#1003 Diabetes Pro Tip: Pre Bolus
Scott talks about the importance of pre-bolusing for people with diabetes. He is joined by Jennifer Smith, a registered dietitian and certified diabetes educator, who shares her insights on the topic. They discuss how pre-bolusing can help ensure that insulin is well-timed with meals.
You can listen online to the entire series at DiabetesProTip.com or in your fav audio app.
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Key Takeaways
- Pre-Bolusing is Essential: Rapid-acting insulin isn't instantaneous; it takes 15 to 30 minutes to begin working actively. Putting insulin in before eating gives it a head start to match the speed of carb digestion.
- The "Tug of War" Strategy: Think of insulin and carbs pulling against each other. Letting insulin start pulling first creates downward momentum, preventing carbs from gaining unstoppable speed that rockets your blood sugar up.
- Rely on CGM Trend Arrows: The direction and speed of your blood sugar (the trend arrows) are far more critical for making treatment decisions than the current static number on your CGM.
- Super Bolusing (Trading Basal for Bolus): You can tackle immediate carb spikes by taking future basal insulin and adding it to your meal bolus upfront, then setting a temporary basal decrease to prevent a low later.
- Use Temp Basals, Never Suspend: Always use a temporary basal rate (even if set to a 0% decrease) instead of fully suspending your insulin pump. This ensures insulin delivery automatically resumes if you forget.
Resources Mentioned
- Wrong Way Recording: wrongwayrecording.com
- Diabetes Pro Tip Series: diabetesprotip.com
- Juicebox Podcast: juiceboxpodcast.com
- Integrated Diabetes Services: integrateddiabetes.com
- Juicebox Podcast Type One Diabetes (Private Facebook Group): Join on Facebook
- Dexcom CGM
Introduction and Podcast Overview
Scott BennerHello 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 CDE 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 revisitable. 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. 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's 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.
The Reality of Pre-Bolusing
Scott BennerIn the episode about insulin, I told you that that my nurse practitioner CDE told us that fear of insulin was the biggest sticking point for people making good decisions with their diabetes, right. And after I got past my fear of insulin, the next hurdle I had to get past was Pre-Bolus. And I am now years and years later at a time where I will tell you that if you do not Pre-Bolus a meal, the likelihood of success is near zero. And if you have success without Pre-bolusing all that means is that you gave yourself too much insulin prior to that. And it's just catching up now. And so this is it. We're going to talk about Pre-Bolus and we're going to talk about how about insulin action right the action of the insulin and how to balance it against the impact of the carbs or your body function. So tell me let's go over the part that people aren't going to find comforting at first right which is the amount of time it takes insulin to begin working in a person varies person to person and insulin to insulin is that pretty fair to say?
Jennifer Smith, CDEIt's pretty fair to say yes and insulin to insulin. I would definitely say most of the the rapids on the market should be fairly similar okay? The rapid acting insulins on the market and their time of action should be fairly similar now. Person to Person yes, that may vary situation to situation as well as situation it may vary but again, that's the learning part of it.
The Tug of War Analogy
Scott BennerOkay, so person the person could end up meaning just your body chemistry could mean where your infusion set is right, you know, your your injection site,
Jennifer Smith, CDEabsolutely. Say
Scott Benneryou're a person who gets stuck on, I always injected my belly in the same place, that spot might not be as reactive to the insulin as if you would just try a new spot. If you went to a new spot, it might work quicker than it has been in your old spot. Right? If you're wearing an infusion set it could we alluded to it before you could get better action from your insulin on day one than you do on day three or better on day two, then, you know, two hours after you've put it on, there's a lot of different variables. But we're speaking generally here to you'll apply them to your variables later. Now, if you've heard this podcast before, you'll know that I have alluded to how insulin works in a number of different ways. So I'm gonna give my kind of cartoony description of it, and then we're gonna let Jenny talk about it for real
Jennifer Smith, CDEcartoony, might be better, actually, we'll see.
Scott BennerSo here's how I pictured in my head a couple of different ways. The first way is I think of a tug of war. And I imagine a rope with a with a flag hanging in the middle of it. And on one side of this tug of war rope is insulin. And on the other side is your carbs and your body function. It could be adrenaline, it could be fear, it could be anxiety, whatever it helps to drive your blood sugar up. That stuff's on one side of the rope. The insulin's on the other side, unlike a tug of war in a schoolyard, our goal is not for one side to win, our goal is for them both to pull and pull and pull until they get exhausted, they both go, I can't do this anymore, and they dropped the rope and our flag's still in the center. That flag represents the blood sugar. You start at when the impact of the carbs begins in my mind, so I'll explain a little more. If you let them both start pulling at the same time, the carbs are generally speaking, going to gain power and momentum before the insulin begins to work. So now your rope is going towards a high blood sugar and you're you're starting to head up. Now suddenly, you're 50 points higher. And what if you started with 150 blood sugar, now you're at 200. And now these carbs have momentum. They have speed, they're pulling your blood sugar up. Now all the sudden, 15, 20, 30 minutes later, the insulin's like, oh, no, no, wait, I have a job to do. I remember and it kind of comes online. But now it's pulling, it can overpower the the momentum that the carbs have created. Plus, you now have another 100 points of blood sugar to contend with. And all you have is the insulin that you counted your carbs for. So even if you counted your carbs perfectly, and realize that this meal is five units, once the momentum of the carbs is rocketing your blood sugar up, once you have a number that is higher than you started with those five units are not even going to begin to cover what's happening, let alone the food that you've put in. But if you put the insulin in first, and let the insulin come online slowly and begin to pull down and create the momentum in the other way, then you flip the script. And now the carbs are fighting. So instead of having a fight at 180, blood sugar, you're having a fight at an 80 blood sugar. And instead of your blood sugar falling at 80 It's being the attempt is that it's now trying to be pulled up by the carbs. And that's how when you see people with a stable graph, that's how theyre doing it. And so for me, in a perfect situation for me, my daughter's blood sugar is diagonal down when I give her most foods. There's differences you know, food to food, situation to situation but in a perfect world. To me, that's it, you want your insulin working, your blood sugar trending down, creating some momentum down, when you allow the carbs to begin to pull up. Correct. Now, you to explain that in a technical way that sounds
Jennifer Smith, CDEand in most in most settings, yes, that's 100% I mean, insulin, our rapid I've always thought that rapid is such a misnomer. Honestly, rapid indicates like now rapid is like you know, click, click click light switch. It's on, it's working. And it's you know, still education is take your insulin and start to eat. I mean, even from most endo offices, it's take your insulin and start to eat, it's going to be working very, very quickly. That's not the case and anybody who's been taking insulin long enough, and you've seen the spikes, and you've seen the issues, despite counting your carbs as precisely and weighing them and everything and you're still seeing these issues. It's the mismatch of insulin timing. It is so our rapids take anywhere between about 15 to 30 minutes to really get that active peak, not peak but that active phase where then when you start putting your carbs in there They will match. As you said, the carb digestion will start to match with the insulin, you'll get a nice gentle curve up. And it should then start to curve back down. And there is a lot of, there's a lot of education that also focuses on, as you mentioned, watching for that curve down, watching for the curve down to start so that you know, the insulin is already moving things.
CGM Trends and Dispensing with Fear
Scott BennerYeah. And to give you some context that a person I spoke about in a previous episode, who was having trouble, told me, but what am I gonna do, I'm going to be scared. I said, well try it a little bit, this time, and then a little more next time and a little more next time and go forward. And, and so I always tell this story somewhere. And I think here's the right place to tell it. Prior to glucose sensing technology being a thing that anyone knew about prior to Dexcom, I was again in the office and the CDE says to me, Hey, you're gonna get one of those Dexcom things. And I thought, I don't know what that is, you know, and she starts telling me, it's a continuous glucose monitor. And I'm like, Yeah, I again, don't know. And then she tells me this simple story. There's a 17 year old boy in her practice, who loves candy, certain kinds of candy, and he can't figure out how to Bolus it. So he gets a Dexcom, whatever the first one was, I don't even remember anymore. His whole goal was to eat this candy without a spike. So he goes out to the store. And he buys like little grab bags of these candies, and a number of them enough for a week and every day starts on this experiment first day, just like you said, eats, gives himself as his insulin, just like he'd been told his whole life, blood sugar goes up to 200, something like that sits there forever. Eventually, he has to give himself more insulin to bring it back down again. Next day, he tries a little sooner, give himself a few minutes, 5, 10 minutes gets a little less of a rise. So the next day, he goes even sooner. And then before you know it, it's a little sooner, a little more, and he starts adjusting it back and forth a little more a little sooner, a little later, until one day, he eats the candy. And his blood sugar never moves. And she tells me that story. And I thought immediately Wow, that means it's possible. Yeah, that was the first time I thought I was like, if that kid can do it with candy. I can do it with anything. Like anything, right? And so yes, give me that CGM place. And I got it. And I started dispense with my fear. And I started learning about it. There were hiccups along the way, right? I've given her insulin, and she's gotten lower than I meant to for two when she's eating. But you know, once twice, I'll go back to this over and over again, when something goes wrong. It's not a mistake. It's a learning experience. It's data for next time. Right? Right. So I put the insulin in, and she goes down to 70 and sits at 70. While she's eating. It's beautiful. You know, like, there she goes. And then and then then a spike. Even if I really messed up on the amount of insulin, I used a spike takes you to 120. Right? Right, right. It's not right. It's just, it's all about that timing and amount. And I repeated over and over again, that you all the things you and I are going to speak about all the things that people hear about on this podcast, if you want to know how to use your insulin, at its core, the very first step is timing and amount. If you get used the right amount at the wrong time, you can use the wrong amount at the right time, that it's too much, you have to have the right amount of insulin at the right time, you have to balance the action of the insulin against the impact of the carbs. If you do that, I don't want to say it's easy, because that's insulting to people. But let me just say I don't think about diabetes that much anymore.
Jennifer Smith, CDEIt's easier, it's much easier if you do that. It is easier. Absolutely. And it's a lot more. It gives you a lot more visual than to understand. Because it's not so much of an unknown Well, gosh, I counted the carbs and it took the right amount of insulin and this is always happening to me. Why. And if you can start to put those pieces together, it's not a why anymore. It's like turning the light bulb on.
Reading the Arrows and Being Fluid
Scott BennerHere's how I explain what Jenny just said. I think of it as this equation that it's a mathematical equation that doesn't have any math in it. I did this that happen. So next time I'll do more less sooner, you know, little less little more, that kind of thing. And I always just I always just keep looking at it like that. I did this and that happen. It's the idea of being in a fistfight and you want to hit first because now you have cause and effect. Right? And if you and so now you know I've done something. And that's what happened next. Now I can make a good decision about what what I do next, instead of waiting for diabetes to do something to you. And then you're just covering up your face hoping not to get knocked out. Right? Like because you don't know what's happening. You don't know why it's happening, you have no context for what's going on. But when you make the first move, you can be sure that what happens next was impacted by what you did. I put insulin in 10 minutes before you ate 10 minutes before I ate. And my blood sugar went to 150. So the next time I'm going to try 15 minutes. And if it goes to 130 I might try 20 minutes. And you know if I get low than later, I might say okay, I might need a little more a little less. Now here's where people always say, Well, how much Scott How long? You know, give me the time give me the amount? That answer for me. It's always going to be I don't know, figure it out for yourself. Okay, you have to
Jennifer Smith, CDEthis is the starting place. Yes. This is where to start. This is how to start. You have to do your own. I mean, diabetes is a science experiment. It's a daily, I feel like every day you're almost given like this new petri dish. And you're told, keep the dots growing purple today. Okay, let's work on keeping the dots growing problem is that something green pops in and then these like little horny pink things pop on? You're like, oh, no, but it is it's like it's a science experiment that for the most part, when you figure out what does work, the timing around the most typical foods that you eat and whatnot. It takes a lot less thinking out of the equation.
Scott BennerYeah. And while this isn't about Pre-bolusing and it will come up later, but it's important for me to say because I think this is impactful. When you really stop and think about your your habits around food. They're pretty similar Right, right. So, you know, you're not I always say like this, like, if you're a person who gets a pizza on a Friday night and has two slices, you don't suddenly next Friday have seven slices. You don't go from being a two slice person to a seven slice person, right? Like, yeah. And so, so you can start making these decisions about how much insulin and when, and you can make them based on Yes, historical knowledge about what's going on. Yes,
Jennifer Smith, CDEI usually tell people as the Pre-Bolus piece, you've got, most people have about 20 to 25 foods that are the most common for you to eat regularly. Yeah, that's at least 80% of your control there, at least. So if you can nail the Bolus timing around those and figure it out, for the most part, you know, variations in setting will happen, whatever, yeah, but for the most part, if you've figured that out, you're also much more likely to be able to figure out food that isn't your norm, because of the similarities to what you've chosen. And what you're usually eating, because you
Scott Bennercan stay flexible, I call it saying stay fluid, right? So here's, here's where I'll tell people this, don't get mad. I don't count carbs. I actually think about it a little backwards from maybe how most of you think about it. I don't look at the food and say, you know, weigh it or measured and say okay, well that's 25 carbs. And my pump says that I get one unit for every 10. So that's two and a half units. In honesty, there is no accurate insulin to carb ratio set up in Arden's pump. We don't even I don't even pay attention to that. I look at a plate and I say to myself, that's seven units. I think that if she's going to sit down and gorge herself on nachos and cheese, the last time that happened, it took 10 units. But I think of it as insulin, not as carbs. And of course that takes a little practice, right?
Jennifer Smith, CDEIt does, it does. And it is a little contingent on you having a CGM.
Scott BennerI'm not going to lie about that, right, because I start with a healthy Pre-Bolus. And healthy would mean in amount and time. And then I watch her CGM, and I don't really watch it, I have her tolerances set tightly enough that if she leaves that range, I find out about it. So as an example, if I were to give art in something incredibly carb heavy, I might use a Temp Basal increase, and a Pre-Bolus to try to spread out the action of the insulin across this timeline where there's going to be these carbs, right? If I make a Bolus, and 30 minutes after I do it, she's 121 30 Diagonal up. I look at that line. And it tells me something based on my previous knowledge, it's I say to myself, ooh, this I missed, like, this isn't enough insulin, and I will give her more I will bump it and nudge it back. It's not a ton more, it's enough to stop the arrows,
Jennifer Smith, CDEright. And the arrows are very important to bring up in this in this as well. Because if you are using a CGM, those arrows do indicate a rate of change. And again, that's not something that most people realize. They don't understand that and not understand and people won't tell us but it's that they've not been told they've not been told, Hey, these arrows tell you that you're increasing by 30 to 60 points in the next 30 minutes. Okay, if that's the case, and I know what my kind of correction factor is, or whatever, I can say, Okay, I'm going to need this much more insulin, because if I don't correct my rising 130 blood sugar in the next 30 minutes, I could be 30 to 60 points higher. I could be as high as 190. I don't want to be 190 I've obviously miscalculated someplace, I can throw in a bit more insulin to counter that expected and stabilize it. Yes. Yeah.
Super Bolusing and Temp Basals
Scott BennerIt very much. It very much is remembering to like I guess the way I usually say it is that you have to trust that what you know is going to happen is going to happen. Right? Yeah, you see. And I think that the least important aspect of what the Dexcom does is the number. It's the direction and the speed, direction and 100%.
Jennifer Smith, CDEI wish more please say that again. It is the direction it's the trend. It is not just the number.
Scott BennerThe number is nice, like don't get me wrong. It's a starting point. But, you know, if you're 60 and stable, and you haven't had insulin for three hours, you haven't had food for three hours when maybe you could get away with like a Temp Basal decrease of 100% for half an hour, maybe you'll rise to 90 Right? But if you're 60 and you're falling well Then you don't have enough time because as we've now discussed over and over again, insulin doesn't begin working right away. Also, Temp Basal is our insulin. It's funny how people think of bolusing. And Basil is different. But once you're on a pump, it's the same thing. You can't just turn your basil off, and it starts happening right away,
Jennifer Smith, CDEtakes about 60 minutes for circulating insulin level to be different.
Scott BennerAnd I always write and I always try to think of it a little bit as like Ardens Pre-Bolus. Time Like if Ardens Pre-Bolus time is 20 minutes, well, then setting a Temp Basal is not really going to start working for at least 20 minutes plus, it's a fraction of the Basal rate, if, if you're getting a unit an hour, and I say to it, okay, let's double it, let's double it to two units an hour, that impact of that doesn't begin for 20 minutes or so plus, it's not the whole unit extra. It's the it's the fraction of it. So when we talked about basil, we'll get to that. But so Pre-bolusing is really just the idea of balancing, again, the action of the insulin against the impact of the carbs, giving yourself a chance, not letting the carbs wash you away, because here's what happens when the carbs wash you away. Count your carbs exactly right, you put your insulin in, you spike up the 200. When that happens, that insulin was only for the food. It wasn't for the 200 blood sugar, and it wasn't for the momentum of the rise. And so when I see that, like, I guess an easier way to say this when when I don't have time for a Pre-Bolus. And Pre-bolusing to me is never about the number, you can Pre-Bolus a 65 blood sugar, you know, you can Pre-Bolus a 90 blood sugar because still no matter what, if you're stable at 65, the insulin you put in, it's not going to start working until it starts working. So you have and so don't get me wrong if I see a 65 blood sugar and an artist needs 10 units for what she's eating. I don't put all 10 units in at a 65. I might do an extended Bolus which we'll talk about and extended Bolus but I get some insulin moving, I make sure the insulin is on the winning side of this tug of war to start. But in a situation where I can't Pre-Bolus Let's say I know the meal is five units. 100% certain it's five units. But for whatever reason life, let's call it I can't Pre-Bolus and Ardens. You know, I'm going to start eating right now. I'll give her seven units. Because I Pre-Bolus for the food, the five units for the food I knew. And I pray. And I'm Pre-Bolus seeing the rise I know is coming and the end, the number I know is coming. So I'm already treating a high blood sugar that hasn't happened yet. Because I didn't Pre-Bolus Right.
Jennifer Smith, CDEJohn Walsh goes into detail about what you're doing in a little bit of a different way. He calls it super Bolus I call for bolusing. Yeah, and he calls it super Bolus in the way that you take that five units, let's say in your example. And let's say your basil behind that meal for the next two hours is one unit an hour, you actually take your basil running for the next two hours, and you add it into the Bolus for the meal and you take it all upfront. And then to decrease the chance of being too low leader. Because of so much upfront action and the blood sugar staying normal, you actually set a temporary Basal decrease, he recommends starting with 100% Because you've loaded that onto the front to avoid a low but on the back end. Some people find though that attempt Basil 100% off is too much. They only need a 50% they still call the spike and prevent it. But in the back end, they're not having a low then. So similar kind of concept. Yeah,
Scott BennerI consider that trading Bolus for basil. So So you know, say 120 Diagonal up 3040 minutes after a meal and I go oh, geez, I got to stop that arrow. How much do I Bolus to stop there? I usually Bolus an hour's worth of a base of Basal insulin. That way if the arrow stops and I stay steady, and she doesn't go down, I say okay, well obviously I was just wrong on the initial amount. But in those situations where you push the button, you know the unit and a half goes in, and five seconds later the arrow goes from 122 Diagonal up the flat you go oh, I didn't need that. Right Temp Basal off off half hour. All I've done is trade the basil for the Bolus. Absolutely. Here's a good place to say this. And we'll say this in each of these little vignettes. Never suspend your basil. It's always temporary Basil is when you suspend your shutting your pump off when you shut your pump off.
Jennifer Smith, CDEIt does not turn back around. You have to remember to turn it back on. Yes, yep.
Scott BennerIt's always temporary because you can set a Temp Basal for a half an hour or an hour, two hours but at the end of that time, it goes back it'll go back on to start delivering your basil it's always temporary Basil is not not don't suspend your pump. Oh Okay, so I think Do you think we covered Pre-Bolus there?
Jennifer Smith, CDEI think that's pretty good. Good. Yeah, that's awesome.
Episode Conclusion and Pro Tip Series Outline
Scott BennerJenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer and most makes and models of insulin pumps and continuous glucose monitoring systems. She has also had type one diabetes for over 35 years and she works at integrated diabetes.com If you're interested in hiring Jenny, you can learn more about her at that link. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed you're starting over episode 1001 all about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two in Episode 1018 pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and an episode 1025 We 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 us 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 that Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active. Took me already from a decent 6.5 A one C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.
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