#1025 TRANSITIONING (REMASTERED Diabetes Pro Tip)

September 24, 2023Scott Benner

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

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

Scott Benner 0:04
Hello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right, you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CD and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisit double. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. While you're listening please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have an amazing offer for you. Right now at my link only contour next one.com forward slash juice box free meter you can get an absolutely free contour next gen starter kit that's contour next.com forward slash juice box free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries G voc hypo pen. Find out more at G voc glucagon.com. Forward slash juicebox. What I would like to talk about today is transition. Just a an overview concept for this one, but transition from just finger sticks to CGM transition from MDI, to pumping, transition from pumping to algorithm. Sure, can we do that? Yeah, I thought we could all thank Isabel here for having her finger on the pulse of the people in the Facebook group and knowing exactly what people ask about and what they seem most confused about. Why don't we start with MDI, because everybody starts there, right? After you're doing it for a while, like let's put ourselves in that place. We've been doing MDI for a while it's working pretty well, or at least at a baseline. We're shooting a Basal insulin once a day, and we are shooting a meal insulin to correct blood sugars and to cover our carbs. That's the basics of MDI. Okay, correct. So then we're in a doctor's office, but it make up yeah, I'm gonna make up some numbers. Let's, let's say our Basal it's like, I don't know, let's say our basil is 10 a day. And let's say we're, I don't know, one to 10 for carb ratio. Okay. All right. Let's say our correction is one to 100. Let's keep it all very like, like that, so that it's easier

Jennifer Smith, CDE 3:53
to talk about. Okay, round 10 numbers

Scott Benner 3:57
and numbers, we're gonna do that. So the math makes sense when people are listening. So we're in the doctor's office, and the doctor says, you know, you might like a pump. Is he gonna say it just like that? I mean, if it's a lady, she might be like, You made like a bump? I don't know, like, exact. or anywhere in between. There's some women have more masculine voices. Jenny, this isn't the point of what we're talking. Oh, yeah. So they see you might like a pump. You are. I'm guessing. Gonna have a couple of different reactions. I see a lot of people scared. Oh, no, don't change something. I see a lot of people are like, Yes, please. Because this isn't working. And maybe this will they don't know why they think that just right. They're hoping for a change. So the first thing that's going to happen is the doctor is going to translate your Basal insulin to this pump. So Jenny, you do that math for me? I get her I get 10 units a day. Injection. What are they going to do on the pump for me?

Jennifer Smith, CDE 4:56
Most often on a pump, because it's expected that your Basal insulin which, and this is kind of outside of it, but within your Basal insulin will now be given by the pump as rapid acting insulin. So that's the first thing to understand is that you're injected Basal insulin, which is a specific long acting kind of insulin will now sit in your refrigerator as a backup in case of pump failure, right. So you don't put Basal insulin into a pump. The only insulin that goes in the pump is your rapid acting insulin of any of the brands, right. Depending on the pump, company, they all have a little bit of different kind of recommendations for type of rapid insulin, but it's a rapid insulin and to translate your Basal dose of what we said 10 units into a pumped Basal delivery, you would essentially take 10 units into a 24 hour day. Right? And that translates into a a dripped amount, right? Because insulin pumps drip drip, drip drip consistently to deliver that total amount of basil that you want.

Scott Benner 6:15
Okay, so let's clean it up for people who get lost very easily. You may be injecting trust Siba love Amira, Lantis, what are the other ones, Basil Glar.

Unknown Speaker 6:27
These are all basil, JL,

Scott Benner 6:29
these are basil insulins, these are now gone. You don't use those anymore. Because as Jenny points out, you're going to take your mealtime or your fast acting correction insulin, put it in the pump, and it's going to split it up, those 10 units are going to get split up over, not just over hours. That's how the settings the pump work, right, you're going to come up with what is it going to be like point four, maybe an hour if you're 10. Today about like that, right? Right, depending

Jennifer Smith, CDE 6:53
on your pump, all of the pumps differ in their precision of a single drip of insulin. Some pumps can drip as little as point one, one, some can drip as little as point oh two, five, or point oh five. So it just depends. But if you broke this down 10 units a day into 24 hours a day would be a rate of about point four, two, if you do rounding, right, some pumps, you may have to round that 2.4, because they can't deliver the point oh two,

Scott Benner 7:24
and you're, you're gonna hear that if you're MDI and think, oh, at the top of every hour, it's gonna give me point 14 Its events on but it's not doing that it's going to break those correctly for Twos Up over the entire hour, over the

Jennifer Smith, CDE 7:36
course of the time. Exactly. Now, the other step to this calculation is that we expect that your Basal insulin you've been injecting I'm trying to think how to say it, so people don't think their insulin is not working. But when you inject Basal insulin as its type it, it will not be absorbed as efficiently I guess is the better way to say it as it would from a pump where it gets infused in those little tiny drips over a very precise amount of time, a very precise dose. So your rapid insulin in your pump gets infused out of sight. And so we usually take your base Basal dose down by about 10%. Some even some physicians even go down by 20%. But the general idea is taking your base dose down by 10%. So 10 units a day taken down by 10% is one unit less, so nine units instead of 10 units. So if you do the math there, nine into 24 gets your rate down instead of point, let's call it point for an hour, down 2.37 an hour, which again, we'd probably round down 2.35.

Scott Benner 8:48
And you're going to want to keep an eye on that because I've seen it go either way. I've seen that be right. And it's amazing. I've seen that beat Now. Not enough insulin and people are getting high blood sugars. And they immediately like you hear them say like the pump doesn't work like well, you gave yourself less insulin and turns out you need right. So pay close attention to that.

Jennifer Smith, CDE 9:10
It also translates into the next step. Once you've been making some notes on this 24 hour dose of let's call it point three, five units an hour. And you can say Well, it seems okay here. But then at this time of the day, I'm always high no matter what I can skip eating and I'm high I can eat and I go even higher. Well, that's when the next step is Basal testing. Right? We need to really look at it and say, where is that point three, five, sufficient and where is it not and where might it be too much.

Scott Benner 9:43
And you might notice, and this is this might sound a little heady if you're thinking of switching but you could put your pump on your belly and have a different reaction to the insulin that is if it's on your hip or your thigh. There's reasons like Arden's thigh doesn't work as well. As her stomach does,

Jennifer Smith, CDE 10:01
you know, neither does mind I don't use my thighs anymore. Yeah, back of your arm might

Scott Benner 10:05
be better than your, the back of your butt or who knows, like, right

Jennifer Smith, CDE 10:10
and with with this being new from coming from MDI, to going to using a pump, I would suggest initially utilizing and testing out within an area of the body, you know, we talk a lot about rotation, not only should you be rotating, if you're doing MDI, your injection should be going multiple different places, not just the same site over and over, the same goes along with pumping, those sites need to be rotated. If you're new to pumping, however, you really want to get an idea if your settings are fairly good. Stick with rotating around your abdomen, right? Get an idea. And then once you have that fairly well set, you can then move to upper body or the back of the arm or maybe your thigh or you know, your lower back and see if you notice any difference some people do and some people don't at all.

Scott Benner 11:02
Yeah, right. No, I mean, there's it's your body composition, hydration, how you know where it's actually going inside of you? Is it subcutaneous? Is it very close to a muscle? We don't want to overwhelm people, but the muscle can kind of, I don't know what the term is like, what a large muscle group can, it kind of lessens the impact of the insulin, but for the life of me, I can't think of why right now. Do you know what I mean?

Jennifer Smith, CDE 11:27
Like lessons? I know, I don't know what you know,

Scott Benner 11:28
I always thought that's why the thigh was in a good spot because it was a large muscle.

Jennifer Smith, CDE 11:34
Well, it might have more to do with how well the insulin at that site is getting absorbed. Like that's a big reason that I don't use my thighs is because whenever I tried using it, either I got a collusion alarms because the cannula was bumping into muscle or potentially that I had nicked, like a small vessel under and it had been clouded kind of near that site where it was trying to infuse. And so that backs up into the pump and the pump tells you hey, the delivery of insulin has stopped. It gives you nice alarms. Right? So I think in some cases that may be part of the issue is the proximity to muscle. Yes. But also I it was either painful or I got occlusions like it just never worked on my thighs.

Scott Benner 12:24
Okay, I'll see. Look, I'm learning from the podcast. Finally. Finally, I learned about this every day, you learn a lot. Yes. Okay. So now we've, I think here's a good place to insert that it is possible that there are some people in the MDI who are achieving reasonable lower blood sugar's some how do I say this? Sometimes your doctors over baseline you because they don't think you're covering your food correctly. And

Jennifer Smith, CDE 12:55
that, or they may not have looked at your records enough to know why they've you know what I mean? Like, it might just be easier to backup with enough Basil with what they're seeing in your data. Yeah. And it may as you're saying, it might be wrong, right,

Scott Benner 13:09
right. So like, imagine if you're a person who has been getting more basil than they really technically need, but you kind of forget meals, sometimes you don't cover all your food. But now all of a sudden, you have this pump, you're like, Oh, it's so easy. Now, I just push the buttons for my food. So now you're covering your meals well, and you're like, why am I low all the time? Right? It might be because you're using more insulin than you have been in the past. So those are things to look for that I see people struggle with the beginning with a pump. And I do want to say I think there's a I think there's a period of transition there. It's not going to be like if you're nervous. It's not unfounded, you know, like you are starting a whole new way of doing something. But it really is just another way of delivering insulin to you. It's not that complicated.

Jennifer Smith, CDE 13:59
And I can say personally, when I switched from MDI, having done MDI a long time before I started using a pump. By the time I started using a pump I was already doing. I was already doing somewhat of a Pre-Bolus. But it wasn't the same once I switched to a pump, there was a definite time difference between my Pre-Bolus with injections, and there still is, I can take an injection and my Pre-Bolus Time is not as long as it is on a pump, right? Again, and have one. But that's what I noticed. And so those are some things to pay attention to between MDI and what you're doing along with what you said about maybe the doses you were taking on MDI. We're covering a certain way for your rapid insulin for meals and corrections. And now that you're on a pump, your meals, the food hasn't changed, your strategy has stayed the same and things are looking weird,

Scott Benner 14:58
right right there in You'll have to step back a lot and try to see what's happening. One reasonable reason for that could be reasonable reason why it wasn't right. But anyway, you use an omni pod and delivers insulin a little slowly. Like it doesn't just like you take a needle and you go. Yeah, and the pump is pumping over time. And and I don't imagine you use very large bonuses, but larger bonuses take longer. Yeah, I've seen, I've sat at a restaurant with Arden. And, you know, you forget you've done it, and you kind of still here like that, like think like click clicking, it's still giving her insolence feels like it's been five minutes, you know, and yeah, so that's, that could be part of it. Anyway, these are things you're going to learn along the way. They're new lessons, but they're not a reason, not just try, because you're going to gain weight, you're gonna gain so much, right? Like if, to me a pump is, at its core, I've always thought of pumping as a way to be able to manipulate basil. Whereas on MDI, I shoot it in, it's in there, nothing left to do. If it's too much, if it's too little, it's what it is, you know, with MD with a with a pump, you know, you can go back and listen to the Pro Tip series, I think about like, wow, if we sit down to a meal, that's all of a sudden, much carb heavier than what I usually eat, I could do a Temp Basal increase, they tried to help me with this. You know, I was thinking a minute ago, when we were talking about breaking the 10 units down into point 4.35, that if you think about putting a sprinkler out on a dry, dry lawn, right, and you need to give your lawn 10 gallons of water, you could come along and dump it on all at once. It'll just be there, that'll be it, right, or it could break it up into little point three, five gallons every hour and go back and forth. And just a light covering, covering, covering, covering, you're never gonna soak it down, you're and it's just I think of basil like sort of like that. Sometimes you're just,

Jennifer Smith, CDE 17:03
and that's a good way to think about it too. Because if you consider that slow Basal drip that you are getting from a pump, when you inject your Basal insulin all in one clump, right? You can, depending on the kind of activity you like to do, you may have found that you have to pay attention to Gosh, I'm doing like a really heavy arm workout, I'm probably not going to inject my Basal insulin into my arm today, I might inject it someplace else, right? Because there's this whopping dose sitting underneath your skin. And any kind of insulin, whether it's rapid, or Basal can get enhanced in action, the more active you are, and especially if you're using that site. So, you know, those are the kinds of things that having those tinier doses that you can manipulate and adjust, especially with the variables that you know, are coming in the day.

Scott Benner 18:04
If somebody's listening and thinking like, well, they have spent the first 15 minutes talking about Basal insulin, it's because it's really important, and nobody tells you it's important in setting. So if you listen to this podcast, like Well, I do MDI, they're always talking about, like, their settings on their pump or anything. This is still settings, you know, if it's MDI, it's your settings, it's, you know, these Basal carb ratio, correction factor, they're all settings. So it's just very important to have them. If they're not accurate to your needs, then everything else is just going to be a mess. And especially Basil, basil is wrong. The whole day is confused. So okay, so we've translated our basil, our insulin to carb ratio, does the doctor keep it the same? Do they usually like what is common?

Jennifer Smith, CDE 18:49
They may keep it the same, especially if your records prove to show that it seems to be for the most part working fairly. Okay. Right? Could there be improvement somewhere, possibly, or whatever, maybe that's also part of the reason that they feel like a pump might actually be better. Maybe you're the kind of person that just eats really slow digesting food. And so you've had problems with taking your insulin and having these big drops in your blood sugar too fast, and then it ends up catching up with you. And then you end up high later, and you've treated low blood sugars, right? And there's not a timing thing that you can really get quite right with MDI. And maybe the doctor says, Well, why don't we try a pump, because, hey, you're eating these types of foods more frequently. We could actually use some of the smart features on our conventional pumps that allow you to take some insulin for food. We're calling these extended boluses. And you can just kind of like basil. It's almost like a secondary use of Basal but for a Bolus where you drip drip, drip drip drip a Bolus in over a certain amount of designated time. You

Scott Benner 19:55
know, there's just there's so much you're gonna get out of having a pump there. Yeah. There's also going to be some things you need to know, sites can, like they're going to tell you whatever pump you have, they're gonna say this pump you can wear for X amount of days or X amount of hours. But sometimes sites go bad. You know, sometimes new sites don't work as well in the beginning. Those are little things that you'll learn along the way. There's, if depending on Arden's blood sugar, she might put on a new pod, and we might just Bolus a little bit to get the site working. This morning, I woke up in the morning, I saw that artists blood sugar was trending up overnight. And listen, for those of you just switching like Arden is looping, but I can see how much insulin is left her pod remotely, which most of you aren't gonna be able to see. But I can see she was down to like 30 units. So this is the end of her sight, right. And I just spent the weekend with her. And doesn't matter. But we were in a lot of restaurants this weekend. So Arden got a lot of insulin this weekend. And in my heart, her blood sugar is drifting up, because this site is kind of done. So because you have experience, yes, I can just tell and you will be able to one day as well. So I sent her a text and I said I wouldn't go to class with this pump one. Because if she does, she's going to spend her whole day with blood sugar's around 150. And she's going to be fighting with them constantly, and bolusing. And they're not going to work and and by the way, if that happens, and then all of a sudden she gets crazy active out of nowhere, she might experience a low blood sugar from all this insulin kind of sitting in this right over use. Well, yeah, get in this pool, right? And so like, that's just the thing you'll learn along the way, you'll learn, you know what people worry about so much like, well, you know, do you travel with pumps? You know, if we go too far from our house, we do if it's a 15 minute turnaround, we don't like you know what, I'm gonna have to have insulin with me now. Like, yeah, I don't know, we don't travel with insulin that frequently, as long as we're near home base, you know. But if we go far, you know, half hour, 45 minutes, and it's not something we want to turn back from, we'll take insulin with us, you know, it's just you. My point is, is that it becomes all second nature at some point. Just like everything else about diabetes, you're gonna have experiences they're going to teach you you'll learn from them and move on. Speaking of moving on, you'll think I'm going to go from MDI, to pumping, to pumping to algorithm pumping, but I want to do CGM first. So okay, you have a meter. And that's how you check your blood sugar. And that's all you have. Hey, you're in the doctor's office. The doctor is like, you know what you want to do?

Jennifer Smith, CDE 22:42
It must be the same deck.

Scott Benner 22:43
I wanted to draw here. Take this a sample you try. You'll love it. They're gonna try to give you they're gonna say to you, hey, you might want to libre, you might want to Dexcom if you're on a Medtronic pump, they might ask you to do whatever the Medtronic CGM is called. And you're gonna say I don't need that or you're going to be newer. You're gonna Yes, please. That remastered diabetes Pro Tip series is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have a unique offer just for listeners have the Juicebox Podcast. If you're new to contour, you can get a free contour next gen starter kit by visiting this special link contour next.com forward slash juice box free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juice box free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen. It fits well on your hand and features Second Chance sampling which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash juice box free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips you can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now through your insurance. Contour next one.com forward slash juice box free meter go get yourself a free starter kit. while supplies last US residents only are touched by type one has the back of people living with type one diabetes. Take for instance, their D box program touched by type one knows firsthand the intricacies of living with type one diabetes. And so their team has created a D box which is a starter kit that provides important resources and supportive materials to individuals with diabetes, they want you to thrive. The D box is completely free and available to newly diagnosed people. All you have to do is go to touched by type one.org. Go to the Programs tab and click on D box. While you're there check out all the other resources and programs available at touched by type one.org. Speaking of support, touched by type one.org is available in English and Spanish. Don't forget to find them on Facebook and Instagram too. You do not want to miss what touched by type one is doing. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. G voc hypo pen is a ready to use glucagon option that can treat very low blood sugar in adults and kids with diabetes ages two and above. Find out more go to G vote glucagon.com forward slash juicebox G voc shouldn't be used in patients with pheochromocytoma or insulinoma. Visit G voc glucagon.com/risk. Wherever you fall on that you do want it if your insurance covers it, you want it? That's for sure. Right? Tell me why.

Jennifer Smith, CDE 26:38
And I think it applies in all realms of diabetes as well. Right? Not just in type one diabetes, but also type two diabetes and even worthwhile and gestational diabetes. I know there are some rules in terms of when it can be prescribed whatnot. But I think it's beneficial all around what you miss with finger sticks are all of the little dots in between. So where things were trending, right, so if it is something that your doctor does bring up? Absolutely say yes. Right. You may not know how to look at the information or what you're getting from it initially. But it's so worthwhile. You want

Scott Benner 27:21
to know what you don't know. And with finger sticks, especially if you're newer to diabetes, or if you just been doing them your whole life. And this is how you tend to think of it. You do the well i i test before I eat or I test before I go to bed or I test before I drive. And and I know you've asked yourself what's happening when I'm not looking. Right, like and if you haven't asked yourself that. I wonder how do I go from 250 to 50 in an hour, like how does that happen? And you'll learn you'll start seeing the impacts of activity and the lack of hydration and different foods that you eat, the age of your your insulin pump site, all these different things that have a huge impact on the way your blood sugar moves. And now suddenly, it's there. A CGM is going to show you minute by minute. I think it's every five minutes. Right.

Jennifer Smith, CDE 28:21
And I think there are there are some people who have been using it long enough that can say there can be some frustration around the amount of data that you get. And I wouldn't disagree with that. I but I do you think it's how you interact with the data, right? It's how you actually take a look at things and what you do with it and what you learn from it. And you have to you have to expect that in the first month. Let's call it of using a CGM, you're gonna see a lot of stuff. And so rather than being so very emotionally reactive, again, taking a step back and kind of looking at the data to be able to make better decisions about what you felt like was probably happening. And now you can actually see,

Scott Benner 29:10
well imagine you have your sprinkler out on the yard. And you have to keep the dirt moist because you've planted grass seeds, except every time you look out it's kind of dry. That's the CGM. You look at the CGM ago Oh from 3am till 6am. My blood sugar's 140. It's pretty stable, but it's 140. I wish it was lower or moister. I can turn up the sprinkler a little and put on a little more insulin and make it where I want it to be like push that number down a little.

Jennifer Smith, CDE 29:37
And the CGM can show you that if you're really looking at it. That way the CGM can show you where did it start to lose right effect? Where do I start to need to add more insulin? It's not once you get stuck higher or once you get stuck lower than you want. It's before that so any drifts up or drifts down. Now, you can see that very clearly on a CGM I, you have a really good example I think from when Arden first started using her CGM, it was like that overnight thing that you are constantly missing was at Lowe's when you had finger sticks. And I would put

Scott Benner 30:14
or you could see them. I thought it was a genius. I've said it before I would put Arden to bed at 180. And she'd wake up at 90. And I was like, Look how good I am at this. And what would happen. We put a CGM on her. She was 180, she'd go down to the 50s sit there for hours, I'm assuming her liver would be like, hey, here, try not to die. Here's some, you know, some, here's some, here's some glucagon, I'll give you a little bit. And then she drift up to 90 overnight was happening constantly. So the reasons for that are mind numbing in not for this conversation, but we were bad at bolusing for dinner, we were her basil wasn't like there were so many things that weren't right, you know,

Jennifer Smith, CDE 30:52
you didn't know it because you couldn't see what was happening unless you really did a finger stick even an hourly finger stick, it would have caught a drift, it still would apply it. But it would have still been confusing unless you sat down and you connected all those dots. And you could say, well look, look at this. And you probably I mean, not necessarily wanting to see your child sit at 50 for three hours before your body actually reacts and gets you the glucose that is needed to bring it up. But you'd have on a first finger stick probably under 70, you would have ended up treating, so you also wouldn't have had the information to show. Well, how much do we need to take away? And what do we need to do differently?

Scott Benner 31:34
I can't I can't say how valuable it is to be able to see a graph and to enter look at it every three hours or you know what's it look like over six hours, like Jenny's point is great is that you? You don't know why? What happened happened? It's um, if you're married here, it's nine o'clock at night. And you're now in an argument. Right? And you think I don't know what just happened. But mostly this is guys like they're like what? They searched the last five minutes in their brain. And I've not done anything wrong in the last five minutes, right. But if you could step back and see a whole graph of your day, you'd realize that at 630. At dinner, you said something really stupid. And now it's hit me at nine o'clock. So I think that that can be similar. You could have cheeseburger with french fries at dinner at eight o'clock at a restaurant and hit it with a great Bolus. And you're like, Oh, well, my blood sugar's still where I want it to be it's 140 After dinner, that's not bad. And two hours later, it starts to jump up. And that doesn't make any sense to you. Because you haven't listened to the Pro Tip series. You don't know about the fat and the French fries and the slow digestion and how you're going to go up afterwards. But at least if you see it on a graph, and then you go have those French fries and that burger again, you see it happen again, you can go Oh, I could get ahead of this. Right? Yeah, I could not say that stupid thing at dinner. And now we'd be watching television, and she wouldn't be yelling at me.

Jennifer Smith, CDE 32:56
Right. And if you have a pump, you can also address it a different way than waiting for it to finally start rising and getting too high. You can offset it ahead of time knowing what is coming because you've had the experience that, oh, it always hits around two hours. So I'm going to start doing something about an hour and a half before that. So that it actually doesn't happen. Right. So I mean, yeah,

Scott Benner 33:21
million ways to handle that if you're from Arden, an hour after she has french fries, we have to Bolus for the fat. And there's a calculation you can do. And there's that heads off that secondary rise and doesn't cause a low later. That's the other great thing is that everyone, when you don't have enough data, you think, Oh, if I just keep throwing in more insulin here and there, it's gonna be it's not true. Like you can match the need up with the impact of the insulin and never cause a low. Right. And that's something you're going to learn looking at a CGM that, that uh, that a stable line on a CGM is really, your insulin, your insulin is pulling down, and your food and your other impacts are pushing up. And neither of them are winning like so if you can kind of imagine that line going off into affinity nice and stable. There's invisible lines. cables attached to it. One's trying to pull it up. One's trying to pull the line down, and neither can win because you have a great balance between your insulin and your knee. Yeah, so that in the CGM, like, seriously, like I don't care like there's decks comms and advertiser. It's not like I'm saying that like get a CGM. It's of any,

Jennifer Smith, CDE 34:33
right? Absolutely. I mean, I've said before, many times if somebody was going to take my technology, I would fight for my CGM. Before I'd fight for my palm. Yeah, no, I would 100% would keep my CGM.

Scott Benner 34:47
I'll throw this here too. Even though it's about like, leaving quote unquote, finger sticks. You're never going to leave finger sticks by the way, you're going to need them. You're gonna pass when you're not sure about your CGM. You're gonna test when you're making big I listen to my daughter's blood sugar looks high on her CGM, and we're gonna make a big Bolus. I said, Look, you gotta test, we got to know this numbers, right? We can't just start throwing insulin in here. And you're actually 40 points lower than this or whatever.

Jennifer Smith, CDE 35:12
And I think it's also really important to acknowledge what you know about how you feel around certain blood sugars. Because, again, technology. It's wonderful. And it's so much better than it was years ago. But it may still not be accurate at certain points. So always those finger sticks are important to continue to use. Because if your symptoms or how you're feeling doesn't go with what your CGM is reading, I guarantee a finger stick isn't gonna lie to you not unless you still have like, apple juice on your fingers or something.

Scott Benner 35:47
I was gonna say, and I didn't get to it just an accurate meter, just the blood glucose meter. Yes, they're not all the same. They don't all work as well. Don't just take the one that doctor handed you from the drawer, do a tiny bit of research. He's the one that I that advertises here because that's the one we use and it's amazing and, you know, like or do what you can do your own research and find out I will throw out a little story here. Because I did spend the weekend with my college age daughter, which I haven't done in a while as a visitor at school. Second night she was with me. We replaced her CGM. Okay. So at five o'clock at night, I said, Hey, your Dexcom is going to expire one in the morning. You should switch it now. It's before we're gonna eat dinner. We'll get it back online. It will have it we can do some finger sticks through dinner. And then it'll be rolling and working well by the time we go to sleep, because it does take a little while for some people to look right. You know? She does. I don't want to do that right now. So then when do we change her CGM? 11 o'clock, you know, like, oh, so then it's done. So then it's wonky for the first couple hours. And for Arden, if her Dexcom is wonky, it's wonky low when she first puts it on, mine is too. Okay. So like I made it, it'll be like you're 42. And she's 100. Yeah. 10. Like that kind of thing. Yeah. So there's a lot of consternation in what you should do. I'm a fan of letting it be on for a little while and calibrating it to help it get along a little more. But now we're asleep. And it's like Beep, beep, beep. All I could think was like that tone. I know. I said this. Nobody listens to me. But that's fine. And I'm like, and I know she's not that low, like and but it's worrying. So now she's, she's asleep. And I get up and I'm checking her blood sugar and she wakes up. She's like, What are you doing? I'm like, your CGM is going off. She goes, I'm fine. It's like, okay, so I tested her. And she was 130. And I was like, okay, so she's right. And I did a calibration and it came together pretty quickly. And that was it. Having said that, we could have done that at five o'clock. There. So there is a way to time, your technology. Now the new g7 is going to have a shorter warmup period, which will help overlapping you'll be able to soak your sensor, which I'm not going to bother explaining here. But as the technology gets better, so should those things. But that is not to say it's not like hands down. The most valuable thing that's happened to people who have any kind of diabetes, since I've since I've been aware of diabetes, some absolutely. Okay. All right, Jenny. Now we got our CGM. We're using a pump. We're looking online. And we're like, see, this isn't that the doctor is not gonna go you know you ought to do. That's not gonna happen now. Because this stuff's also new. Maybe maybe a really in tuned doctor might say, once you get an algorithm, but for the most part, I don't think I think that's the thing you're going to figure out on your own a little bit. So all this stuff we're talking about about, you know, the Bayes will be incorrect. And you might need a Temp Basal here, you might need to extend a Bolus for fat, you might need all this. There are pumps that make those decisions autonomously. Yeah, you have to be wearing at this time, you have to be wearing a Dexcom. Because it works with that. Right, but

Jennifer Smith, CDE 39:08
or med tronics. CGM? Yes, because they're their system also works with their pump, right? Yeah, so

Scott Benner 39:15
there's a Medtronic version of this. There's a tandem version of this. There's an omni pod version of this. All their algorithms are proprietary, they work slightly differently, but long and the short of it is they're going to give you insulin when you need insulin, and they're going to take insulin away when you don't need it. They're going to endeavor to stop you from getting low and endeavor to stop you from getting too high. You

Jennifer Smith, CDE 39:37
still had how they do that it was with targets Yes, right. Right, specific targets in each of the different pump systems. Medtronic newest one was just approved, which is really nice. But they all have specific targets. So how that algorithm works is based on when and how to give you more or less be Send a target and based on what the system is projecting off of your current CGM trend. So it's a very interesting like the algorithms don't just willy nilly deliver or take.

Scott Benner 40:13
Like, I think maybe now more,

Jennifer Smith, CDE 40:14
right? Yeah, exactly. There's a math to the algorithm

Scott Benner 40:19
Gremlin inside of your pub flipping a coin going, Oh, my God heads. Let's do it. So but it's it's it's stunning. Now there's another version. There's a number of other versions there are Do It Yourself versions. There's Android APs. There's loop. I think, Jenny, you loop. Right. I do. I think you and

Jennifer Smith, CDE 40:37
I've been looping for five and a half years.

Scott Benner 40:41
And Arden has been doing it I think since 2019. Maybe? So okay, yeah. And your Arden's using loop three as a mic, and you just switched to it as well. So like, so they're all just different versions of an algorithm making decisions about insulin based on your CGM tread tread. That's it? Yep. They're astonishing. They work incredibly well. They are not magic. Again, all settings, all knowing how to Bolus for certain foods, understanding the impacts of things, your digestion, your hydration, like all the things that are important about MDI are the same things that are important about pumping are the same things that are important about using an algorithm.

Jennifer Smith, CDE 41:28
And you made I know, people can't see you, but you were very in a line going from MDI, to pumping to algorithm. And I think that's, it's a really important piece. For those who are listening to understand if you're kind of listening to this, because these are not pieces in your life already, right, and you want to get an idea. There is 100%, I'd say 1,000% value in learning on MDI. And then moving to a conventional pump, that does not do anything for you, meaning it does not use an algorithm. There's absolute value in that, you know, we talked about testing, and evaluating settings, and learning about all the variables, food and activity and everything, and how to adjust your pump, or your insulin doses to accommodate for those variables. I think, as you mentioned, when you said, you know, your pumps, like, hey, let's start on algorithms. I can't go as deep as you. So it's a totally different doctor. Right. But in that sense, there are I think, more doctors today who are thinking algorithm, but in my personal and professional opinion, I think some of them are thinking that too fast. Okay? They are they are moving somebody to, hey, you're MDI, let's move to this algorithm driven system, whatever the system is, whether it's Omnipod, five, or tandem or Medtronic there is, there's a missing piece in the middle there, that if for some reason, and we talked about CGM is potentially not being always accurate or technology failing. If your pump fails in its algorithmic dosing, and you have nothing to step back to, you're at a loss. And it's important to understand that, you know, so I can't emphasize.

Scott Benner 43:32
It's incredibly important. Jenny's been talking to me about this privately for years. Honestly, she's like, people can't just be put on the machine, the machine does the whole thing. And they don't understand why it's happening. Because, you know, the general argument is what if the machine stops working? I don't even think that's the need for that I think the need is that this is a thing you have to understand. Like it right, no matter what none of this machine stuff is at the point where you don't need to know how to how it works. It's not AI, it's not even a computer like you know, you used to have to know how to fix your computer because it would break all the time. Nowadays, you buy a Mac, it'll just do the thing you want it to do, you'll never have to touch it, and it'll die. At the end. You'll recall my math doesn't work anymore, you get another one. And you don't need to understand how a computer works. To use a computer. You need to understand how diabetes works. To have diabetes. I don't care what version of care you're using. I don't care what the next one is. Now, if someone magically comes up with something one day, where it just works, no matter what, like a, like a laptop from Apple, okay, then then okay, then God bless. If you want to skip it, then skip it. But I'm still gonna say that isn't happening anytime soon because of not just the things we've mentioned today. You know, your insulin pump site might not work on time, like your CGM might not be right right away like all the other things. It's just not happening anytime soon. So you don't want The worst thing I can imagine is that you put an algorithm on a nine year old who it works for. And then five years later, the kid hits like puberty hard or something, and you have no idea, like the algorithms doesn't know you just became a completely different person, you're gonna have to change your settings to make that work, right. And that takes experience. If you I think if you ever find yourself listening to Jenny and I talking and thinking, How come whenever something comes up, they just fill the next space with something valuable. It's because Jenny has been living with diabetes for over 30 years. And I've been staring at my daughter for 15 years watching her have diabetes, and I have a never ending supply of experiences and answers in my head because I live through them. Yes, that's why and that's why you absolutely yeah. Like you didn't go to like diabetes University where they told you something secret that they don't tell everybody else, right?

Jennifer Smith, CDE 46:03
No, no, not at all. I mean, I have valuable behind the scenes, like information about disease states and those types of things from a medical knowledge base. Absolutely. And understanding them helps me to understand some of the navigation of that with diabetes, but the lived experience and the work that I get to do with so many people, that's the valley that you can't teach that right? In a university, you you can't teach, there's no degree and diet.

Scott Benner 46:36
And for your situation, you've been helping people for so long. And professionally. I tell people all the time, like, it's, it's gonna sound self serving, but it's not like, it's that I was able to get advertisers for the show. So I could turn the show into a job so that I could put this much effort into it. Because I learned that every day I talked to people, like you'll hear me say, like, Oh, I was talking to a guy the other day, he said something about this, that's me. hearing something I'd never heard before and right and retaining it and being able to apply it to a situation go, oh, you know, where that'll help here. And then you get to keep expanding those conversations. I'm gonna get to something here. And you get to keep expanding those conversations till they help other things. We did fibroid episodes. Now we hear from people are like, Oh, my God, my life is different. Because I got my thyroid managed, well, I'm getting a lot of my I didn't realize about my iron and my ferritin, like, a lot of women especially are getting back to me, like they're feeling so much better, because it's something they heard on the podcast, they heard it on the podcast, because I was able to focus on this because this is what I think about. And now and now it's coming to digestion. And that because we had to figure out a problem with my daughter's digestion. And then we shared it on the podcast now I've seen that help other people. That goes for little things about diabetes, too. Yes, that's how this stuff spreads. This is a repository of information, but you're gonna build that in your own mind. Correct? Not if somebody slaps new algorithm on you and tells you don't worry about the thing will take care of it.

Jennifer Smith, CDE 48:07
Right? Because it one that's such a, that's such a big thing that I hear well, shouldn't it be helping me with this shouldn't be doing this shouldn't? The one word I hate is learned, I shouldn't have learned that I don't need this much insulin at two o'clock in the morning. Nope, your system isn't learning. I promise you. It's not learning. It doesn't keep track of two o'clock in the morning, gosh, I gotta give less insulin for this person. It's not that's it's not smart.

Scott Benner 48:33
And Jenny, you know, oddly enough, as we make this episode, I put up an episode today called Rise of the Machines, where a guy comes on to talk about his Android APS system and how it he does believe it's going to learn in the future, which is so exciting, but not now. Like, you know, what's one of his examples? He said, location services. So if you say I'm having pizza, and it realizes you're at Domino's, okay, and you have an experience with insulin, someday, it will remember that experience. Yeah, if you go to a different pizza place and have a different experience. It'll remember that if you go to a third pizza place, it'll remember that if you head back to Domino's, it's gonna go Oh, we're back at Domino's. This. That's not happening right now.

Jennifer Smith, CDE 49:22
No, in fact, there is there are some. There are some apps that actually you can track that way. Like you can take a photo of something and tap the location indicator and the next time you come back to that location, you'll be able to see what your dosing looked like what your CGM trend looked like so you can learn from Bob's pizzas, Friday night last week to this Friday night. Maybe I should change my strategy. It looked like this and I want to improve this right or do it differently, but those they need to be married right into the pump so that not only do you have Okay, now I'm at Bob's pizza. This is what I had. And hey, let's the pump then can acknowledge and I'm going to do something different for Jenny.

Scott Benner 50:06
But for that happening just automatically, that's not here yet. 2023 on the pod five doesn't do that. Tandem T slim doesn't do that the control IQ doesn't do that the Medtronic doesn't do that. They know it may have happened one day. Sure. But the other I think the other thing is, I know you want your days to be easy. And they can be they can be much easier than they are now they can be more your intuition can come into play as you grow. But this is a lifelong thing. And what you want is you want to get to the point where I saw Arden get into this weekend, where we sat down to this meal, there were 16 different things. And she just looked at it and picked up her phone and went and push the button. Yeah. And I was like, How much does she give? She was I don't know, I told her it was like 85 carbs. And I was like, and she and I was like, okay, and then she was okay. And it was okay, look at a table at a restaurant. And she's like, I think about this much. And that's boy, forget this podcast and everything else. It's that's where you want to get to where it just where you wake up at two in the morning, you see a high blood sugar and you go, Oh, I know what this is. And that does come it really does come. So anyway. But you're going to transition along, by the way, I think algorithms are amazing. And

Jennifer Smith, CDE 51:31
yes, they are absolutely i i love my algorithm. Absolutely. But I've also learned to work with it. And I've learned what it can do and what I still need to tell it to do. I think that's the big thing about algorithms is knowing that you still have a fair amount of action to put in to it so that the algorithm can work with you.

Scott Benner 51:53
Yeah, yeah, I wouldn't want anybody to think like, oh, you're using a do it yourself loop. It's magical over the other. There, it all is about the same. Like they all need your help. They all need your intuition. They all need your knowledge. There's nothing if you think you're going to just put a loop on or on the pod five, and it's just going to be perfect. Like, you don't have to do anything. Like that's not going to be the case. No, yeah. So but don't be afraid. Like I'll say something here on the spot myself Saturday, make them clean and make myself set up. Yesterday was my friend Mike would have been my friend Mike's birthday. And I don't want to bring all this down. But Mike had diabetes, type one when we were teenagers. He's not with us any longer. I believe that one of the reasons Mike's not with us any longer is because Jenny alluded earlier that I was stepping along with my hands while I was talking about things like Mike never came along. He just somebody gave him regular an MPH. And he used it long, long after he should have been and you know, didn't have updated meters and didn't you know, he didn't do the little things that you do to come along. I mean, I guess what I'm saying is you don't want to be managing your diabetes like it was 10 years ago.

Jennifer Smith, CDE 53:12
Right? I don't think he's tonight. I think you're also bringing something in here. That's really important to consider. Because you've you've talked about, you know, practitioners bringing up hey, why don't you try a CGM? Hey, why don't you try a pump? If, if you're the one always going to your doctor asking for what's new. I don't know. I you know, and your doctor is very willing and can talk about it then with you. Maybe they didn't bring it up. But they're very, they're knowledgeable about it. Once you do get on it fine. But if this is someone who's never really brought it up and kind of like, shrugs their shoulder and like, sure you could try it, whatever you may need kind of like your friend maybe didn't have a doctor who was keeping up with what could have been better for him. Yeah,

Scott Benner 53:59
yeah. Yeah, you don't you have to take this as a, I don't know if you want to call it a disease or like, some people don't like that word. But this is a way of living, that it begs you to be involved in it. Yes. Like it just it just really does. You have to be aware, you have to take some time to learn what is happening with technology, what's happening with insolence, you know, and you need to move along with it. Because if you look back 50 years, I still interview people who are like in their 70s and have had diabetes forever and they don't even understand why they're alive. Like Like you don't want your life to be a coin flip. You don't I mean, like there are things you can do to to to give yourself better health outcomes. And those health outcomes are not just health outcomes, their quality of life. They're your they're your psychological state of being like there's so much good that comes from just understanding. I know that sounds silly, but How to set your Basal rate and make sure your correction factors, right. And you know how to cover the foods you eat?

Jennifer Smith, CDE 55:05
Absolutely, I think and on a bigger scale, we're also we're all supposed to be a participant in our life, right? health in general, you may have been given good health to begin with, but you're the keeper of that health. Right? It's just like, you're the keeper of the car. If you continue to let the salt buildup on you never wash it off, you're gonna have a rusty car? Well, you're your body's the same way, right? You're the keeper of your health, you got to do things to maintain your health, diabetes, it stepped up a level it is

Scott Benner 55:39
absolutely and so prepare to transition by getting as much good information as you can. But then at some point, you just have to do it. You have to just dive in and do it and then learn a new thing. And then once then you'll be surprised at what else comes from that. And anyway, listen, it's also not to say that you couldn't get an algorithm pump right now and teach yourself backwards. I actually think you can. Sure. I think some people have a harder time with that than others. And I don't want you to be in a position where you're lost and something's happening. And you don't understand why because it won't be any different than a person that gets over Basal on MDI and thinks they're doing okay, but it's not really covering their meals well, right, you know, and then doesn't get hungry one day and it's up low all afternoon doesn't understand what happened, like crack diabetes. There's no reason that if, if you have an if you have enough information and understanding diabetes doesn't have to happen to you. And I think that's maybe the most important part like I would if it feels like it's happening to you, instead of you are doing something and then something's happening. I think you have to have to look and get a deeper understanding, because it shouldn't just be happening to you. That's all. Okay. Awesome. Thank you, Jerry. I want to thank assenza diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free contour next gen starter kit at contour next one.com forward slash juicebox free meter, while supplies last US residents only. If you're enjoying the remastered episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org. A huge thank you to one of today's sponsors, G voc glucagon, find out more about Chivo Capo pen at G voc glucagon.com. Ford slash juicebox. you spell that GVOKEGLUC AG o n.com. Forward slash juicebox. If you're living with diabetes, or the caregiver of someone who is and you're looking for an online community of supportive people who understand, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, there are over 41,000 active members and we add 300 new members every week. There is a conversation happening right now that would interest you, inform you or give you the opportunity to share something that you've learned Juicebox Podcast, type one diabetes on Facebook, and it's not just for type ones, any kind of diabetes, any way you're connected to it. You are invited to join this absolutely free and welcoming community. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer and most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com If you're interested in hiring Jenny, you can learn more about her at that link. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bumping nudge 1008 The perfect Bolus 1009 variables 1010 setting basil insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low Beegees. In Episode 1015, Jenny and I talked about emergency room protocols in 1016 longterm health 1017 Bumping nudge part two, in Episode 1008 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022, weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025, we talk about transitioning from MDI to pumping. Before I go, I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with this and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insolence so that is active as the carbs become active, took me already from a decent 6.5 A one C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.