that up with the same ideas after you've had a 30 too low. And you start coming back up again. And you Bolus like when you're 50 diagonal up like you're a ninja at that point. You're just

Jennifer Smith, CDE 38:11
like, yeah, I need a lot more because I know I eat 60 grams of carbon I really only needed like 50 and

Scott Benner 38:19
start knowing how much insulin the bolus to overcome, not Pre-Bolus Singh again, you've been at this a while but I learned that from the Dexcom. Like I never would have liked so you know, when you see those arrows flying up? Not it's not what was me time, right. It's what is happening. Like what what could I do next time over blessing is an incredible tool

Jennifer Smith, CDE 38:42
so and over bolusing in the way that you're doing it is very I think we talked about this before probably is it's actually what john Walsh from pumping insulin, he calls it a super bolus, right, right. And he does it in a little bit more of a calculated way. He says, you know, you take the Bolus, as suggested by your pump for the food that you're going to eat or the calculated, let's say you said okay, she needs five units for this all the time. Well, today, there's no time to Pre-Bolus usually, you would have done a 20 minute Pre-Bolus for that five units. Okay, he says, You're then going to take the insulin and bazel that's running behind that meal for two hours. And you're going to actually add it on to that five units or whatever your pump is suggesting. So maybe if your bazel is running at a unit an hour, that's two units of extra insulin, you're gonna pop that on top of the suggested bolus, but then behind the scenes, and you probably do this a lot too with that heavier bullets up front, you're like, I'm probably going to need to watch and do a Temp Basal decrease for a little bit after because I know that this is too much in the end results, right? We don't want to cause a low he says to start by just taking the Basal down to zero for about two hours. Yeah. And then evaluating I've got people use it and say, you know, I tried it. The Superbowl is part of it works but I don't need to turn my bazel completely off led to a 50% bazel instead of 100%. Yes.

Scott Benner 40:00
And that's where the Dexcom again comes in incredibly handy. You need it when you need it. You don't when you don't, right. And then I consider that idea trading Basal for Bolus, like there. There are times where I think, Oh, ardens you know, Basal rates 1.4 an hour, I just bought a unit and a half. Listen, there's going to be a moment, right? There's a moment for everybody. There's gonna be a moment where you see the arrow up, put in the insulin, five seconds later, the arrow flattens out, and you go, Oh, my God, I didn't need that insulin, right? Oh, that's when I'll trade the bazel for the balls. Now

Jennifer Smith, CDE 40:31
you can only say cut it out to be the law. Yeah, but do you know that? Do you know that if you don't have a CGM? You don't know. You don't know when that transition was happening? Right? If you had none, and you were very aggressive about just finger sticking, you're like, Oh, my gosh, you know, 20 minutes ago, it was here. And now it's like 50 points higher. I have to slam this with more influence. Yeah, awesome. But if you're not willing to do finger sticks, then like every 20 minutes after that, to see where things are go. You never know when that horizontal is coming, or when a downtrend is coming, either. Yep,

Scott Benner 41:03
I am wrong now texting art. And while you and I are talking, so what I say it is now been an hour and 12 minutes since she got her bolus for her food. I got a little I didn't panic. But because you and I were talking and I could see what was happening. I shut off or at the very tail end of our Expendables and her Temp Basal. Yep. And now she's 105 diagonal up. I'm bolusing that, because I'm putting in the insulin that I bailed on from the extended bolus and the base, I should have trusted myself, right. And so instead, I'm putting it back again, when I will stop this diagonal up arrow around 115 120, she'll float there for a while, we'll come back down. I expect you to be at five by like an hour and 45 minutes from now.

Jennifer Smith, CDE 41:50
And the interesting thing about that, too, is what you're saying in in terms of her management. And I know her agency has been like in the 5% for, you know, for a long time. But the bigger beyond that, and we had a whole we had a whole we did a whole long podcast about a Wednesday and kind of what that all means right? But I think bringing in to the fact here CGM translates into that CGM, because what we're really hoping for is more gentle rolling hills within our target, rather than these major rises and falls of a roller coaster. And if you start to analyze your data in CGM, you can actually start then to be able to say, Okay, I need to tighten things up here. I've got an awesome looking at one See, but I have a huge what's called standard deviation, which speaks to the variability between highs and lows, right? You may have this awesome looking at one C, but if you're going up and down and you look like a big Jagan, you know, roller coaster or mountain range, that's not helpful, your standard D deviation value should actually be low, which means the variance between the highs and lows are also more gentle, rolling, rolling, rolling,

Scott Benner 43:03
right. And the way I found to say that to people is that if you were 350, and then 60, and then 350, and 60, all you're doing is tricking the a one c test. And he comes back and tells you Hey, you have an average a one C of seven, which you do when you average 60 and 50. Again, but you also have a, you're also not living in a healthy way, in any specific way. So don't let that number for you. Right. And Jenny's right there is an episode called all about a one see that she and I did probably more than a year or so ago. Yeah. And I'll link it in the show notes so you can find it, but I have Arden's last five days. And her hurt, let's see, her average blood sugar over the last five days has been 114 she's been in range 56% of the time, which probably seems low, except that her ranges from 70 to 100 that's another thing you need to be careful of when you look at these reports. If you have your high set at 300 and your low set at 60. And you tell me I'm in range 100% of the time Well,

Jennifer Smith, CDE 44:06
sure sure you are Yeah,

Scott Benner 44:07
I mean, good

Jennifer Smith, CDE 44:08
standard deviation within that time and range,

Scott Benner 44:11
right what what is that and standard deviation is just a simple mathematical idea that I didn't understand in school and still don't understand now but it's a basic right it's a it's an average is it an average of maybe it's a mean I don't know see I didn't pay attention to math. You know it's funny you were talking about Walsh earlier talking about like all these ideas about like over bowl his Super Bowl is and I call it over bolusing and when I think about it all I think about is more like the word more just pops into my head more insult and he's over there like with his college degree being like what you want to do is for two hours and this is I'm like more

Jennifer Smith, CDE 44:49
right but you've also figured it out. You're more is not a dangerous more random more now. It's not a random you've figured it out in your you know, this is your diabetes. may vary, you figured it out in in art and diabetes, but you know how much more to give. It's not like you're slamming in five more units you're like, she needs based on experience about a unit more, or she needs based on experience to units more based on what went in what has transpired up to this point.

Scott Benner 45:18
So people who listen to the podcast know that if this wasn't a special episode called diabetes, pro tip, continuous glucose monitor, I would just call it Roger Moore. Because you have no idea how many times I hear from people they're like, could you just make the title something about what's in it? I'm like, No, I can't. That's not fun at all. I want to talk for a second about what happens when you're brand new, shiny decks Come on. And it tells you your blood sugar's 90, but then you test with your meter and your meter says your blood sugar's 140. niggle I don't know which one of these things to believe. So I think it's important to note that CGM is measuring interstitial fluid around your meter is measuring your blood. Thank you for bringing that up. Yeah, both of them have an FDA requirement of only being within 20% of range. So if if a meter says your blood sugar is 100, it could very easily be 80, or 120, or somewhere between 80 and 120. As people living with type one diabetes in the 2000s ease, you're gonna have to accept this is pretty much the best we have right now. And not to make yourself mental. So imagine that your CGM tells you you're 100. But it's off by 20%. High. So you're really 120. And your meter says you're 140. But it's really off by 20%. Low. So you're really 120. They both agree the numbers you're seeing don't agree. You cannot spend a ton of time being upset about that. You have to pick something and believe in it. And I know that's crazy. But I tell people all the time, there's somebody online, there's like look at my meter says this, and my Dexcom says this, and I'm like you're holding a brand new Dexcom g7 your hand and a meter that was made 12 years ago. And you're telling me I believe the meter and I always ask them the same thing. Why did you decide to believe the meter over the CGM? Is it because you had it longer? Because it's testing blood? And that seems like something that's more accurate to you like what is the random thought your brain has had that's made you decide that one of these is more accurate than the other one? Which do you I test sometimes when I don't,

Jennifer Smith, CDE 47:26
but I'm not. So really I mean, blood glucose is the first line of glucose change it is interstitial glucose follows blood glucose. And so with those random, you know, differences most often I would say people on G five and G six, for the most part have pretty good accuracy finger stick to actual CGM, we're, I think a lot of discrepancy can honestly come in is from a finger stick value of let's say it's telling you 140. Right, and you're looking at your CGM, and it's 100. Well, as we kind of started out saying, it's not about the number on the CGM, it's about the trend. And like you do very often you're saying, Okay, now there's a trend going up, you know, you just bolused what you misgiving before because you started to see a trend up. Well, her fingerstick might actually be reflecting a higher glucose than what the CGM is showing right now, because again, glucose changes first in your bloodstream. And so CGM is going to lag especially in those time periods of more significant glucose change such as after food, or after or during exercise, that that can be a varying time. So finger stick 140, your CGM is trending up, or you've got an angled arrow heading up and it's telling you your one or two and you're like, hmm, so what do I do about this? The CGM just hasn't met yet the glucose value in the bloodstream, it will catch up right? It will, it's just that it hasn't gotten there yet. Because really, if you think about the way that glucose sort of moves in a simplified form, it moves out of the bloodstream sort of has to move through insert interstitial fluid before it gets to the cells to get absorbed, essentially, I mean, that's simplified, but and so your, your, your interstitial fluid is also always for the most part gonna lag, especially in special times, like food and movement.

Scott Benner 49:26
And I'll tell you to and to circle back around with the idea of the quality of your meter. Arden's had an omni pod forever, like since she was four, so she's gonna be 15 soon. Point is, that thing's been around a long time. It's got an old freestyle meter in it. They've always been kind of wonky. And now we're using the Contour. Next One, it's the little tiny meter that's going to start calling

Jennifer Smith, CDE 49:53
accurate on the market. Yep.

Scott Benner 49:54
So when Omni pod decided to switch over to dash which should you know, you might be listening to this and that Might be a thing already, but it's about to happen. They're going to offer you a free Contour Next One meter to come with it. So I've been using it for a few months to get my head around it. It's spectacular. Like what a great accurate meter. It's absolutely insane. Like I just compared to what was in that PDM. It was nuts how much better it was?

Jennifer Smith, CDE 50:19
Well, and this brings up for the people to who might still be using a G five, or a CGM. That requires calibration. What you calibrate with? Yeah, really mix accuracy on the CGM hold better, right,

Scott Benner 50:34
right. And if you're calibrating with a band meter, so you have a G five that still asks for calibration, and the G five says it's 90, but you've tested with a 10 year old meter, it's like it's not it's 150. What if you really are 90 and now you're telling the two five, everything you think is wrong? You're 150. But the algorithms like that's not right, we're nine. And did you confuse it? And then it it blows

Jennifer Smith, CDE 50:54
up? Again? Three, three question marks for three hours.

Scott Benner 50:59
And then you go this something wrong with the CGM? Actually, no, it was you, you know, you put the wrong information. And so none of this technology is obviously perfect. But again, I always like to say you're not boiling your urine to find out what your blood sugar is. So you're doing right, yeah, right, you're doing great. I all I can say for sure, as we as we kind of come up on the end here. And I might ask you to kind of sum up in a second. But what I can tell you is that, as I've said before, ardens a once has been between five, two and six to four or five solid years. And it's going to be a lot to do with the tools that you hear us talking about here on the podcast and how I've learned to implement them. But how I learned to implement them was the information coming back to me from Arden's glucose monitor. So if you have an opportunity to get one, and I know they're not covered by everybody's insurance, and they can be expensive, but if you can get one, you absolutely In my opinion, should the absolute will just change your life. So

Jennifer Smith, CDE 51:52
yeah, I 100% agree. Yeah.

Scott Benner 51:55
Did we forget anything? Because at this point, people who listen, probably aren't surprised. But I don't pre plan these with Jeremy, I should put on her headphones. She goes, what are we talking about? I'm like CGM. And she goes great. And then we just started talking. But again, I like the way these conversations flow. So did I forget anything? That is like wildly wrong?

Jennifer Smith, CDE 52:16
I don't think so. I, I do think that if, I mean, this is just from an education standpoint, your own education with your CGM. If you really need some pointers, I mean, it's helpful to look or ask more of your care team. You know, if you do need some pointers, some some endos. And CDs are really awesome. Some don't know much more than just telling you how to slap it on. But look beyond I mean, because there is there's a wealth of of benefit to knowing. And some of it is self experiment, experimentation. In fact, I think a lot of it self experimentation. But if you need some help with looking at things, I think searching out somebody can be helpful.

Scott Benner 53:00
Yes, somebody who can look at the graph and just make sense of it in a second. Yeah, we've talked about before I can at this point, I can look at someone's three hour graph and go, is this where you're putting the insulin? And they're like, how did you know I'm like, yeah, cuz it should have been here. And it wasn't enough. And this would have stopped that and like, it's pretty easy to see after you can see it, right. It's like those, you know what it's like? It's like those posters that you look at it. You're like, there's somebody tells you it's a tree and it's a sailboat, you stare long enough, it turns into a tree. I think that's what happens after you look at it long enough. I know people can get scared of the idea of data. I don't like the word because I think it I think it scares people off. Like, you need to understand the data. Well, that sounds scary to me. Right? Right. There's a little line on your thing, okay, that line tries to go in a direction you look and see where you put the lights on. And you see how harshly the line tried to go in that direction, you make a better decision next time.

Jennifer Smith, CDE 53:53
You know, I think that actually brings in one point that we may have missed is that especially dex comm does allow you to use event markers. So if you are really wanting more, you know optimization, and you're the only one who can really look at your your lines and your info. Using the event markers. I know in G six at the at the bottom of your at least your screen on your on your phone app, you just choose events. You can log things like food or exercise or illness or even alcohol and like your your cycle or monthly and all that kind of stuff. It'll put little marks on your actual trend graph. And that way you can make more sense of the if you're again, the one that's really trying to look back for what what happened, why did it happen? You

Scott Benner 54:41
don't have to remember that I ate lunch at 1130 you can just say food and the amount of carbs and then make a note about what the food was. Right? And that helps you when you look back. See again, that's well more way better thought out than I can ever be. But that makes a lot of sense. That's why you're here. You're the you're the smart part of this conversation. part of the conversation.

Jennifer Smith, CDE 55:03
Were both important for me then.

Scott Benner 55:06
I'm pretty sure that's true. Okay, I think you have to go in a couple of minutes, right? I'm gonna let you go now and say goodbye. Don't forget, you can hire Jenny Smith to help you with your type one diabetes at integrated diabetes.com. There's a link in your show notes that will allow you to generate an email right to Jenny. It's magic. Thank you Dexcom on the pod and dancing for diabetes for sponsoring the Juicebox Podcast. I cannot tell you how much your support means. Don't forget that when this episode went up to other diabetes pro tip episodes went up along with it. You're looking for bumping nudge and the perfect Bolus. There will be more episodes with Jenny coming up next month. And the programming note. Next week. I'll be talking with Katie. You might not know who Katie is Katie is one of the people who is key right there in the middle of the DIY looping world. Katie and I are going to talk about the new looping option with Omni pod. Which by the way, I think I'm gonna try

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