#1005 Diabetes Pro Tip: Insulin Pumping
Remastered Diabetes Pro Tip: Insulin Pumping
Scott and Jenny Smith, CDE share insights on type 1 diabetes care
You can listen online to the entire series at DiabetesProTip.com or in your fav audio app.
You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Music - Google Play/Android - Radio Public, Amazon Alexa or wherever they get audio.
Key Takeaways
- Precision and Flexibility: Insulin pumps offer unparalleled dosing precision (down to fractions of a unit) and smart tools like temporary basals and extended boluses that MDI cannot match.
- Basal is the Foundation: Setting the correct basal rate is critical when starting on a pump; if your basal is wrong, your meal boluses and correction factors will not work properly. Expect to need slightly less basal insulin (10-20% less) when switching from injections to a pump.
- Mastering Extended Boluses: Pumps allow you to spread insulin delivery over time (dual wave/square wave), which is essential for managing slow-digesting, high-fat, or high-protein meals that spike blood sugar hours later.
- Understanding IOB and Action Time: Knowing how your pump calculates Insulin On Board (IOB) based on your set active insulin time is crucial to prevent stacking and to allow aggressive, safe corrections.
- Expect Site Change Variations: Inserting a new pump site causes temporary inflammation, which can initially decrease insulin absorption. Pay attention to how your body reacts to site changes to avoid unexplained highs.
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
- Insulin Pumps: Omnipod, Tandem, Medtronic
- Insulin Brands: Lantus, Levemir, Tresiba, Apidra
- 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.
Advantages of Insulin Pumping
Scott BennerWe are back talking about insulin pumps today. Awesome. And the idea of pumping in general not any specific pump, although we might go over the ones that are available at the moment. So we discussed in the MDI episode that it's tough to get an insulin pump right away, you'd have to be have great in insurance, you'd have to be able to get over the what do we want to call them roadblocks that some endo offices put up to you getting? Right getting in? It's on top. But But congratulations if you've gotten that far and you're thinking about getting an insulin pump. Why do you think? Well, do you think let me ask you, do you think pumping has advantages over MDI and if so, what are they?
Jennifer Smith, CDEYes, I mean, a broad a broad statement. Yes, there are advantages. I think there are pros and cons to everything. But there are a lot of pros. I think one of the biggest ones is precision in dosing. I mean, you know, from the standpoint of injections, we can dose accurately, like, quote accurately, to the half a unit with an injection, right? I mean, I've even got a couple of friends who still do MDI don't like pumping and, and they've sort of figured out how to get that quarter unit in an injection. But is that accurate? No, it's not like the pumped accuracy, you know, pump can get down to the point 05 Or the point 025 of a unit. That's, that's precise, that's miniscule, you know, and for the broad spectrum of people that need insulin in different doses, the very, very little to the adult who Who is very, very sensitive for whatever reason, that can be important.
Scott BennerOkay, and I agree, I think that when, especially when they're younger, I've used Mo, I've had moments with art and where it's a point one or a point to Bolus that can really move somebody and the, you know, obviously, the lower your body weight, the more that kind of precision makes incredible differences. I guess the con to that can be if you are so small, it's possible that it might be difficult to set your Basal rates up. Because if your Basal needs are that little in the beginning, you can do that I've seen people do all kinds of crazy stuff, like set a Basal rate on for one hour off for the next one, back and forth. And that's, there's a way to get through that. I think if you have a smaller child and you want to pump, there's a way to accomplish it.
Jennifer Smith, CDEThere is Yeah, absolutely. So precision, definitely. And then, you know, I, the icebergs that kind of pop up in your day. You know, you I know your strategy. And a lot of people strategy is kind of the navigation of blood sugar, right? And utilizing the smart tools on an insulin pump smart being things like the extended Bolus and the temporary Basal feature. You cannot do that with an injection. You just can't. And that is that's another huge pro pump.
Scott BennerYeah, I can't say I agree anymore. I am in full agreement. I didn't understand at all about pumping. When Arden was injecting, right. There were just a lot of words, I didn't understand people were talking about bolusing and all that. And what's that? What's an insulin to carb ratio? I have no idea. I know a little bit from objective, but it was so much more specific talking about with pumping ahead its own language. And I've mentioned before that as we were in Arden's pump class at at her children's hospital, and I recognized that insulin was going to be used, like fast acting insulin is going to be used as Basal insulin. Yep. And that I could turn it off and turn it back on and increase it and decrease it. I'm telling you angel saying like, light bulbs are going off, like everything happened. I was like, okay, immediately. Yes, please. I genuinely think that before you have a pump, and for a lot of people after you have it. People just believe the pump is a way to avoid injecting. And I want to I want to, as we do the overview about insulin pumping today, I want to show them that it's just so much more than that. So it is
Jennifer Smith, CDEYeah, absolutely. And I think another piece to definitely clear up, even for anybody who might be listening to these that doesn't necessarily interact or is a caregiver for somebody but with diabetes, but they've come across it because they just want information. A pump is not the magic, do it all. You don't plug it in, and it takes care of everything that is is not the case. And for those who might be newly diagnosed in our hearing oil pump is like the magic thing. It does all these ones. It does what you tell it to do. And it does it based on the parameters you set within the pump. Yeah, there's it's it's personal input is what makes the pump as beneficial as it can be. So you can then see that if you don't know what you're doing. It could be not that the best thing.
Setting the Basal Foundation
Scott BennerSometimes you hear people say I've had this pump for a month, and I'm thinking of going back because I think they have doing what I need. Yeah. And I think they had that expectation like, look, I bought the pump, I put it on why did my A1C not go down? How come my spikes aren't going away? Why is my blood and in some cases, people's blood sugars get worse in the in the in the beginning because they don't get their basal setup correctly, right. Or, or I think for some people, your insulin needs change, sometimes greater or lesser, when you go from injecting the pumping
Jennifer Smith, CDEbecause of the precision, especially if that Basal, sometimes with the imprecision of an injected Basal insulin, and the fact that it isn't based on your physiologic need and the change through the course of the day, that Basal insulin could be off via injection at a time when you need less insulin. And so things look like they're happening around a Bolus when it really isn't the Bolus's problem. It's the Basal. So getting that Basal set is huge. It's like the foundation of a house
Scott Bennerand the opposite as well to not instead of the Bolus's problem. You can't you can't give the Bolus credit. Sometimes Sometimes you have a lower stable blood sugar that you think you made this scrape Bolus off Bolus but but your Levemir or your Lantus you have too much of it or it's just it's working stronger at that point or something like that. So when you switch to a pump, and you go to these more precise Basal rates, using a fast acting insulin in the background And then if you don't have that correct at that number, you don't you no longer have that sort of like, I don't know what to call it like when you inject Basal insulin, it's just sort of a is it a catch all? Is it a is it it's a blanket of insulin that you may or may not?
Jennifer Smith, CDEYeah, good way to think about it. It's kind of a blanket of insulin. But it's not a blanket that's always warm and cozy at the right places through the course of the day. I mean, I My example is, before I started pumping, I was using Lantus was my Basal insulin, and I took it in the evening, if I did not have a snack, when I went to bed after taking it, I could have bet a million dollars that I didn't have that I would have a low blood sugar between two and 3am.
Scott BennerAnd that's because your new Basal insulin starts coming online, and it works.
Jennifer Smith, CDEAnd it worked the way that it did, I needed less insulin at that time, but Lantus didn't know that Lantus was like, Hey, you put me in here, I'm gonna get this, I'm gonna do my thing that I was supposed to be doing right. So I needed at that dose for the rest of the day. But I didn't need that dose for that action time of the morning. So that's
Scott Bennerour first kind of lesson here. With pumping when you get an insulin pump, your Basal rates need to be dialed in. And there's two things about that. The first thing is, and this of course, is not true for everybody. But I do meet a lot of people whose doctors under whelmed them with Basal insulin, when they put them on a pump i because they don't want to cause a low, they don't necessarily tell you that going out of the office or you don't expect it. And so you get hot, you get home, you're high all the time. And it doesn't ever occur to people that it's basal. So get on a pump, get the basal right, I think the next thing is done
Jennifer Smith, CDEone comment about that as adjustment factor. And you mentioned it before insulin means may change going on a pump, we usually find give or take, we usually find that when you start on a pump, your Basal injected insulin dose in the pump will need to be about 10, sometimes 20% less than what you were injecting in your Basal dose. So let's say your Basal insulin is giving you 20 units a day via Lantus or Levemir, to you know, to jail or whatever it might be 10% less than that is two units less, okay, so we would actually dose your basal in the pump on 18 units across that 24 hours versus 20 units. Because it's it seems to be that the body responds better to that one type of insulin or rapid and coming in at one precise point in the body all the time, rather than being injected like all over.
Scott BennerSo then it can really be either then you can you can get your pump set up with Basal insulin and find yourself high all the time and realize your Basal is not enough or, or too low or where you have to come in. So that is why doctors start that way. Because I guess more over the likelihood is you'll need less. But for the people who that's not true for it's the situation I described. Right? So what we're really saying is, you're not going to know until you know, but but figure it out, get it in there and figure it out. I also want to know what you think about multiple Basal rates in the beginning, because in my mind, I think you set one up, and then you start adjusting off of that one. Right?
Jennifer Smith, CDEAgreed? Absolutely. Even when I started pumping, you know, as an adult, once there were finally pumps, like I'm ePad. So it wasn't about tubing. I wanted that pod. But when I started doing that, you know, I actually did I started on one solid Basal rate. And I was already an educator. So I knew about pumps, I just, you know. But yeah, you have to test you have to evaluate and see what does that one solid basal? Where do I need it to be less? Where do I need it to be more right for how long?
Adjusting Basal Rates and Ratios
Scott BennerYep, I think we're going to talk about the adjustments in our own little piece of this. So okay, so let's, we'll move on now to to the idea of bolusing. So I want everyone to understand that, that doctor, your doctor is going your pump trainer, whoever you talk to is going to do their best based off of what they know about you to set up an insulin to carb ratio in the pump. But it is incredibly important to know that that is a number that is not completely made up. But it is a guess on some level. And so if you're putting insulin in for a Bolus, and you just you say to yourself, Man, I counted these carbs 100% correctly, and it's telling me three units. But I used to eat this food on injections and I had to inject four units or two units or it was different in some way. I just think it's incredibly important to remember that your doctor just did the best they could putting that in there. And this becomes where sort of the next step of how people We'll get confused starting pumping, because things don't go the way they expect. And they never diagnose the idea that it's the it's the insulin. And I mean, this series is obviously, it's all about timing and amount, right? You're using the right amount at the right time. Their minds. I think Siri just heard me say something. Sorry, Siri wasn't for you. But it says, Hey, Siri, have it's obviously it's all about timing. Shut up, Siri. Oh, wait, sorry. My point is, is that you're our brains somehow focus on the idea of the pump, specifically and not and we forget about the insulin. So I got on a pump and something didn't go the way I wanted. There's something wrong with the pump. That's the LEAP you make. It's the it's, it's very likely the insulin. So you can't jump over the obvious answers to get to the other ones, then then we run into the problem that people don't want to make insulin adjustments in their pumps in the beginning. So for all of you listening, who are about to start pumping, or are new to pumping, and you're seeing something in your heart, you know, isn't right. I would implore you not to sit around for three months waiting for your next endo appointment. Right? Okay. So if you're not, if your blood sugar's high, you probably have not enough insulin, it's possible that you know, you haven't timed it, right. But there's safe ways to make small adjustments to your insulin on your own. Right. And so and so. Would you talk to me about how you would How would you if someone called you and said, Hey, I don't know what to do. And you you looked at their graph and said, I think your Basal insulin needs to be turned up or turned down? What percentage do you tell them to move at it depends
Jennifer Smith, CDEon what the overall picture looks like you know if there are small if there are small, less aggressive looking changes to their blood sugar's but it's in a Basal only time period and you can tell that obviously something is wrong. We recommend making an adjustment If there's more than a 25 to 30 point shift up or down from a set blood sugar, so let's say if you're testing the overnight, you go to bed at this rock solid, you know, 102 blood sugar, but by you know, and that's 9pm. But by 1am, your blood sugar's at 201. That shouldn't happen on Basal insulin, that's there's something incorrect there. So, you know, with a shift like that, we would bump basal probably by like a point one in that time period to offset the incoming flux of or incoming need for extra insulin. Usually, if it's a smaller incremental change to blood sugar, you know, you're going from a blood sugar of 102 to 152, you probably don't need that much of a change. And so maybe more of like the point 05 In a rate, smaller increments to the point zero to five, which most of the pumps on the market can do, not all of them, but some of them. So that may be something that you play with, especially if you feel like you're pretty sensitive to small changes in dosing, then you may want to start smaller and make an adjustment up or down,
Scott Bennerright. And so again, it's a good place to point out that the numbers not important, because we can't tell from one person to another. And I'll give you an amazing anecdote about that I was with a group of people this past weekend, there was a college age kid there who in my best guess was 610, and must have weighed 230 pounds. And his Basal rate was lower than my daughter's who is five, six and weighs 125 pounds, my daughter is also growing, and you know, gets a period and things like that. So you can't, you can't reach out into the public into back to your doctrine. So just tell me how much to turn it off. You know, like, you have to pick an increment. That's not, that's not crazy, it's not dangerous. Obviously, you're not going to take 8.5 Basal and make it a one. You know, you're right, you'll try point six, you know, like, if you're, if you're a little high, try point six. And then if you do it for a few hours, and nothing's going on. I mean, try point seven like and you know, we might get to a point where you Oh, now I'm a little too low. And then again, I'll dial it back point six, five and, and make that decision on your own like, think it
Jennifer Smith, CDEcertainly communicate with your provider, if you want some assistance, saying, hey, you know, even calling your endo office, most often you get connected with a nurse, the nurse is then going to relay your message to the Endo, you might get a call back, hopefully 24 hours, maybe 48. Or, you know, whatever it might be, but at least you're acknowledging, hey, I'm seeing this issue. I'm making my adjustment because I'm the one living with diabetes 24/7. I'm just I'm telling you, so that if you've got any additional feedback,
Scott Bennergreat, I'd love to hear it. Yeah. But you can't. You definitely can't do what happens to some people where you just freeze because I want you to really consider what we've been talking about what you've been listening to going back to your doctor four times a year, and saying, Hey, look at 90 days worth of my blood sugar's and adjust this and make it correct. It's just they're not guessing. But they're just doing their best and their best is limited because they're not with you. And so I know your that it's probably happened to you before you sit and you stare at these blood sugars. And you think, well, this isn't what I was told. But just remember, you're getting this machine and it needs to be dialed in. You just you have to get it right, you got to get it running, right so that you can start enjoying the benefits which are significant. Once you get it going. And I will say that I was one of those people who got a pump for my daughter when she was four years old. Oh my god, over 10 years ago. Wow. Yeah. And, and I slapped it on her. And then I stepped back and I looked at her blood sugar and I looked at her A1C and I'm like, okay, just start going down. You know, like here comes Everybody get back this this this Oh, my gosh, back then this 8.9 A1C it's going to be magically lower. Well, it did go down a little bit. But not a lot. It only went down a little bit because I guess I was able to bumper insulin a little more. That's where we started right? Well, I guess a little more because back then if you missed on a Bolus, doing it again meant injecting again, and no one never wanted to do that. So you just waited and hoped and crossed your fingers right? But now I could give a little more in a little more but in honesty, just adding an insulin pump without understanding it did not bring Arden's A1C down that that far.
Jennifer Smith, CDEI think it's kind of like I mean, the adjustment is kind of like getting wheels aligned on a car. Right? I mean, if you have if you want to ride this straight line, you have to do these incremental adjustments so that you're not consistently like veering off the road.
Scott BennerYou got to rotate your tires. You need to get your your ball bearings all straightened down everything that was just the extent of my knowledge of cars. That's what You've heard but you want, you know the engine, I joke a little bit I understand. So people who really understand cars, there's tau in Canberra, there's these, these tiny adjustments that get made to your front wheels that keep your car moving straight. And it's the same situation. Those again, just like bumping and nudging blood sugars, these are tiny adjustments to get you where you want to be. And the difference between being 190 all day long and 90 all day long, could just be point one, a half a unit of a change, depending on your size and your weight, your needs, the tiniest amount. And just imagine that, you know, we talked about it all the time, if you if you don't have enough Basal insulin going when you Bolus, a lot of your Bolus is just replacing the Basal you don't have. And so
Jennifer Smith, CDEthat's why Bolus isn't there. You're wondering, well, why I didn't even eat at this point today. And what's happening here?
Bolusing Strategies: Extended and Square Wave
Scott BennerWhy is this happening now? And so so you need to get these things straightened out. Now. I guess moving on to the idea of bolusing. Yeah, before when you had your shots, you were counting your carbs, doing your thing sticking in your pan or your needle and pushing it in there and just hoping you know, hoping for the best right? You are now opening yourself up to an entire world of Pre-Bolus saying and and doing it with different and what Pre-Bolus Pre-Bolus boluses all the things you're pumped, you know, well, first of all, Pre-Bolus is not a setting. It's just the idea of putting in your insulin and giving it a head start over the food that you're about to eat right. But an extended Bolus. So we're talking right now it's 11am. And 40 minutes ago, Arden texted me and said lunch is soonish I want you to really hear that. She didn't say she didn't say in 10 minutes. Right? She didn't say 20 minutes from now she said soonish and I know based off of how this year is going at school, we're going to Pre-Bolus here. And I thought about what was in her meal. There's not anything incredibly like simple sugary, that's going to spike her right away and she was 106 when we did this. So she'd been a little resistant towards the end of her period this week. We did a Temp Basal increase of 40% for an hour and a half. And so that takes Arden's Basal rate from 1.4 to whatever 40% More of that is for an hour and a half. And then I did a 11 and a half unit Bolus. We did 20% of it upfront and the balance over an hour. So 20, whatever 20% of 11 and a half and 11 and a half units is goes in when she pushes the button. The balance of that goes in incrementally over the next 60 minutes coming online and getting active along the way. And now it's 40 minutes later and Arden's blood sugar is stable and 90. And she probably started eating 20 minutes ago or so. I'm expecting the food to begin to impact her right now. Right right. And so we got we got momentum on our side for the insulin, we've got her going down. You know we've got that tug of war set up we've we've given you know, we've we're letting the insulin cheat. And we're going well, now, I'll tell you right now, if 20 minutes from now she starts curling back up. I might you know if there's any time if there's any extended Bolus left, I might cancel it and put it all in at once. If the extended Bolus is over, I'm gonna go I might have missed a little bit. There's all kinds of different adjustments you can make to change the timing and the amount of the insulin. I want you though to talk about first about extended boluses and I want you to talk about it the way I know I can't which is technically in smart play.
Jennifer Smith, CDEI think you give very good description. I think the biggest thing to understand to begin with when with an extended Bolus is that all pumps can do them. They all term them or call them something a little bit different. And it really just kind of boils down to how you're telling the pump to give this this dose for a meal whether you want it all up front, meaning like you'd give an injection you get this whole normal amount of insulin deposited under the skin all at one time. That's normal and extended allows your pump to drip drip, drip drip almost like your basal is dripping all day but in an The time period you've defined whether it's 30 minutes an hour or three hours, you told the pump I want to deliver 11 units over the course of some now, and some in an hour time period. That's what we kind of refer to as a dual wave Bolus. Being you get some normal upfront, meaning a bump right now like an injection, and then the rest of the the meal like you said, 2080, right. 20% Now is the normal 80% over an hour. So your pump is now saying, Okay, I'm going to drip drip, drip drip drip this 80% in and by the end of an hour, that whole extra 80% will have been dripped in. But it's action time then is pushed out, because you didn't deliver it all right now that last pulse of insulin at end of our one still has now an active insulin time for whatever you have set in your pump, three hours, four hours, five hours out from that last active pulse. So I think that's the important thing to know about extended boluses some people first start to think of them as Okay, well, I'm going to get some insulin, but then three hours from now it's gonna give me the rest of my insulin. That's not how extends work. They always give some and extend some drip drip. Or you might want to say, for this meal, I'm eating a big ol plate of broccoli and a chicken breast. There's carb in that broccoli that you do have to count and cover. Is that broccoli going to hit you like white rice? No way. It certainly isn't. So a meal like that. You may say okay with these really low glycemic carbs. I'm going to extend the full Bolus, something we call a square Bolus, you take that meal that suggested as a Bolus, and you drip drip, drip the whole amount of it out over your designated time period. And there are different reasons for all of those.
Scott BennerYes, and you got to figure them out. And you can I was with a person eating low carb this past weekend, I Vicki and we sat down at a restaurant, she had a meal that you would expect had almost no carbs in it, but a ton of protein. She sat she ate it, she sat and ate it. We got in the car drove away. It's now 20 minutes or more past when the food was and she grabbed her PDM from around the pot and gave herself insulin. Because she does know she needs insulin for that protein. And but she didn't need it. If she would have Bolus and sat down or Pre-Bolus sat down, she would have gotten incredibly low. Yeah. And she it was amazing to see somebody figure that out. I was and I'm going to add what I learned about that to me like how the protein needs more later.
Jennifer Smith, CDEAbsolutely. It takes into the fact that we know these things from a set of rules. But I mean, the classic your diabetes may vary. Your diabetes bolusing strategy will vary. Well, yeah, not not me. It will vary. I mean, I my breakfast every morning, I've got a friend who eats the same exact breakfast after talking to me, she was like, Wow, that sounds awesome. I like it. I want to give it a try blah, blah, into them. Now she loves it her Bolus strategy for it. similar, but not 100% of what I do. It's different because physiologically, she's different. Yeah.
Scott BennerAnd so if you've ever heard me speak live somewhere. There'll be a moment where someone in the audience asks the, you know, the question, how much how long, you know, and I go, I don't know, figure it out. You know, I
Jennifer Smith, CDEI think places there are some starting Oh, sure. Things. Yeah. It's like kind of like, you know, the How much do you adjust the basal up? Oh, point point. O 5.1. It's a starting place, right? Sure. Give it a try. If it doesn't work. Okay. Next time you adjust different,
Scott Bennerright. And I'm more aggressive. Like when I adjust Basal rates, I adjust them like 30% of the time, because I'd rather cause a low and then back down from the low to find a level spot than to stay high for several days, I didn't nickel and dime the high, right? Because also because I feel like you're getting a more accurate depiction of what's happening. If you're using more insulin, when you're using less insulin than there could be resistance going on and maybe, you know, maybe in
Jennifer Smith, CDEthe field too, then that you have to correct and so you never really get a true picture of what does the Basal adjustment really just do because now I'm high and I want to correct and I'm not going to leave it High. So I don't understand what the Basal I know. I just know it's not enough,
Scott Benneryou'll get a look into my parenting style that way too. Whenever my children asked me something, I respond immediately with no, and then we work backwards from no. And so I sort of do the same thing with the insulin I slammed the insulin, and then I work backwards from there to find a level spot.
Insulin Action Time and Insulin On Board (IOB)
Scott BennerI wanted to say about insulin action time. It's another idea of settings in your pump, right? So there's an amount of time that they, you know, insulin should work in your body, like how long from when you put it in to when it stops working. And you'll see people say all different kinds of numbers, you know, four hours, you know, it's different for me here and there. Same insulin, you know, they're using one kind of insulin. Some people say, Well, my action time is four hours by x times three hours. Arden uses Apidra, and her insulin action time in her pump is set at two hours. And so I have found that when you Bolus Arden that Bolus stops having any effect on her in by two hours. Wow. Most of the time. Some of the time now, I don't know how to tell you the difference. But most of the time, it's Yes. Last night it was now last night I couldn't get Arden's blood sugar to budge off of 180, it didn't matter what I did, she had an incredibly carb terrific afternoon. Like I said, she still has her period. And you know she's going along. Now there's a moment where I'm like pushing and pushing and pushing. And I'm finally that guy. This is enough, like this insulin is going to start working eventually. And it did later at night after a hot shower. Her blood sugar started coming down and we had to catch it and it was hours and hours later. That doesn't make Arden's insulin action time six hours. Right? That's a specific situation. Most times insulin I put in now doesn't cause her to get low two hours later. Now keep in mind, insulin on board is calculated by the insulin action time set up in your pump. Am I right about that? Correct. Can you explain that for us, please? Yes.
Jennifer Smith, CDESo insulin on board specifically uses your active insulin time that you have set in your pump. So for Arden, two hours, if she were to get a Bolus now for you know, at 11:07am. Two hours from now at 1:07pm, the pump would no longer identify active insulin on board from this Bolus, which means that if she chose to Bolus at 1:15, it's only going to factor in blood sugar and the carbs she tells it she's eating to give a Bolus suggestion. However, with in active insulin time, let's say, you know an hour from now somebody's birthday comes up and they bring a big old treat to school and she's like, Hey, Dad, I'm totally,
Scott BennerI'm going to eat another 30 I'm gonna eat another 30 carbs over top of what we just Bolus for an hour ago.
Jennifer Smith, CDEExactly. But that was an hour ago. So your pump still assumes, hey, there's still insulin on board from this Bolus that she gave an hour ago, there's this much active insulin left. Important thing about IOB is that you have to feed the pump information in order for it to consider IOB information being blood sugar, and carbs. If carbs are a piece in the picture here, right? Because if you do not feed the pump, a blood sugar, it doesn't know the effect of the insulin on board that's still left. And to calculate the next Bolus correctly, it sees the insulin on board, but it may not be able to adjust because it doesn't have a pinpoint of glucose value to now say, okay, she was an hour ago at 82. Now she's at 179. That insulin on board that's left is coming into the picture but the pump also sees a higher blood sugar. So it's going to say, okay, she's high. She wants to eat this much more. This is how I'm going to calculate the Bolus despite there being active insulin left
Scott Bennerbut in a situation where like for instance, now Arden's blood sugar's 111. Okay. And I'm seeing a curve up on her CGM, but her pump right now if you test it right now say she didn't have a CGM she tested right now for that, you know, surprise treat an hour later. And and it says, Oh, your blood sugar's 111. You have all this insulin on board from the meal, go ahead and eat that you don't need insulin for this or you don't need you don't need as much insulin for that. That would be stacking. Now that would be okay. And that's a word that doctors are going to throw at you. And they're going to mean for it to scare you. And maybe maybe it should in the beginning. I'm not 100% Sure, but what they're going to tell you, you can't stack insulin because eventually it's going to it's going to catch up to you and it's going to make you low. I say to that. Yes. If you don't need the insulin, if you do need the insulin, it's not stacking it's bolusing. Knowing the difference is the is the trick, I guess it is to go back to I'm going to layman's terms a little bit more about insulin on board and action time if I can. So if you decide that your insulin action time is three hours and by you I mean the doctor sits down says that's is what it is for most of my kids this age, so I'm going to set it for three hours for you. But your insulin action time is actually less or more, then your pump is going to make decisions based off of that number. It doesn't make it right, I want to be clear to everybody, the pump doesn't have a magic sensor that's in you somewhere that knows that it's telling you the right thing it's making, it's making a static decision from a static number. That's not necessarily correct, it's probably a good guess, it probably won't hurt, you know, it's going to err you on the side of caution a lot. It's going to keep you from being, you know, from getting low.
Jennifer Smith, CDEAnd I think that's a good, that's a it's a very good point to bring up. Because what we've actually found, especially in the community of people who are doing the do it yourself looping types of pumps, which is a whole nother broad topic, but I bring it up in this mainly because what we've found is that the action time of rapid acting insulin is actually beyond what most people have it set in their insulin pump. And the reason that we have it set for less time and an insulin pump, is because we inherently do not want to run high blood sugars. And so if we give the pump an active insulin time of three hours, when really that Bolus is probably lasting about four hours for us. What it means is that at three hours, and one minute after this Bolus was delivered, if your blood sugar is still high, your pump now no longer sees any active insulin and it can Bolus you more aggressively for the blood sugar that you now want to drive down. Right. Whereas if you had it set for four hours, at three hours in one minute, you were like I'm high, I want to Bolus to get this blood sugar down. Your pump's going to be like, oh, let's be a little conservative here. Because you still have this like quarter of that last Bolus still working.
Choosing the Right Pump for Your Lifestyle
Scott BennerIf you have an Omnipod, your pump is going to be completely self contained, it will adhere to your body, the insulin will be in there and all the smarts and everything and you'll use a wireless controller to tell it hey, I want you to change my Basal or put in a Bolus or something like that. All other pumps have tubing and an infusion set, right. So you'll have an infusion set that will put your cannula in tubing will run to the pump, and that pump will have its insulin in it, you'll need to keep that with you. It'll be clipped to somewhere, right. And that's
Jennifer Smith, CDEa good point to make to about the difference Omnipod, the PDM does not have to be on your person for the pod to continue delivering. That's a big question that a lot of people have, well, I don't want to carry around this extra thing all the time. You don't have to once the pod has been told what to do. It does it as soon
Scott Benneras it beeps and it recognizes the signal you're done. Actually you can walk away from if your insulin starts in like say you're putting in 10 units delivering right. As soon as it starts delivering, you could you could run to you could run across the state and your PDM be in your house and the insulin will keep delivering Yes. It's also important to talk about there about pumping in general is that to bathe or swim on a tube pump, you're going to have to disconnect to most of them for most right. So even in more aggressive like sports, for instance, like give, there's a lot of people who disconnect to go play soccer or football or something like that. With Omnipod you'll always be wearing it. I think to me, that's a huge point that made me want to do it. Because you always hear people say like, oh, I went to the beach and I got high. I get high at the beach. And I always think back to someone who was on the show. I think it was just a few episodes ago, where he said if you put a pencil in your back pocket, and then rob a bank pencils don't cause bank robbery. And, and so the beach doesn't make your blood sugar high, taking your insulin pump off made your blood sugar high. Right, right, like that kind of an idea. So just understand that there's different ways to manage with different pumps. I'm not telling you which pump to get.
Jennifer Smith, CDEAnd that's a lifestyle look, right. And that's the biggest thing when I work with people. They're always like, what what do you think is the best? There isn't a best, there's the best for me. Yep, there's the best for you. You need to take a look at you know the pros and the cons of all of the pumps. What are the what's the pump that has the most pros for your life 100% navigate your lifestyle your needs, you know an athlete, I've got a lot of athletes who really prefer Omnipod because of the tubeless piece I've worked with a lot of triathletes who really they need I mean from going from a swim into a bike into a run. They need something that's a seamless management then they're not having to clip in and pop in and reload and you know everything. So there. I think it takes a lot of examination of your lifestyle. Yeah,
Scott Bennerno, absolutely. There's no I would I would jokingly say that you know you I'm sure you think that I think you should get an Omnipod. And probably if you ask me my personal opinion, I would say yes, right? Not just because they advertise on the show, but because Arden's just worn it for 11 years. And it has been nothing but absolutely fantastic for us. But I completely agree with Jenny, you should decide what works best for you. You really have to do that. Not everyone's going to see the same pros and cons as everyone else.
Jennifer Smith, CDEAnd all of the pumps despite delivery, and mechanism of driving insulin, they all do have some features that are different and may apply better to your lifestyle, then another brand.
Scott BennerAbsolutely. So. So again, figure it out for yourself, do your due diligence, do your homework. Yeah, I think the greatest thing about the Omnipod might be is that they offer a demo, they'll send you one to your house and let you try it like that's where it and the other companies are at a loss, they can't really do that. Because of the way there's a setup
Jennifer Smith, CDEvery big and expensive. Let me just send you this. I'll send it back to
Scott Benneryou. Please, please give it back. And a couple of other ideas. And he's right, so what I was getting to whether you're using an Omnipod, or you're using another one, there's going to be some adhesive of some sort, you know, a simple preparation, like we talked about back in the MDI episode. I think I don't over prep Arden's skin bright, clean skin.
Jennifer Smith, CDEDry without lotion or anything on it, you're good.
Scott BennerPut it on, you could see. You know, if you have soreness with a pump, right, it shouldn't hurt. No, right? So it should not. So be careful. Like if you start if you have soreness that you know, I mean, after it first goes on, obviously, you know, it's not fun to have a hole poked in you. And that's going to be done by any one of these pumps. But an hour later, whatever it is, if it's hurt, so it's hard to bend your arm. Sometimes the cannula can hit a nerve, or muscle like looking up again. All of these companies will if you call them up and say, Look, I had to put in an infusion set and it hurts so bad. I took it out. Can you send me another one? Generally speaking, they're their customer service is good, they will
Jennifer Smith, CDEcorrect and that's it's really important because it can affect absorption at the site. If you've got a site that isn't it that's hurt, or you know, maybe getting infected or for some reason there's irritation under the site. If that site is bothering you, there, that's not good. Remove it, pop in a new one do something
Scott Benneryeah, don't sit in pain. And that I think that's important. Tubing is something I don't completely understand i How much tubing do I need is it just as much to get me to where I want to store my pump?
Jennifer Smith, CDECorrect. It's it's in that depends you know, tubing comes in many many different lengths for the tube pumps being of which there are only two on the on the market either tandem or Medtronic or the tube pumps that are available now, at least here in the States. So the tubing length depends on exactly where you're going to move that pump to and pop it in. If it's in a pocket, you may need short tubing 18 inches. If you're going some some of the guys I work with, you know where the shirt stays around their lower leg to keep their shirts tucked in, well they end up just clipping their pump down their leg and then they can easily lift up their pant leg to Bolus during the day. So if that's the case, you probably want 40 plus inches Oh tubing to kind of reading how tall you are. Right You know, if you're Shaq, you probably need like inches but yes
Scott Bennerand and the two pumps also when you go to put them on they have to be primed, which means that you have to fill all of that tubing with insulin right before you can put it on the Omnipod self Primes so you when you know tubing, and there's no tubing. There's a tiny little cannula that that obviously goes under your skin and stays there. Yep. So, again, there you go. There's pros and cons with all of them. You know, I hear people say that. So Omnipod has a failsafe, right? If it gets around too much electrostatic electricity, and it and it affects the internals of it, it will shut down and ask you to right to change it. Yep. I've had it happen in 11 years, six or seven times, you know, it's happened. And people go well, that doesn't happen with a tube pump and I'll say Well, yeah, and my daughter has also never walked past a drawer in the kitchen and gotten her tubing caught on it and yanked out her infusion set right that's the tube pump version of that to me like they all have something if you're looking for something right if you're looking for perfection. Don't Don't ask a machine to do anything.
Jennifer Smith, CDEabsolutely and I think you know one even that might be going towards the tube pump potential need would be if for some reason, the angle of the cannula is a concern or an issue for you. That is one I would say potential drawback of Omnipod is that there is only one cannula When it comes on every pod, it's exactly the same cannula. And it goes in exactly the same angle for every single person, which may not again, your diabetes will vary because your body physiology may be very different. So you may need to choose a pump. Despite not wanting tubing you may need to choose a pump. That's tube because you need a different type of cannula or what's called infusion set. You may need something to go in at a 90 degree angle versus an angled, you know, you may need a steel cannula versus a plastic cannula for various body reasons. So there are a lot of considerations.
Scott BennerAbsolutely. But don't take, don't keep this in mind, no matter what pump you're thinking about. I know this is gonna sound a little dirty, but it's it ends up being true. Companies have salespeople, salespeople influence doctors, doctors get stuck prescribing things, the same pump right over and over, you walk into an office and say I want an Omnipod and the guy goes, no, no, you want one of these? Trust me. You don't need to trust him. You know, you can say that you appreciate your input. But I'd really like to try the Omnipod or vice versa. I don't want an Omnipod. I really would like to try that. Eastland you can you can you can speak up for yourself, please, please do that. Absolutely do that.
Managing Pump Site Changes and Inflammation
Scott BennerSo at the very end of this I want to talk about about something that can't, it doesn't happen with injections that could happen with a pump, right. So as long as you inject your insulin with your injections, you remember to put in your Lantus your Levemir your Tresiba, whatever it is. And you you know, remember to put in your insulin for your food or your high blood sugars. You're watching the needle go in your arm, you're pushing the button, you pull it away, you know the insulin is in there. With any insulin pump, the possibility could exist that your cannula could get bent, that your tubing could get kinked that the pump could I don't know, the batteries could die like like, you know, Omnipod doesn't have batteries. And there's the but the other ones, there's mechanical,
Jennifer Smith, CDEleave the house and totally forget that your reservoir only had five units and for the rest of the day, you actually needed 20 units. And now you have no insulin you're
Scott Bennerand you're in trouble. Right? Right. So these are things that can happen when you try i We have a radius in my mind if I'm more than 30 minutes away from my house for any extended period of time. I bring insulin and another pump with us. The other day, we drove an hour and a half to something stayed there all day had all this extra diabetes supplies with us didn't need one of them. You know, most of the time you don't need it. But when it happens, it happens. Now, in 11 years, I'm happy to tell this story in 11 years, we've had one insulin delivery problem with Omnipod. And it wasn't the pump it was us. We changed a pump by sight. And it you know it was at a pool. Right so we put it on and I she got back in the water and I think the adhesive didn't have time to adhere and it loosened up a little bit and it pulled her cannula out through the course of a day right along July day of swimming. We got home her blood sugar was still fine now, was it still fine because the cannula was still in it hadn't worked its way out yet because she was so active during the day. She didn't need as much as I don't know. But what I can tell you is, is that overnight Arden's blood sugar started to skyrocket. And I kept bolusing. And it took me a while to figure out that my boluses weren't doing anything. That's not going to happen to you injecting, right and so is it is it I actually saw a person say the other day, I'm scared to get a pump because of that. And I think if that's why you're scared, I think you're worrying about things you don't need to worry about. But you do need to be aware of them. Correct, right? Your tube, tube kinks, something happens, you're not getting insulin delivery, you're also don't have any slow acting insulin. And so when you lose your pump, you lose your slow and your fast acting, you can go from everything's right on to DKA. Pretty fast, quick.
Jennifer Smith, CDEExactly. Absolutely. And that's, it's a really good piece, you know, to discuss because it's one of the primary things when I work with starting somebody on a pump that we discuss, right in the pump training is the risk for DKA or the risk for a pump malfunction and how do you how do you navigate that without having such tremendously high blood sugars that then take forever to bring down because you're at such a deficit of insulin right? I mean, our our recommendations really are with a pump, an odd high blood sugar or now with the use of a CGM blood sugars that are like you said, just all of a sudden skyrocketing and there should be no reason for that skyrocket like you didn't go eat the whole Dairy Queen cake and just not Bolus for it right. There is something wrong you Bolus from the pump. If that initial Bolus doesn't start make a dent in that glucose within the next 30 to 60 minutes, you change everything out, you change the site, the tubing, the reservoir, the pod, whatever, you might even change the insulin, you know, especially if it's been a day at the beach and your insulin hasn't been kept change the insulin out really important
Scott BennerI bail on in a pump site. As soon as, as soon as I know too, I will sometimes if I if I get stuck number, but it's not too high. Sometimes I'll inject a little bit. And if you inject instead you go, Oh my God, it started moving right away, maybe I'm gonna get off this pump site like a little sooner. And that's, you know, to just go over a couple of like ideas, you can't keep reusing the same site over and over again, they eventually become less effective. For reasons we talked about in other episodes, you have to understand that when you when you put in an insulin pump, you've you've a needle has poked a hole in you and left behind a piece of plastic in most cases, right. This plastic is a foreign body. It's an irritant, right, it's an irritant. I remember discussing with Aaron Kowalski from the JDRF, one time that he thinks one of the most ignored technologies for people with diabetes that we don't spend enough r&d time on is cannula, materials, and how to make them less irritating to the body. Because when your body thinks it's injured, it sends white blood cells to the place it believes there's an injury. And I don't know anything technical, but in my mind's eye, in my mind's eye that draws cartoons of what I think the world looks like, and how I understand things. There's little white blood cells, sort of like the beginning of Jurassic Park, when they show that cartoon to explain that I know DNA, in my in my mind, I see little white blood cells coming and attaching themselves around that cannula and making my insulin not flow correctly. I know none of that's probably technically correct. But I do know that when when a place gets irritated like that, that insulin becomes less effective. And there are times you have to bail on a site sooner than you want to.
Jennifer Smith, CDEThere could be and it's also a good just around site change itself to be very aware that the potential for that new site to be less absorptive, from really what you're talking about, there is inflammation. Anytime you introduce something underneath the skin, you ask your body to become irritated. And inflammation is what follows. So absorption at that site is significantly decreased. Everybody's a little bit different. Some people it's for about an hour, some people it could last as long as four or six hours, that inflammatory response. It's also I guess, for those who are using a continuous glucose monitor, you know that two hours sink in window? Yeah, it's a big reason for that two hour sink in window, besides that sensor needing to get wet. You've put something to sit underneath your skin, your body's got to get used to that and you don't want glucose values coming in from a site that's probably injured. Right? So same with a pump, you really have to pay attention. What do your site changes look like? How does your glucose level change around site change times? And is this normal? Is this a normal flux in glucose? Or is my gosh, my blood sugar's never 300 after I change a site, right, therein lies the difference of change it out or figure out how to navigate the site change, so you don't have a high blood sugar.
Scott BennerAnd I think it's incredibly important to know that while this may sound scary, that you'll figure it out very quickly. It's not something that's going to dog you for your entire existence. There's little is the word peccadilloes, there's small things about everything that you have to you have to figure out along the way. And the only way just like we talked about with insulin, the only way to figure it out is to do it. Let it go the way you didn't expect, you know, suss out what happened and fix it next time.
Jennifer Smith, CDEBut I think just the fact in you know, this episode, especially talking about these little pieces, it's really, really important because these are pieces that are often not talked about from an endo education standpoint. They're not they're missed. They're things that you've figured out along the way. And you've talked to other people, and you're like, Ah, I'm not the crazy, man. This is what's happening. Right? Me, me, too. I mean, I, I could have sat and asked my endo about it. But there are things that in interjecting and working with other people and my own self experience. I'm like, I'm not crazy. This is what happens. And I'm not the only one great
Scott Bennerexample, that when Arden was younger, and we changed her pump, she'd get high. And people say oh, that's a thing. That's a pod chain tide only happens with Omnipod and blah, blah, blah. And I'm like, you have to Bolus boring with Bolus with the old pod before you change the new pod because the new pod won't work and everything. None of that was the truth. You want to know the truth. Arden was incredibly nervous. To get her insulin pump changed when she was little, and the adrenaline would hit her and shoot her blood sugar up. And one day, Arden stopped being nervous about having her insulin pump changed. And that all stopped. There was no magic. So people had had imagined this entire story around this. And I started buying into it. At first I was like, oh, obviously, the pump doesn't work right away. And, and all this. And by the way, it doesn't it that's not an unnecessarily incorrect statement. There. Like you just said new inflammation. There's an injury, you do sometimes need more insulin upfront, and I don't disagree with that. But the LEAP she got wasn't the pump change. It was it was adrenaline. And I still, like we talked about earlier, a new pump. As soon as I put on a new pump, I double the Basal for an hour, like right, just to get it going. But But I started thinking down the it's again, this cause and effect, it's the pencil in your pocket, right? Like, I changed the pump and her blood sugar went up, obviously, the pumps not delivering insulin anymore. Make sense? didn't end up being correct. Right? Right. So just you'll figure it out.
Jennifer Smith, CDEAnd my experience was coming from a tube pump to Omnipod. So I had experience with site change from a tube standpoint on to Omnipod. And I'm glad that I had that because I do experience that site change inflammation. And I had experienced it on a tube pump with the cannula. And so I knew it was likely going to still happen on Omnipod. Yep. So, you know, again, your experience is
Conclusion
Scott Bennergonna be different from somebody else's. It's 100% Right? Ah, good. Oh, did we didn't miss anything? Do we do okay? I think I like what you said at the end. I appreciate it because I wanted this to be a real world conversation, not some like shiny. Oh, you'll get a pump and you'll love it and it's gonna and by the way, you will love it. It's in where you won't. I don't know who you are. You know, I can tell you it's been an amazing experience for us. I believe wholeheartedly that the Omnipod is one half of the reason that we are able to keep Arden's A1C where it is
Jennifer Smith, CDEwhere it is. Absolutely. population of people that come off of a pump is small. But there are people who I've got a good friend who pumped for years and was like, Man, she had a major issue with her pump and she was like, No, I'm, I want to make sure I know I'm getting my insulin. She's been on MDI she's gone through pregnancies with bolusing via MDI. It works for her. But again, that's her choice. And most people will stay on their pump.
Scott BennerListen, here's the here's the key, be happy, be healthy. That's all I care about doesn't matter to me what you do, just no differently than the way I talked about using insulin. I talk about pumps and glucose monitors the exact same way. I want you to know how it works. I want you to know what to do when you try it. And once you try it, if you don't want to do it, whatever, man, I don't care. You know, like, I'm not going to tell you what to do. I'm here telling you, you shouldn't make decisions based off of bad information when you have good information, make good decisions, do whatever you want. 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 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 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 insulin so that is active as the carbs become active. Took me already from a decent 6.5 A1C 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.
Jennifer Smith, CDEJenny 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 on 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.
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