#1849 Bolus for Zaydino
Natalia from Hong Kong asks Scott why her 7-year-old son's blood sugar spikes on weekends. They discuss navigating pizza , fat and protein impacts , and Omnipod 5 bolus strategies.
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Key Takeaways
- Simple solutions often work best for skin reactions; a basic, fragrance-free body wash can sometimes resolve adhesive irritation better than complex barrier routines.
- Daily routines and activity levels drastically affect insulin needs; children are typically more active during the school week, which can make less active weekends more challenging to manage.
- High-fat and high-protein meals (like pizza and french fries) slow down digestion and cause delayed blood sugar spikes, requiring more insulin delivered over an extended period.
- When an automated insulin delivery system (like Omnipod 5) suspends basal insulin to prevent a low, it can lead to a background insulin deficit that exacerbates a later post-meal spike.
- Pre-bolusing remains one of the most effective tools for preventing post-meal spikes, even when eating tricky foods or managing changing activity levels.
Resources Mentioned
Introduction and Sponsors
Scott Benner Welcome back, friends, to another episode of the Juice Box podcast.
Natalia Hi, guys. My name is Natalia, and I live in Hong Kong. I have a seven year old boy now who is type one diabetic. He was diagnosed last June.
Scott Benner I created the diabetes variable series because I know that in type one diabetes management, the little things aren't that little, and they really add up. In this series, we'll break down everyday factors like stress, sleep, exercise, and those other variables that impact your day more than you might think. Jenny Smith and I are gonna get straight to the point with practical advice that you can trust. So check out the diabetes variable series in your podcast player or at juiceboxpodcast.com. If you're looking for community around type one diabetes, check out the juice box podcast private Facebook group. Juice box podcast, type one diabetes. But everybody is welcome. Type one, type two, gestational, loved ones, it doesn't matter to me. If you're impacted by diabetes and you're looking for support, comfort, or community, check out Juice Box podcast, type one diabetes on Facebook. Nothing you hear on the Juice Box podcast should be considered advice, medical or otherwise. Always consult a physician before making any changes to your health care plan.
Scott Benner This episode is sponsored by Able Now, tax advantaged savings accounts for eligible individuals with disabilities. If you or your child lives with diabetes, you may qualify for an ABLE account because of ongoing medical needs, and many people in the diabetes community do. With ABLE Now, you can save for future expenses without affecting eligibility for certain disability benefits such as Medicaid. Learn more and check your eligibility at ablenow.com. You spell that ablenow.com.
Scott Benner Today's episode is also sponsored by usmed.com/juicebox. You can get your diabetes supplies from the same place that we do, and I'm talking about Dexcom, Libre, Omnipod, Tandem, and so much more. Usmed.com/juicebox or call (888) 721-1514.
Scott Benner The podcast is also sponsored today by Omnipod. Check out the Omnipod five now with my link, omnipod.com/juicebox. You may be eligible for a free starter kit, a free Omnipod five starter kit at my link. Go check it out. Omnipod.com/juicebox. Terms and conditions apply. Full terms and conditions can be found at omnipod.com/juicebox.
Meet Natalia and Zaydino
Natalia Hi, guys. My name is Natalia, and I live in Hong Kong. I have a seven year old boy now who is type one diabetic. He was diagnosed last June. So I would like to just I have some questions which I would just like to talk about, ask Scott about. Let's see how it goes. So thank you for having me, Scott. Really appreciate it. Yeah.
Scott Benner Well, I appreciate you doing this because I know it can feel exposing to come somewhere and say, I don't know what I'm doing and you know? Because you said right before we started to record, like, I don't even know if I have anything to say at certain points, but I don't think that's the Yeah. The value in this conversation. Also, I'm just gonna reiterate, although I said it at the beginning of every episode, not a doctor, not advice, but I'm happy to try to talk to you about it and see if we can figure something out. So
Natalia Great. Thank you.
Scott Benner No. It's it's a pleasure. I appreciate you allowing it to be recorded so other people could hear. Mhmm. So your son's seven, and he was diagnosed ten months ago. Is that about right?
Natalia Yeah. It's ten months already. Wow. Yeah. It's been ten months. I mean, every day has been like a roller coaster. In the beginning, we were on you call it the MDI, the injections.
Scott Benner Mhmm.
Natalia So he was on it for three months. And after that, we started putting him on the o p five, Omniport five.
Scott Benner Okay.
Natalia So that has been helpful. But, yeah, he has his moments of not wanting it and not liking it. So because his skin started getting too red and too inflamed over time.
Scott Benner Yeah.
Natalia So, I mean, it's been taken care of now. It's doing much better.
Scott Benner You figured out how to prep the site so that it doesn't happen?
Natalia Yeah. So I tried everything, and then we have a good support group also over here, which they keep telling us what to do. But what really worked, I took him to his own pediatric doctor, and she just gave, like to put, like, a very basic, body wash. You know? No fragrance, all that kind of stuff. And, literally, that's someone that overnight literally worked.
Scott Benner Oh. So That's awesome.
Natalia Said to put the skin prep spray and the nasal spray and the all these kind of things and use different patches and the prep and the first and the last. I just left everything.
Scott Benner Yeah. Because you got a good result with the one I right. Why complicate it? Yeah. I would have asked you, do you use alcohol to clean the site?
Natalia So now I use the alcohol once before I put it on.
Scott Benner Mhmm.
Natalia The techs command that, and nothing happens. He's absolutely fine.
Scott Benner Oh, there you go. Sounds like you might have found the answer.
Natalia Yeah.
Scott Benner You wrote to me. Is that right? Yeah. Why don't you go over that email for a second? Just tell me where you're at and where the struggles are.
Weekday vs. Weekend Variables
Natalia Okay. So the thing is that daily routine I'm just because see, he's diabetic. He's growing up, and he's at an age where he wants to do his own things also. Can't blame him. But it's just a scary fact that when we go out, that's the problem where we go for a restaurant. And now he's getting so scared that I have to count everything what he has, and he loves eating. Mhmm. So if he can't eat a pizza, I don't allow him the pasta. I don't allow him the hot dogs. You know? So then it's just like, why don't we stay home and just eat what I can in a bigger quantity? So, you know, that's become a thing. So I was just a little worried. How do I, like, embrace all that? Because his levels would go to, like, a 22. You know?
Scott Benner That's like a 400. Yeah.
Natalia It would, like, hit the roof for hours, and to get him down six to eight hours would go nowhere. You know? So his daily routine, breakfast, lunch, dinners, school snack, coming home snack, everything is fine. But the weekends come in, and it just goes through the roof.
Scott Benner Okay. Well, I'm gonna ask you a few questions first. Yeah. So on the weekends, does he become more sedentary?
Natalia What would that mean?
Scott Benner Well, does he not move around as much on the weekends as he does during the week?
Natalia Relatively. Yeah. Yeah. Yeah. Okay. Yep. He's mostly home. He just likes to relax, do nothing, or we just go out for, like, a walk or to the park. So but nothing much.
Scott Benner But not as much as getting up, running to school, running around at school, all that stuff. Yeah. Okay. Alright. So Yeah. I'm gonna take some notes. Not usually something I do, but okay. So during the week, he's moving more weekend Yep. He's more still. Okay.
Natalia Mhmm.
Scott Benner And does he eat differently on the weekend than he does during the week? Like, you know, during the week, is it simpler?
Natalia So in the morning, his breakfast would include a normal egg or a milk or a bun or a bread because even the cereal spikes him a lot. Oats spike him a lot. Mhmm. So that's been cut down to maybe on the weekends, I give him cereal. But the problem is he's not so active, so the cereal goes even higher on the weekends.
Scott Benner Yeah. So cereal, he's not getting during the week?
Natalia No. He's not getting during the week.
Scott Benner More like you cut out for a brief second. But during the week, like an egg, something like that.
Natalia Yeah. For the egg or a half glass of milk with a bun and butter. So everything is, like, you know I got it. Portioned.
Scott Benner Yeah. So you would call the week more knowable.
Natalia Manageable.
Scott Benner Yeah. Yeah. Well, because you're doing the same thing over and over again too. Yeah. I see. Okay. Is there any chance that on the weekend, you're just not counting the carbs as well as you are during the week, or do you think it's more about the makeup of the food?
Natalia So on the weekend, I can. I'm counting the carbs, but it's like since there is I feel he's very like, you know, if there's activity, he works very well. The levels work very well with him.
Scott Benner Mhmm.
Natalia But when it's not, and he's sitting, he's just watching. So it suddenly just spikes out of the blue. Even if it's the same breakfast. Yep. Even if it's the same one, weekends treat him differently.
Scott Benner Yep. Okay. And on the weekend, what are we eating? I guess, maybe take me through an average day of his meal during the week and an average day during the weekend and do breakfast, lunch, and dinner.
Natalia Okay. So the weekday?
Scott Benner Mhmm.
Natalia He loves eggs. He loves milk and bun or bread and butter. So these come to around 24 carbs because the bread I get is, like, less in carbs and stuff like that. So that's like morning is that, egg, milk, bread
Scott Benner Mhmm.
Natalia In some form, and yogurt, the small baby yogurts which he gets. And then he has a snack, 10:00 in school. That, I try to make it as free carbs because then the nurse has to keep running to him to give him the dose, which I don't want. So it's mostly like a seaweed or cheese or cucumber or something around these things mostly. Then he has lunch. Lunch is his turkey sandwich or a roast beef sandwich or a egg sandwich with just literally a slice of turkey, cheese, butter. Mhmm. That's it. And apple. He loves, like, one apple and one sandwich. Even on the weekends, if he's home, I make the same thing for him at home for lunch. And then he has a snack, which is, like, either crackers or as you also said, the Ritz crackers affects your daughter. It hits her a lot. I was hearing you say that once. Mhmm. So, you know, stuff like that, like, just crackers and biscuits and because when he comes home, he likes to have his stuff. So fruits, milk, whatever he wants to eat, I dose him accordingly. And then dinner is mostly the basmati rice because the sticky rice take him to another level.
Scott Benner Yeah. Yeah.
Natalia Then it's, like, homemade, either grilled chicken or chicken with some kind of tomato and onions, all home cooked. Mhmm. So it's all pretty much, like, manageable, very easy to make, and with some cucumbers and carrots, and that's about it.
Scott Benner Going out to dinner is more difficult?
Natalia So dinner, I have tried. Now we don't go out for dinner because the dinner foods make him it's like a whole nighter. So Mhmm. It's really hard for that to work out. So we do lunch outside. Okay. And dinner is mostly home. Yeah.
Scott Benner When you have gone out to dinner in the past and it's been difficult, I like how you said it it turns into an all nighter. What kind of food was doing that?
Natalia So mostly living in Hong Kong, we get, like, Chinese food, Japanese food. So it's mostly sushi or Chinese food, you know, with the sticky rice and nice little gravies and chickens and fried chickens and Korean fried chicken, so stuff like that. And if everyone's having it, it's hard to keep him away from all that. So now we also try not to order and have that kind of food.
Scott Benner Sure. Well, that's nice of you to do it with him. How big is your family?
Natalia Well, I have a daughter, and this is my son. So two kids and my husband and me.
Scott Benner Okay. The four of you. Mhmm. So do you understand what's happening and you're having trouble impacting it, or are you having trouble understanding what's happening?
Sponsor Break
Scott Benner As I told you earlier, Able Now is sponsoring this episode. Able Now, of course, tax advantaged Able accounts for eligible individuals with disabilities. If you or your child lives with diabetes, you may qualify for an Able account because of ongoing medical needs. Many people in the diabetes community do. With Able Now, you can save for future expenses without affecting eligibility for certain disability benefits such as Medicaid. And thanks to updates to federal law, Able accounts are now available to more people than ever before. That means more individuals and families can use ABLE now to save and invest. Funds in an ABLE now account can be used for a wide range of everyday needs, including education, transportation, health care, assistive technology, and more. There's no enrollment fee, and you can open an Able Now account with a small initial contribution and build from there. Learn more and check your eligibility at ablenow.com. That's Able Now dot com, ablenow.com.
Scott Benner This episode is brought to you by Omnipod. Would you ever buy a car without test driving at first? That's a big risk to take on a pretty large investment. You wouldn't do that. Right? So why would you do it when it comes to choosing an insulin pump? Most pumps come with a four year lock in period through the DME channel, and you don't even get to try it first. But not Omnipod five. Omnipod five is available exclusively through the pharmacy, which means it doesn't come with a typical four year DME lock in period. Plus, you can get started with a free thirty day trial to be sure it's the right choice for you or your family. My daughter has been wearing an Omnipod every day for seventeen years. Are you ready to give Omnipod five a try? Request your free starter kit today at my link, omnipod.com/juicebox. Terms and conditions apply. Eligibility may vary. Full terms and conditions can be found at omnipod.com/juicebox. Find my link in the show notes of this podcast player or at juiceboxpodcast.com.
The Impact of Fat and Protein
Natalia I just find, like, I feel I'm dosing wrong because I was hearing you with your fat protein and all these talks about it.
Scott Benner Yeah.
Natalia So I just wanted to ask the carbs. Like, for example, we were on our Singapore trip right now. We were on a good vacation. He was actually okay. Yeah. His highest took on the trip would be a one eighty, which I wouldn't consider high. So he was, like, active. We were eating. We were going places and walking and doing many things. So that was, I think, working out so well for him
Scott Benner Yeah.
Natalia That we would tell our friends also who we stayed with. We're like, sorry, but, you know, we are staying away from such and such foods. So they took us to places where we would have grilled chicken or, you know, some kind of healthier options. And then once when we went for the pizza and all the Western, you know, all the high fat foods
Scott Benner Sure.
Natalia I tried to manage, like, from one slice of pizza, I cut it into a quarter pizza slice. And so, you know, I was trying to manage with that with a grilled chicken being pushed in with little veggies pushed in, which I can't do all the time. If we're going to a pizza pasta place, you only get that kind of food. Right. And what happened on a vacation is I cannot count because in the restaurants, there is no count for it. Mhmm. I started dosing him extra.
Scott Benner Good.
Natalia I feel it was the first time I did that. I was scared something would happen, but everything was okay, and it worked. Yeah. So since I've come back, I feel I am giving I'm just throwing in an extra five if I'm at home. I'm throwing in an extra 10 if I'm out Yeah. But still avoiding the full, you know, like, three slices of pizza and fried stuff.
Scott Benner Let me run over a couple of ideas for you. Okay? Yeah. So the first one about the activity, that's very real. Okay? So when you have less activity, your body becomes more resistant to insulin. It's just kinda the way it works. Right? I can get you a more technical answer, but it's about how the glucose is handled by your body. Okay? So Yeah. We are in this Omnipod five setting Yep. And it's adjusting to your daily needs. Yep. And so during the week, I think you're getting a there's a combo of a number of things here. Yeah. He's eating the same stuff over and over again. And Yeah. You sent me kind of a sample menu. He's eating things perfectly honest with you. They're very healthy choices. You know? Yeah. I'll breed for people. Turkey, roast beef, eggs, apples Yeah. Fruit, you know, basmati rice, great pivot there away from the white rice. Meat, vegetables, eggs, like stuff that's not terrible to bolus for because they're not very high in fat. They're not fried. It's not processed food. Right? It's as helpful to the process as possible, these types of foods. So you've got the food on your side, and then you have the exercise on your side, the activity On top of that, the Omnipod five is saying, okay. This is about how much insulin we need for these days, and you start to pick up a rhythm at Monday, Tuesday, Wednesday, Thursday, Friday. Then all of a sudden on Saturday, he stops moving. You lose the value of the exercise. And on top of that, you're making maybe the same decisions with the food, and it's going okay right up until you try to go out. And then, you know, you see chicken, pizza, all that stuff there. Right? Yeah. Yeah. That all sounds about right. Right? That's how it's going?
Natalia Yep.
Scott Benner Okay. So I understand that when you get out of the house, it's hard to count carbs.
Natalia Yep.
Scott Benner Just how it is. Right?
Natalia Mhmm.
Scott Benner But what it's gonna take is practice. Yeah. It's not a great answer. I mean Yeah. I could tell you right now, you probably could open up an AI app on your phone and tell it where you're at and probably get a more accurate feeling for the carbs and everything. But if you don't start incorporating the impact of the fat that's happening to his blood sugars, the carbs aren't gonna really matter. Yeah. You know? I mean, not that not that it's not gonna be helpful. Yeah. You know, if a chicken sandwich out at a restaurant is actually 60 carbs and you were guessing 40, of course, that's gonna be a big deal.
Natalia Yeah.
Scott Benner But if there's, I don't know, seven, eight, nine grams of fat in it, that could end up costing him another unit of insulin, and the timing gets changed as well. Yeah. And do you understand why that is? Because it changes the the digestion process?
Natalia Right.
Scott Benner Okay. So you eat all those carbs, and one of the ways those restaurants make flavor is with sugar. So there's probably more carbs, probably more sugar. And on top of that, more fat, a lot of it ends up being fried, which you're not frying anything at home. You take in that kind of oil, degrease the fat, etcetera, and it slows down your digestion. So those carbs, which are probably more than you guessed to begin with, are sitting in his stomach impacting a longer timeline. And that's how you said, you know, it turns into an all nighter. Right? Because those carbs are in there impacting him all night long. There are ways to stagger your boluses to get in front of those rises and the lung digestion. Yeah. So did you find the calculator? I'm so I think I'm supposed to call it an estimator. Did you find the estimator on my website? Yeah. You did for the fat and protein, and did that help you?
Natalia Yeah. It was just too much, so I didn't
Scott Benner Oh, you got a little overwhelmed by it. Okay. Yeah. Yeah. Talk about it now. That's okay. So can you tell me how much he weighs?
Natalia He weighs around twenty kilos.
Scott Benner Twenty kilos.
Natalia That'd be into two point two four pounds. So around forty something.
Scott Benner Oh oh oh, I fret. You said he was seven. He's little. Yeah. How old is your daughter?
Natalia She's 10.
Scott Benner Oh, you have a young family still. Yeah. Yeah. Lovely.
Natalia Pretty small.
Scott Benner Yeah. Was the diabetes a surprise, or is there autoimmune in your family?
Natalia Oh, that's another story. No one has it in the family.
Scott Benner How about other autoimmune stuff? You see thyroid or celiac, anything like that with people?
Natalia Nothing. Nothing. No. Or as I joke with my mom that maybe our grandmothers had it, they never knew about it. Yeah. I don't know.
Scott Benner What's your background? What culture?
Natalia I'm originally from Pakistan.
Scott Benner Yeah. Do they talk about their health, the family?
Scott Benner You've probably heard me talk about US Med and how simple it is to reorder with US Med using their email system. But did you know that if you don't see the email and you're set up for this, you have to set it up. They don't just randomly call you. But I'm set up to be called if I don't respond to the email because I don't trust myself, a 100%. So one time, I didn't respond to the email And the phone rings at the house. It's like, ring. You know how
Natalia it works.
Scott Benner And I picked it up. I was like, hello? And it was just the recording. It was like, US med. Doesn't actually sound like that, but you know what I'm saying. It said, hey. You're, I don't remember exactly what it says. But it's basically like, hey. Your order's ready. You want us to send it? Push this button if you want us to send it. Or if you'd like to wait, I think it it lets you put it off, like, a couple of weeks or push this button for that. That's pretty much it. I push the button to send it, and a few days later, box right at my door. That's it. Usmed.com/juicebox or call (888) 721-1514. Get your free benefits checked now and get started with USmed. Dexcom, Omnipod, Tandem, Freestyle, they've got all your favorites. Even that new islet pump. Check them out now at US Med dot com slash JuiceBox or by calling (888) 721-1514. There are links in the show notes of your podcast player and links at juiceboxpodcast.com to US Med and to all the sponsors.
Natalia Oh, yeah. Yeah. They do all their checkups and stuff, but it's just been, like we've been here, what, sixteen years now
Scott Benner Mhmm.
Natalia In Hong Kong. So, like, both my kids have been born here. So it's just like he overnight, he was looking weak, and it just so happened that after school finished last year, I took him to the pediatric, and she said, just do some blood tests. And overnight, like, the blood test was in the morning. The doctor called at seven in the evening and said, take him right now. His level was something like 40.2.
Scott Benner Okay. And
Natalia it was just like an ICU. It was an overnight thing. Like, no one even saw it coming. But I guess the symptoms I was telling my doctor were there where he was thirsty overnight, you know, all night long, going to the loo every now and then. So the signs were there, but I didn't know what it was. So because of that. Yeah.
Scott Benner Did it come on very quickly, or in hindsight, had he been losing weight for a while or sick for a while?
Natalia He was looking weak since a month, maybe.
Scott Benner Okay. Feels like you caught it pretty quickly.
Natalia I wouldn't say that, but, yeah, that's what everyone says. But, yeah, I I felt so bad when that happened. But yeah.
Scott Benner That's pretty common, just so you know. Yeah. Yeah. Nataimas It is what it is. Most people talk about that and and have that feeling. Yeah. I'm noticing here on your menu that you sent, you have different carb ratios for is it different times of day?
Natalia Yes. So for the morning, it was just something that the, what you call, the diabetic, educator we were in touch with, she said this because he was going a little high and low at different times.
Scott Benner Yeah.
Natalia So we just changed this around, and we just did it, like, nineteen thirty one forty one according to morning, afternoon, night.
Scott Benner Was that before the pump or after the pump that they noticed that?
Natalia After the pump. Yeah.
Scott Benner Actually,
Natalia even before, sorry, even before the pump, the endocrinologist had him with, like, it was pretty much same, but it just wasn't you know, the curve was just going up and down a bit. There was no consistency.
Scott Benner So let's talk about that before we get into the menu. So if these variable insulin to carb ratios were set prior to pumping, then what they were doing is trying to probably get in front of problems you were seeing at meals based on injected basal insulin, which doesn't work as stably as it does from a pump. Yeah. So I also would wonder if maybe you don't need to find out what his carb ratio is and set something a little more stable because you have, insulin correction factor here of one unit moves in 41, one unit moves him 19. So you have it more aggressive at breakfast at nineteen. Yep. It's aggressive for the snack. It gets less aggressive at lunch, and then actually, oddly, much less aggressive at dinner. Yeah. So is he getting high at night before bed?
Natalia Not at all.
Scott Benner No? Okay.
Natalia He gets low. Like, low is what I would call it. I know there are different lows, but he goes around 90. 72 in this range. So but it's still manageable, but sometimes he does go low. He has, like, few sips of juice. Yeah. And he's back okay, and then he's sleeping.
Scott Benner 70 and falling or just 70 and stable and you get nervous about it?
Natalia I used to get nervous even less than 72.
Scott Benner Okay.
Natalia But now I let it go to, 70.
Scott Benner Okay. You're getting it.
Natalia Yeah. It's hard.
Scott Benner Takes time. Took me I was crying for two years, just so you know. The first two.
Natalia Yeah. Like, today, I tried to do that with the nurse in school because I've told them at a five point three, make sure you give him juice. Make sure you do this, and you stop and do this, this, this. So today when he was on a 4.9, they panicked, they're like, he's 4.9. He needs to choose right now. I was like, no. Let's wait because I'm seeing him. He pulls up himself. Yeah. So, you know, I mean, I'm just trying just slowly, slowly, and they're trying. So it's like a whole Yeah. No. No. It's like a village.
Scott Benner I I understand. It takes time. Well, I hope you take some comfort in the knowledge that eventually you will get better at this and it will feel easier. I don't think it's actually easier, but it's gonna feel easier. So do you know what his total daily insulin is right now? About how much does he use in twenty four hours?
Natalia I forgot. Let's see. One second.
Scott Benner Take your time, please.
Natalia So he would be like, total daily would be roughly around three or four units a day.
Scott Benner And that's of bolus insulin? Yeah. And then how much basil is he getting?
Natalia I think basal also is around three. That's the background one. Right? With the Yeah. Automatically it being given to him.
Scott Benner Do you know what his basal rate's set at in the pump?
Natalia Basal rate.
Scott Benner So how much insulin does he get every hour from basal?
Natalia Every hour, point zero five.
Scott Benner Point zero five? Yeah. Do you think he's honeymooning? Are there times when you think, like, oh, gosh. He doesn't really need insulin?
Natalia No. Not really. No. I think he needs it. Yeah.
Scott Benner Okay.
Natalia Like, I would say the knight, Tatshaw, so far since this week, since we've come back, has been the best ever where he is literally on a 90 a 108 would be his highest.
Scott Benner Mhmm.
Natalia So he would just be, like, nice flat line.
Scott Benner Nice. Okay. Well and are there times of the day where he's just not getting basil too? Can you see with the pump? Does it cuddle away at times?
Natalia Sometimes. Yeah.
Scott Benner Okay.
Natalia Or maybe an hour or so, but, yeah, not more than that. It just keeps giving it.
Scott Benner Okay. Give me one second. I'm having a studio built in my house for the podcast, and right now
Natalia Okay.
Scott Benner They are, like, cutting into the wall. This got so loud. I was afraid it was gonna bother you.
Natalia No. No. So 820, you can see he's got a point zero five today.
Scott Benner Mhmm.
Natalia And then at 09:15, he's got another 0.05. So it's, like, almost an hour later.
Scott Benner Yeah. It's a tiny bet he's getting.
Natalia Tiny. Yeah. Really less.
Scott Benner Yeah. Well, I'll tell you the other thing to find some comfort is that as he gains weight and his insulin needs grow with that, this all gets a little easier too. Like, when you're working with these really small numbers, there's a lot less room for, you know, making a mistake. But, also, the good news is it's not a ton of insulin. So if something goes wrong, it should be fairly easy for you to get in front of it one way or the other. So I have, like, an estimator on my website that starts with someone's weight and sort of gives you, like, a breakout of where you might expect their insulin to be. Mhmm. If I make him highly sensitive, that puts him at, like, theoretically, like, nine units a day. And I have a slider I can make it less aggressive. But when I do that, it wants to put less basal on. Takes his basal to about point one five an hour. So you are not far off at all from what you're seeing being pretty accurate to what the math would tell you Yeah. Which is kinda great. So forty four pounds, seven units a day total. This has him about point one five an hour, but there's an argument to be made that, you know, he's probably getting that much sometimes and nothing other times and balancing out to what you said, like, three. So let me take a little calculator here for a second. Do the point one five times 24. And sure enough, that's 3.6 a day. So, again, so the numbers are lining up. So I'm fairly comfortable that, like, based on his weight at least, that your settings are pretty good. Okay? So I like that.
Natalia Okay.
Scott Benner Now the sensitivity factor, if it's working for you, I'm certainly not gonna tell you to change it. Whatever you're seeing is much different than what the math says. So I say just go with what's working for you
Natalia Okay.
Scott Benner On that spot.
Natalia So how would that change?
Scott Benner It's gonna take more insulin to move him as he gets bigger.
Natalia Okay.
Scott Benner That's all. And I think there might be a time when you'll just pick one. Well, because you have it at eighteen right now.
Natalia Yeah. Eighteen. Yeah.
Scott Benner Is that that can't be right, though. You think one unit moves him 18 points?
Natalia Oh, good question. Like, when he's high, he doesn't even do that. So I had started giving him, like, point five so he can come down nine units, but that's not true.
Scott Benner What I'm gonna tell you is that at this little bit of insulin, his insulin sensitivity, the math says it's like one unit moves him 250.
Natalia Wow. Okay.
Scott Benner I don't know what to tell you about what to do or not do with that, especially when it's Omnipod five because Omnipod five has let me pull this up here. I'm a little embarrassed. I just made a video for Omnipod about this, and now I'm having to check my own thing to make sure to make sure I'm about to say the right thing. I feel silly.
Natalia Well, that's okay.
Scott Benner Because I stood in the studio and said it over and over again all day while they were way too close to me with that camera. I'm not gonna lie to you. I was uncomfortable at points. I didn't like to see my face that big. You know what I mean? When they were working on it, I said, please. They were like, oh, it's going along great. We can't wait to send it to you so you can see it. I was like, do I look old? It's all I it's all I kept asking. I was like I was like, do I look old? I look old, don't I? Just don't tell me. It's okay. So I have another calculator here, estimator about how to bolus. Right? So your insulin to carb ratio and we need to kinda pick one. So let's just go with breakfast for a minute, and we're gonna say 19 for the carb ratio. I mean, I'm gonna put the 18 in for your sensitivity Mhmm. And say that his blood sugar target is 90. Okay?
Natalia Okay.
Scott Benner And now I'm gonna look at his breakfast here. You say there's 24 carbs for breakfast, and there's an egg, there's milk, there's a bun, there's bread in there. Yes. And you are giving him 1.3 units, which by the way, in this calculator with your settings, it's 1.26. So 1.3, exactly the same thing.
Natalia Oh, okay.
Scott Benner What I'll say is the milk, high fat milk, low fat milk, do you know how what kind it is?
Natalia It's full fat.
Scott Benner Yep. Okay. So we're gonna do some more gazintas here and try to figure out you think it's a cup of milk?
Natalia Half a cup.
Scott Benner Okay.
Natalia So on the true calculation on the packet, it says, like, one cup is around 12 grams of carbs. Okay.
Scott Benner But how much fat is in it?
Natalia See, now that's the thing I don't calculate at all.
Scott Benner But is that bolus working for you, or is he getting high later?
Natalia It's working.
Scott Benner How high does he get after breakfast?
Natalia Mornings, would start at ninety maybe. 90 or 01:08. And the best thing is I pre bolus him twenty minutes. That is the game changer.
Scott Benner Very nice. Yeah. Have to be.
Natalia So he goes up to one forty four or one sixty two.
Scott Benner Okay. So he's not moving much at all on that?
Natalia Not bad. Yeah. Not bad. Yeah.
Scott Benner Let me just say this. At some point, when he goes to one forty or one sixty, the algorithm is coming in and giving him more insulin to bring him down.
Natalia Yeah. Probably. Yeah.
Scott Benner So a cup of whole milk has eight grams of fat. There's four grams and a half a cup. Just adding that to this doesn't change anything. But there's butter on the bun?
Natalia Yes.
Scott Benner I'm gonna see what happens here. Look for the fat in a tablespoon of butter. Gonna try to make so here you go. A tablespoon of butter. Do know much fat's in a tablespoon of butter?
Natalia Not much. 12. I don't even add that. Wow.
Scott Benner So if I have 16 in fat and I resimulate it again, it's not a lot, but it adds a point three eight bolus over time.
Natalia There we go.
Scott Benner And I'm gonna guarantee you that if you go look at what's happening, he's going up and, you know, one forty or so, which by the is great. You're doing terrific, by the way. I have a feeling when we get to the end of this conversation, I'm gonna find out that you're a bit of a type a personality and tell you. I'm gonna start asking you what you went to college for, and it's gonna be accounting or something like that. And so
Natalia Don't ask me because you're almost right.
Scott Benner Okay. Alright, everybody. Natalia is an actuary or an engineer. And No. No. It's not that much. It's not that bad. It's not that bad. Just finance. Oh, yeah. There we go. Okay. Yeah. So when I put in the fat for that meal, the initial bolus is still at 1.26 or 1.3, but it's asking for point three eight, so point four units over the next three hours. Omnipod five doesn't do extended boluses.
Natalia That's my biggest concern. I've been hearing so many podcasts, a few, but how do I do it?
Scott Benner All I would do is, like, an hour after he eats, I'd bolus point four.
Natalia Okay.
Scott Benner That's it. What I would really do since we're talking about it is I'd do it one morning the way you always do it, 1.3.
Natalia Mhmm.
Scott Benner And then I'd wait to see when does he start to rise.
Natalia Okay.
Scott Benner I'm gonna make up a number. Say he starts to rise seventy five minutes later, I'd put in the point four. I would pre bolus the meal. You're doing a great job pre bolus the meal. I pre bolus the meal Mhmm. Then I'd pre bolus the fat rise with the point four.
Using the Bolus Estimator
Scott Benner And you can use my estimator. It's juiceboxpodcast.com/bolus, the number four, bolus four.
Natalia Bolus four. Yeah.
Scott Benner And all I did was put in insulin to carb ratio 19, insulin sensitivity 18. I made the target 90. I put in 24 carbs from your thing here, and I put the fat in, 16, and it gives you a little you know, there's a meal wave and the Warsaw wave that kinda breaks them out for you, tells you about how long to stretch them out.
Natalia Okay.
Scott Benner And that's it. Like so I'm gonna do it again with you, I'm gonna look at the next meal.
Natalia Okay.
Scott Benner This poor kid, you're giving him seaweed for a snack. Is that what he used to eat, or is that a diabetes thing?
Natalia It's a diabetes thing. But he loved it anyway. Yeah.
Scott Benner Hey. Listen. It sounds like you're all gonna be healthier by the time this is over.
Natalia Yeah. Seems like it.
Scott Benner So now let's do the turkey or sandwich and the apple again.
Natalia Okay.
Scott Benner Tell me what kind of a rise do you get from that, if any.
Natalia So that would be lunch. Right?
Scott Benner Yep.
Natalia So lunch is also okay because luckily, it's a fifteen minute eating window, and then they get to play for, like, twenty five minutes.
Scott Benner Okay.
Natalia So that really works for him.
Scott Benner Oh, and that's why your carb ratio is weaker.
Natalia Yeah. He would go too low then.
Scott Benner I see. So you're getting around that by weakening the carb ratio, and that's working for you. Okay.
Natalia Yeah.
Scott Benner But also on the weekends, when you're trying to have lunch and it's pizza, that's also why you're struggling with the pizza because your carb ratio he's getting half the insulin for twice the carbs.
Natalia Yeah. You're right.
Scott Benner So yeah. So everything is settings. It's all timing and amount. Okay? Okay. So I guess so I'm gonna talk to that part of your brain. Everything is timing and amount. Okay? So you you look at that 24 carb breakfast. You see the problem you're having with it. You realize in that scenario, it's not accounting for the fat that probably caused you the problem. Also, nothing you hear on the Juice Box podcast should be considered advice, medical or otherwise. Always consult a physician before making any changes to your health care plan. Now on the lunch one, you've got the carb ratio goes from 19. One unit covers 19 to one unit covers 31, and you have found a great balance there because of the activity. But at that same time of day, at a pizza restaurant, you're not only don't have the activity, but you've added fat that you're not accounting for, lesser quality food. And for every carb he eats, you're getting half the amount of insulin. In a scenario where you probably need more, you're starting with less and not accounting for the pizza. That makes sense?
Natalia Yeah. Yeah. Okay.
Scott Benner Look at that. What do
Natalia you think of it that way? Yeah. That's
Scott Benner okay. That's that's what I'm here for.
Natalia Yeah.
Scott Benner My silly brain's not good at much, Natalia. This, it understands.
Natalia That's a lot to understand. It's way more than we understand.
Scott Benner Listen. I sincerely mean this. I'm not denigrating myself, but I'm probably not nearly as intelligent as you are. I'm not good at math. Whatever degree you have, I couldn't possibly get. All I had was a kid with diabetes before all this stuff existed and my desire to really pay attention to it and try to figure out what was happening. And Yeah. Then I saw what I saw, and contextually, I speak about it very differently, which I think is why, you know, when I stand up in front of a crowd and I say things like all the silly t shirt slogans I say about diabetes, that comes from, like, kinda, like, the I think I talk in pictures. But then over the years, making these episodes and bringing my friend Jenny in and talking about it with her, like, she really, like, helped reframe me the way I think about it, and I was able to kinda rewrite the way I think about it too.
Natalia Yeah. It's great. The work you do is great over here because in Hong Kong, we don't have the exposure. You know? We just have very, I would say, a very I mean, we don't even have bumps over here. We have to order them from other countries. Yeah. So they don't even have the whole thing where they have that support over here where you can like you were saying, take in the fat, taking this, taking that.
Scott Benner No one's gonna tell you about that. You know, I've done a couple of Zoom chats with expats in Hong Kong
Natalia Yeah.
Scott Benner Couple times around diabetes. Nice little group of people. So I understand why the lunch works, and I understand why you also are less aggressive at snack time
Natalia Mhmm.
Scott Benner Afterwards. That all makes sense. But now at dinner, that part throws me off because rice, meat, you know what? It's just not a lot of carbs, really. You're doing meat and veggies with some rice. Basmati's got the index on the Basmati's lower, and you've got the 41 work. Is he super active after school? Does he come home and run around and everything?
Natalia Excuse me. So he's basically he has football, and he comes home on Thursdays, and then he has other activities going on. So he's quite, like, all over the place until, like, we're ready to eat dinner by 05:30.
Scott Benner Okay. That's why you're getting away with the insulin to carb ratio of one to 41 at dinnertime. Plus you're doing most of your carbs are from vegetables and rice at dinner as well.
Natalia Yeah.
Scott Benner Yeah. Yeah. Okay. And there's not a ton of fat in no. There's no fat really in what you're eating at dinnertime.
Natalia Yeah. I avoid doing all those things. So it's either rice or it's roti, the homemade ones. So Mhmm. We use the whole meal. Yep. Yeah. We use that for that. So
Scott Benner Okay.
Natalia He was tested for the celiac disease. He had the whole endoscopy and stuff done where he was cleared from it. So we've kept it as normal. No gluten free or anything going on. So, I mean, I don't see that that's affecting him.
Scott Benner Yeah. No. It seems like you're okay there. Also, a lot of those gluten free prepackaged meals are a lot more carb heavy than you think too.
Natalia I agree. Yeah.
Scott Benner So I'm glad you don't have to use them. But now I think what we gotta figure out is this vacation menu here are the weekends. Like, you know what I mean? Because I mean, I'm happy to walk through it with you, but you already know the problem. Right? Carb ratio is wrong, and his activity is different. Yeah. Yeah. Yeah. So the bigger question is then if the pump is already set up, you don't wanna be changing constantly, you know, your settings and everything.
Natalia Yeah.
Scott Benner I think, honestly, when you're 19 and 31, you could just do the math and find out what the difference is so that when you dial up the insulin how are you gonna do that? You're gonna have to either lie about how many carbs it is or just put in extra.
Natalia Yeah. Just fake carbs. Right?
Scott Benner But I'm not sure what the algorithm's gonna handle better. Because what we would prefer is that on Saturdays, you know, at that time of day, that his carb ratio was more like 19 than 31 if you're gonna go do those kinds of meals. Yep. But you're also gonna want to really look at the fat on some of these things. Like, let's just use the pizza, for example. Like, I've never been to Hong Kong. So what am I getting for pizza there? Is it like pizza?
Natalia Pizza Hut. Yeah.
Scott Benner Yeah. Yeah.
Natalia We do Pizza Hut. Yeah.
Scott Benner Okay. So let's take a look at that real quickly.
Natalia And I don't even use the manual mode, so I don't put it on the extended bolus. I don't know if that impacts it or me just making it $60.40 is also the same thing or not.
Scott Benner You're not putting it in manual mode, making it sixty forty. Impacting what? I'm sorry.
Natalia Impacting his levels.
Scott Benner I mean, I think what's happening is you're trying to eat stuff with more fat, more protein. The pump itself believes that his total daily insulin is seven on a day when it's not gonna end up being more like 12. Yeah. You know? So the you've got everything going at you. You're changing how you normally live, and the algorithm doesn't know it's Saturday, and the algorithm doesn't know you're going to Pizza Hut. Right? So and you're counting carbs and not covering the fat too. So just because I'm on the website here, cheese pizza, pepperoni, supreme, meat lovers, which one would you
Natalia So just plain cheese.
Scott Benner Yeah. Plain cheese. Okay. I asked for the nutrition levels, and Pizza Hut's trying to sell me a pizza. Hold on a second. Oh, wow. And the calorie information, and I clicked on it, and it says, what's my ZIP code? Am I gonna have to give it my ZIP code to get the calorie information?
Natalia It wants you to get one.
Scott Benner It does. Silly little website. It's tricking me. Alright. I have to find a better website than the Pizza Hut website.
Natalia I got a 12 inch eight slices one. Carbs and Pizza Hut pepperoni pizza. Okay.
Scott Benner Gosh. There's so many different kinds of pizzas.
Natalia Pizza.
Scott Benner You should come here and have a pizza in New York, Philly.
Natalia Yes.
Scott Benner Pretty much. Have you been here?
Natalia I've been to New York. My husband's family lives there.
Scott Benner So Very nice.
Natalia Been there a few years ago. But with kids coming all the way to America is a bit much.
Scott Benner Yeah. Just for pizza? You don't think it's you don't think it's gonna be worth the trip?
Natalia Generally, I mean, like, it's we have other places we can go to.
Scott Benner Alright.
Natalia I've lived in Arizona with my uncle for, like, one semester of college. I didn't like it. I came back.
Scott Benner Too hot. Right?
Natalia Oh, just like I was 15 probably. Oh, yeah. Home. Yeah.
Scott Benner Not looking for that. The only thing I really know about your part of the world is I do keep grass lizards from Japan. The little green ones with the super long tails.
Natalia Oh, wow.
Scott Benner Hold on one second. Let me tell my wife that my dog ate. Okay. My dog got sick. He had to have his medicine today.
Natalia Oh, wow. Okay.
Scott Benner My wife's like, did he have his medicine? Okay. So 12 inch medium pan pizza. Yeah. So just using the pizza I'm gonna make a an example here for you. If we put him at 31 for his insulin to carb ratio, and then we say that he has and is one slice true, or is he gonna have two slices?
Natalia Two. Yeah. Two. Two slices?
Scott Benner Okay.
Natalia Let's see how it goes. Yeah. 60?
Scott Benner Yeah. This says 27 here, but we'll go with 60. Yeah. And now the fat is 20. And believe it or not, there is protein in it.
Natalia There's 11 grams of protein in it. So you're getting 22 of protein. We haven't even talked about what protein does yet. Okay.
Scott Benner But protein gets stored as glucose.
Natalia Glucose. Yeah. I was hearing your
Scott Benner Yeah. You see, kinda have to do that there too. So 60 carbs, 20 fat, 22 protein, right, is 1.9 units up front and point four three units stretched out. So you're probably doing two units if you're counting all that correctly, and it really is more like 2.4. But I think the greater point is that that's at the insulin to carb ratio of 31. Yeah. If you change his carb ratio to 19 and do the same math again Yeah. This goes from 1.9 up front to 3.1 up front.
Natalia Okay.
Scott Benner And point seven over the four hours. So that's almost a four unit bolus, 3.86, 3.9. It's 3.9 bolus up from 1.9 that you were using before. So you're using half the insulin that you need and not trying to impact the fat at all. So, basically, think of it this way. You gave the pump two units of insulin to do the job that it needed four units of insulin to do. Right. And on top of that, it doesn't consider fat the way you and I are talking about it. So as he's drifting up, it's not treating him like the food's the issue. It's just treating him like he's drifting up. So you've got this accelerant on his blood sugar, this, you know, this fire you've lit in his belly of fat and protein and carbs and all this other stuff. And you're handing the pump a garden hose and telling it to put it out. It needs a fire hose. Yeah. And so instead of putting that burden on the pump, which, by the way, what does he get to after the pizza? How high?
Natalia He goes to he's been to a 22, which is around, for you, 400.
Scott Benner Okay. So what I would do there is, of course, not as long of a pre bolus for pizza because you don't want him to get low first, and that pizza does not go in and start working as quickly as some of these other foods do. Right?
Natalia Right.
Scott Benner So maybe a slightly shorter pre bolus. Again, the timing and the amount to get the bulk of that insulin where you need it to be. But then when you start to see that first rise, you're gonna have to bolus again. And whatever that pod's gonna do I mean, with a kid who's using seven units a day, it's probably hitting him with, like, point o five, point o five. That's not
Natalia gonna do Nothing.
Scott Benner No. Especially when you're two units deficient already. Yeah. Right? So I think that's your answer there with that food, which is use the more aggressive carb ratio and account for the fat and the protein.
Natalia So does this make sense if I change the 31 to a 19 next time I do this when he has his pizza. And then I for the weekdays, I change it back.
Scott Benner Yeah. I mean, you can whatever is workable for you. Yeah. See, whatever works best in your life.
Natalia I'm just asking, should it have a consistency, or is okay to just keep changing it?
Scott Benner Well, I mean, listen. There's an argument to be made here. Taking the weekend out of it or taking the pizza kind of extra stuff that you don't usually taking that out of the conversation for a second. There's an argument to be made here that you're it's got nothing to do with the carbs. It has to do with his activity.
Natalia Okay.
Scott Benner You're managing lows from activity Mhmm. By using less or more insulin at meals. That's all that's really happening here. Everything's timing and amount. It's the right amount of insulin at the right time. And the timing has a lot to do with the variables around you. Right? Is he active? Is he not active? For some people, it's heat. Are they hot? Are they cold? Are they Yeah. You know, whatever people's variables are, you know, for ladies, a lot of times, a lot of hormonal stuff. Right? Yeah. That's why you hear people talk about diabetes like this way. Like, it's unknowable. Like, oh, I do the same thing every day, and I get a different outcome. Yeah. But you're doing the same thing every day, but the day's not the same. It looks the same to you because all you're talking about is eggs and milk and bacon and 08:00 in the morning. You're not talking about hormones. You're not talking about growth hormones, which he's by the way, you're not gonna see yet. But in a couple more years, wait till you see his blood sugar go up overnight when he goes to sleep. That's gonna be fun. So it's the variables around it that change the impact the the invisible impacts, really. But that's why when people say I do the same thing every day and I don't get the same outcome, they're wrong. They're doing the same thing every day, but all the things that are happening are not the same. It's the unseen stuff. For you, I can see why this would have gotten past you, to be perfectly honest, because they got you those carb ratios set up, and you're like, wow. This is working. And then why the hell doesn't it work on Saturday? That doesn't make any sense. Then all of a sudden, you say, oh, it's diabetes. It's just, you you can't know. But we looked at it for five minutes, and you know now. So Right. It's pretty much it. I mean, there's I I hate to say it. There's not a lot to it. You know what I mean? Which is why I can hold it in my head. Trust me. If there is more to it, I'd be the wrong person to ask.
Natalia Can I just ask you to repeat this whole thing with the bolus? I opened your bolus estimator.
Scott Benner Yeah.
Natalia So can we, like, walk through this together?
Scott Benner Sure. Sure. Yeah. So at the top there, there's insulin to carb ratio.
Natalia Variables. Yeah.
Scott Benner Yep. And there's insulin sensitivity.
Natalia So we put in 31 here. Right?
Scott Benner Yep. And then Okay.
Natalia SF is 18. Yep. Then target blood glucose would be
Scott Benner I made it 90. Okay. Yep. And then you just kinda scroll down a little bit and put in carbs. By the way, I'm not boasting because I don't know how to code, so it was Claude that did it. But, once you leave the website and come back, it'll leave his carb ratios and his sensitivity. All those numbers you put in, it'll remember when you come back to the website, but it doesn't store any of your data.
Natalia Okay. So what is the calc gap? What does this mean?
Scott Benner Okay. So I'm not gonna lie to you. It's a simulation. It'll halt if the output exceeds it. So Okay. It's kind of a safety that's built into it.
Natalia So it's I don't have to put anything here.
Scott Benner You can just leave it at it should be at 25. Right?
Natalia 25.
Scott Benner Yeah. Just leave that. The FPU adjustment factor, if you wanna sit down and really read and understand the Warsaw method, which is probably not gonna be necessary for you with such a little kid at such a little weight. But there are some people who need a different adjustment factor to make the Warsaw method work better for them. I'm gonna tell you right now, I'm not the right person to ask about that. But Okay. It's set at 50 as a default. If it's working for you, I'd leave it there. Okay?
Natalia Okay. Let's leave it. Yeah.
Scott Benner Yeah. Okay. And then carbs, fat, protein.
Natalia So carbs, we have 60. Yep. Fat, we have 20.
Scott Benner Mhmm.
Natalia Protein, 22.
Scott Benner It's 22. Now I did not fill in the current BG number there. Okay? So because we're just talking, like, theoretically. But if you put in there, he's one fifty, like, I'm still looking at your bolus with 6020, 22 as the settings, and it's 1.940.43. Meal wave, 194. Warsaw, 1.43. But if I suddenly make his blood sugar one fifty, then, of course, it's gonna add a correction in. The initial bolus went up to 5.27 to cover his higher blood sugar.
Natalia Oh, wow. Okay.
Scott Benner You're not just bolusing for the food. If he's one fifty, you're bolusing for the food and the elevated number.
Natalia Okay. So let's go through with this. So current BG, we kept at one fifty.
Scott Benner Mhmm.
Natalia That the IOB units
Scott Benner If he's got insulin on board, you can put it in there so it's part of the part of the thing. But, you know, also, if it's been a few hours since he's eaten and he's got a stable blood sugar, I'm gonna kind of assume that the insulin's already done what it's gonna do.
Natalia Okay.
Scott Benner And it actually does help you there. You can put in a an arrow for the trend arrow because right now, I have is one fifty. It's a five two seven bolus. Also, let me mention with the one fifty, when I take the one fifty out, not only is it a one point nine four initial bolus, but it says make the pre bolus nine minutes. You put the one fifty in, and you'll notice when you resimulate it, it turns the pre bolus into more like fifteen minutes. So what it's telling you is like, look, you wanna try to get that one fifty number down more before you start eating is what it's saying.
Natalia Right.
Scott Benner Yeah. And don't take any of, the 15 or the nine. It's not gospel. It's Right. It really is just, you know, a place to start to think about it. Anyway, if you make the arrow stable, that's one thing. If you make it a rising arrow
Natalia Okay. So whatever it is I see from the Yep. The controller. Okay.
Scott Benner And, actually, when you scroll down, it says show calculation steps. If you wanna click on that, it shows you all the math that it's taking into account. And you can continue to scroll down, and there is an incredibly technical explanation of what this thing is doing.
Natalia Okay. Great. I didn't know how to use this. Yeah. Okay.
Scott Benner Makes
Natalia sense. So mean wave would be 5.27 units. That would be
Scott Benner Yep. Upfront. Yep. What it's saying there is it would like to see point four three units spread out over four hours.
Natalia Over four hours.
Scott Benner But you don't have that ability.
Natalia Okay.
Scott Benner So there's where you're gonna have to just pick a time to jump in and put in a little bit of extra to try to stay ahead of the now listen. If ninety minutes later, you're not seeing a spike and it never comes, well, then, okay. The bigger bolus did it. But if you see it
Natalia I get excited in two hours. I said, I think I did it at at the fourth hour comes.
Understanding Basal and Automated Systems
Scott Benner Think I did it. Nope. Well, see, also on the AID systems, all of them. Right? There's this sort of, like, in plain language, the algorithm believes that you've given it the right amount of insulin and that you've accurately described the impact that it's going to see. You know, if your pre bolus gets him to, I don't know, 85 and he's super stable, well, then the algorithm's working off the bolus. So it'll oftentimes take the basal away because the bolus is basically handling the food and the basil needs all at once right now. Okay. Right?
Natalia Okay.
Scott Benner So if it's doing that and you're wrong or there's other impacts from food, then not only is it not enough insulin, but it's also probably got a deficit of basil. So there's nothing there to stop the rise from happening. Right? And then it starts to just like, the way I think about it is this. Basil insulin, if you think of the blood sugar as a number, I think of basal as just enough weight to keep that number where you want it to be. So Okay. Think of your, you know, your left hand is pushing up and your right hand is pushing down, and so the body is, you know, natural body functions are making your blood sugar go up. Right? You're not making insulin. You eat a cookie, your blood sugar's gonna go up without insulin. It's never gonna stop. Right? Yeah. So you need to put enough basal on top of that just for your body functions to keep you level. So think of it as, like, resistance that keeps the number where you want it. That's basil's job. Keep you at a number that you want stably. So the basil's doing that. You take that basal away, there's nothing stopping that number from rising all of a sudden. And so when you bolus on an algorithm, you put in all this insulin, and it's saying to you, okay. Well, we have a stable number. So the insulin that's in there is not only handling the food or the correction that we asked for, but it's also handling the basal needs. So you'll see that a lot of the algorithms just shut the basal off. And sometimes there won't be basal insulin happening for an hour or two.
Natalia An hour.
Scott Benner Yeah. Yeah. Yep. Right? And just imagine if you didn't use enough insulin and it's shutting the basal off because it believes you when you told it how many carbs and what's the impact gonna be of this food. So it's taking insulin away on the other side, then that fat rise comes in and hits you, and you've not only don't you have anything currently laying on top of it to stop it, but you haven't had anything there for hours, so you're deficient on top of that. Does that make sense?
Natalia Right. It
Scott Benner does. Right? And then that's where the rise comes from.
Natalia Yeah. Yeah. This is the information I feel I was missing. It was just not making sense.
Scott Benner Sure. No. I understand. Yep. That's it. What I just said to you right there, I don't wanna give away the whole secret. That's pretty much why people listen to the podcast. Yeah. The idea that nobody talks about this part of it. I mean, you could get lucky and get an endocrinologist that would explain it to you, but mostly, it doesn't. Yeah. I'll tell you, I'm giving a talk tomorrow at a hospital, and I said I'd like to talk about this. And they were like, oh, we don't tell anybody to do that. I was like, yeah. That's gonna be a problem. You know? Yeah. So, I think that's it. I mean, in all honesty, like, I would imagine this weekend's gonna go way better for you. Might be pizza time again. Who knows?
Natalia I hope so. Yeah. So is this what you said is, like, a extended bolus, basically?
Scott Benner Yeah. If you had a regular pump, right, like, wasn't running an algorithm, or there are some algorithm pumps that handle extended boluses off top of my head, tandem does. Yeah. Yeah. So if you had a tandem pump, you'd say, look. I wanna do this exact setup. I'd wanna do 5.27 up front, point four three over four hours, and and then it would do that there.
Natalia Okay.
Scott Benner But Omnipod five doesn't do extended boluses in automation, so you're just gonna have to make the point four three bolus at an advantageous time, which would be before you see the fat rise, but not so much before that it makes you low.
Natalia Okay.
Scott Benner Alright? So the timing of that is gonna be a little bit of you're gonna have to have a couple of pizzas to figure that out. Yeah. You know what I mean?
Natalia I have to go through it. Yeah.
Scott Benner Yeah. Little practice pizza, we'll call it.
Natalia Okay. Sure. Alright. Thank you so much.
Scott Benner Oh, you're welcome. Same thing with all this other stuff. If you're doing chicken and it's a chicken tender or chicken nugget
Natalia Yeah. Oh, the breadcrumbs and stuff.
Scott Benner Yeah. But don't forget too that because they probably deep fry them, there's gonna be fat there.
Natalia Yeah.
Scott Benner So look for the french fries. French fries
Natalia are Right?
Scott Benner Cheeseburger and fries. I don't know if you guys eat meat, but a cheeseburger and fries, you're gonna get the fat from the meat and the fat from the fries. It's gonna be a double whammy of fat. And trust me, just for fun sometime, which, by the way, is why I set this simulator up so people could look at it. Yeah. Like, you have this set up now, 60 carbs, 20 fat, 22 protein, a 150 blood sugar, and you're seeing what it is. But just imagine for a second let me just Google, like hold on a second. I'm just gonna use McDonald's because I don't because it's something everybody knows.
Natalia Like, he's even stopped having chicken nuggets because I'm just too scared of it.
Scott Benner Yeah. No. No. But you're gonna have it now. I can hear you thinking about it. I know you're gonna be okay. Yeah. Large McDonald's french fry, 23 to 24 grams of total fat, 66 grams of carbs. So if we add say he has what you just described now, but with a McDonald's fry on top of it, that takes it to a 126 carbs, and it takes your fat to 85. Yeah. Okay. Now I'm gonna ask you without thinking about the numbers for a second. Just use your old brain. If he had french fries, how much insulin would you give him for french fries?
Natalia Point five, what?
Scott Benner Yeah. Right. It takes his bolus up to 7.4 initially and 1.3 over time. So where you would have added point five or one, you would have really needed two, almost three units.
Natalia Yeah. Yeah.
Scott Benner And that's the kind of stuff, like, when people say don't have any luck at restaurants, this is what they're not doing.
Natalia No. There had to be a reason.
Scott Benner Yeah. This is it.
Natalia Yeah.
Scott Benner Alright. You're done. I fixed it. We're all good.
Natalia Thank you so much.
Scott Benner What time is it for you are? It's so simple. Well, listen. Once you hear my dumbass explain it to you, you actually start thinking, It maybe it is simple. No.
Natalia I'll use the calculator and really I mean, now it's making sense. So Good. Slowly. Let's see.
Scott Benner Yeah. You go to my website up in that menu, this is for you or for anybody listening, not only is there, like, in a little a one c estimator up there, there's, a basal estimator if it explains how the math works behind basal insulin where you can just, you know, put in your weight, and it'll give you some suggestions about where to start looking. There's also the bolus estimator that we were just using. There's also just a fat and protein estimator. It doesn't do the whole, like, the whole meal, but it shows you how it works. Just adding fat and protein to your carb ratio to give you some examples of it. And then there's the setting simulator, which is literally just you set your weight, and then it gives you a starting point for everything from carb ratio, basal sensitivity factor, like, kind of the whole thing. So as he's growing, you might wanna go to that simulator once in while and just kinda check yourself. Like, maybe our settings have moved because he's gonna gain weight. He's gonna keep growing, and those doctors are never gonna mention these settings again to you.
Natalia Yeah. That's every three months I have to go to them, but it's just like, you know, you should do better. And I'm like, how? You know? They don't teach the how.
Scott Benner Yeah. Yeah. Yeah. Well, go back and look at that setting simulator. Like, if things are getting wonky, then just go look again. Anyway, I think those things should be helpful to people. Again, they're not there's disclaimers all over the stuff. It's for educational purposes. You should talk to your doctor first. I barely graduated from high school. Okay? So I'm not I'm not joking. That's fine. Alright.
Natalia It's whatever you make of yourself. Right?
Scott Benner I believe that too, but I just want you to know where you're getting that estimator from. That came out of my brain, so be careful. Wow. That's fine. Alright. Alright. Do you have any other questions or anything else you'd like to talk about?
Natalia Just one more thing. I for the longest time, I thought Basil was just background insulin. He would get only at night. I think it's because of the injection time where Tresiba was just given one unit at nighttime. So I don't know why that has been stuck in my head. And when I talk to people, they're like, oh, you should turn up the temp basil. And, you know, I was like, how is that connected to bolus? Mhmm. So
Scott Benner Well, listen. Now that you've talked to me, go listen to the pro tip series.
Natalia Okay.
Scott Benner Okay? It starts at episode 1,000 where you can go to my menu and go down to pro tips. Jenny and I walked through the whole thing. If you just listen to it straight through, I'm gonna tell you right now, you listen to that thing straight through and halfway understand it, it's an a one c in the sixes.
Natalia Okay.
Scott Benner Okay? And we'll go over all that stuff. But it's funny because I actually did add there's an interactive defining diabetes page on here, which it's just definitions because I did find that people, like, would say, like, well, I didn't know what basil was. And I have kind of colloquial ways of talking about it. And the basil, I just did with you. I just think of it like basil holds you at a number.
Natalia Yeah.
Scott Benner And you decide what you want that number to be. I don't care if you wanna, you know, away from food and away from, you know, active bolus insulin. If you wanna try to be 80, there's a basil that holds you at 80. If you wanna be 90, there's a different basil that'll hold you at 90. And then once that's done, that's done. Yeah. But if that's wrong, to imagine that the basil I know these are big numbers because he's so small. But try to imagine your basil supposed to be one unit an hour, but you have it set at point five an hour. Yeah. So you're deficient every hour a half a unit of basil. You probably got a high blood sugar on top of that. But then you go to bolus for food, and then even if you have your carb ratio right and you've counted the carbs correctly and you say, okay. Well, this meal is four units. Well, it's four units, but you're deficient a half a unit of basil every hour for the last four hours. So your four unit bolus might not even touch your food. You replace the basil and the need that you have with a higher number, you probably didn't even put any insulin to cover food. So just remember it this way. When the basal's wrong, nothing else works.
Natalia Okay.
Scott Benner Okay?
Natalia And the way to see that is in the nights or during the day as well?
Scott Benner It's just easier at night to look at and then kinda work off it during the day, can kind of adjust off of it. But Omnipod five is gonna make the changes for you anyway. There's not a lot you can do about it. But you could you could if you really want to teach yourself on the weekends, you could put them into manual and try to get your settings right to, you know, kinda give yourself a I don't know. Like, you could basal test in manual. You know, you could do a little testing in manual just to see how good your settings are.
Natalia Right.
Scott Benner You know? And then after that, it sounds like you got the pre bolusing down already. You got you know, most meals, you need to pre bolus.
Natalia Yeah. For all of them, I do it. Yeah.
Scott Benner And that's pretty much it. Listen, Nithanya, seriously, I'm gonna tell you something I I don't tell everybody, but when I hear it, I say it. You're gonna be fine because Yeah. You're paying attention and you ask the right questions. That's pretty much it. Yeah. And you're trying.
Natalia Just trying my best.
Scott Benner Yeah. No. You're doing great. And it's gonna work out because you're paying attention and you're asking good questions. You found good information, and you're putting in the effort. I guarantee you wake up six months from now, look back on yourself today, you won't recognize yourself. Yeah. You know? You okay? Are you sleeping? Yeah. Yeah. You're getting good sleep? You're not, like, up all night long?
Natalia Really? No. I get good sleep. Yeah.
Scott Benner Good. Good. The and the algorithm probably helps you with that. The Omnipod five is a lifesaver there, I would imagine.
Natalia It's just that the whole house has iPads ringing if it goes below four. So, I mean, that's the time we wake up. And by default, we give the juice and stuff. So, I mean, I guess it's a way of life now.
Scott Benner Yeah. It is. You'll be okay. You really will be. Yeah. Yeah. I appreciate you doing this with me. I hope this went kind of the way you were hoping.
Natalia Really, really good. Yeah.
Scott Benner Oh, good.
Natalia I had no idea what would come out of it, but
Scott Benner That's excellent.
Natalia I'm looking to it now. I know which direction to go with, but thank you so much.
Scott Benner You're welcome. You're very welcome. Hold on one second for me. Okay?
Natalia Yeah.
Outro
Scott Benner Alright. I'm sorry. I started the recording back up, everybody. So I'm still here with Natalia. We were talking about what to name the episode, and I said, oh, you never said your son's name, or I would have made this episode bolus four and his name, but you said it's okay. So what's his name?
Natalia His name is Zaid, but everyone in school call him Zaidino. So if I show him that, he would be really happy. You'd be
Scott Benner very fine. So spell the nickname. Spell it. Z a
Natalia z a y d I n o.
Scott Benner D I n o. Okay. And I wanted to put this here so that all of you, when you got to the end, you're like, why the hell was this episode called that? So so that's exactly what I'm gonna call. I'm telling the editor right now. Rob, this is Bolas Forzedino, z a y d I n o. Okay. Thank you so much again. I'll let you go. A huge thanks to my longest sponsor, Omnipod. Check out the Omnipod five now with my link, omnipod.com/juicebox. You may be eligible for a free starter kit, a free Omnipod five starter kit at my link. Go check it out. Omnipod.com/juicebox. Terms and conditions apply. Full terms and conditions can be found at omnipod.com/juicebox. A huge thanks to today's sponsor, AbleNow. AbleNow offers tax advantaged able accounts for eligible individuals with disabilities. If you or your child lives with diabetes, you may qualify because of ongoing medical needs. With Able Now, you can save for a wide range of disability related expenses without affecting eligibility for certain disability benefits such as Medicaid. And thanks to recent federal law updates, more people are eligible than ever before. Learn more and check your eligibility at ablenow.com. You spell that, ablenow.com. There's links in the show notes and links at juiceboxpodcast.com. The conversation you just enjoyed was brought to you by US Med.
Scott Benner Usmed.com/juicebox or call (888) 721-1514. Get started today and get your supplies from US Med. I can't thank you enough for listening. Please make sure you're subscribed or following in your audio app. I'll be back tomorrow with another episode of the Juice Box podcast. If your loved one is newly diagnosed with type one diabetes and you're seeking a clear practical perspective, check out the Bold Beginnings series on the Juice Box podcast. It's hosted by myself and Jenny Smith, an experienced diabetes educator with over thirty five years of personal insight into type one. Our series cuts through the medical jargon and delivers straightforward answers to your most pressing questions. You'll gain insight from real patients and caregivers and find practical advice to help you confidently navigate life with type one. You can start your journey informed and empowered with the Juice Box podcast. The bold beginning series and all of the collections in the Juice Box podcast are available in your audio app and at juiceboxpodcast.com in the menu. Have a podcast? Want it to sound fantastic? Wrongwayrecording.com.
